Remember Tenerife

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pelmet
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Remember Tenerife

Post by pelmet »

Remember Tenerife....

An ATC IFR clearance is not a clearance to takeoff. 583 people died on March 27, 1977....

"C-GABO, a DeHavilland DHC-8-300 operated by Jazz Aviation LP, was conducting flight JZA603
from Toronto Leaster B. Pearson Intl (CYYZ), ON to Sudbury (Greater Sudbury) Airport (CYSB),
ON. While taxiing for departure at CYYZ, the control tower instructed Flight JZA603 to line up
runway 05, airborne, left turn heading 360. JZA603 read back the instructions to the tower. A
minute later, JZA603 called the tower to announce they were on the takeoff roll. Once airborne and
climbing through 2000 feet, JZA603 called the tower to confirm if they were cleared for takeoff. The
tower indicated that JZA603 never received an official takeoff clearance and mentioned they did
not want to disrupt the roll as everything was clear. There was no impact on operations, and no risk
of collision."

Beware of ATC clearances while on the runway.
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Eric Janson
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Re: Remember Tenerife

Post by Eric Janson »

instructed Flight JZA603 to line up runway 05, airborne, left turn heading 360
Very ambiguous wording imho.Take-off clearance is implied.

The second part should have been given at the same time as the take-off clearance.
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pelmet
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Re: Remember Tenerife

Post by pelmet »

I remember reading about the Tenerife accident details when I read a book about aircraft crashes back as a young teen. It was pre-internet days and I would also take the bus to the downtown library to read through Aviation Week magazine which had the full accident reports in them over several issues. Perhaps a strange obsession but I think every pilot should have a slight obsession for learning about aircraft accidents. It led me to do similar in my skydiving/scuba diving days, both of which have high rates of incidents from a variety of causes.

Check out the parallels of the Jazz clearance with KLM...

“ 1705:53.4 APP: KLM 8705 [sic] uh you are cleared to the Papa beacon. Climb to and maintain flight level 90 ... right turn after takeoff proceed with heading 040 until intercepting the 325 radial from Las Palmas VOR.

1706:09.6 KLM RT: Ah, roger, sir, we're cleared to the Papa beacon flight level 90, right turn out 040 until intercepting the 325, and we're now (at takeoff).“

You need to hear the magic words.

“.... Cleared For Takeoff.....”

And remember to get confirmation if there is ever any doubt. Maybe in this situation, they had no doubt in their mind, so perhaps it is best to make it a personal policy to confirm you actually have the takeoff clearance whenever a bunch of extra info given in what you believed to be that clearance.
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Canoehead
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Re: Remember Tenerife

Post by Canoehead »

It's a company requirement to verbally confirm, with each other, when cleared for takeoff. There are other "built in procedures" that also aid in confirming when we receive important clearances. This crew missed both safety nets.

The clearance this crew received, along with the "airborne instructions" are normal YYZ ops, especially for a Dash-8. In 100% of IFR clearances out of YYZ, they get an RNAV SID. Yet in 95% of takeoff clearances, a heading to fly is given. Inevitably, it can lead to some extra button pushing at the last minute and errors can occur. It's completely unnecessary but Nav Canada and the GTAA have made things way more complex than it needs to be.

Tenerife is an extreme comparison IMO. Time pressures made that Captain do bizarre things from the time they arrived. Low vis and of course a runway doubling as a taxiway were part of a Pandora's box. That cockpit was so split up it made Humpty Dumpty look organized. I do agree however that we need to remember how bad things can get when those proverbial holes in the cheese align.

Given the way this went down, I almost guarantee I know the moment the captain realized that something was not right.
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Scuderia
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Re: Remember Tenerife

Post by Scuderia »

Eric Janson wrote: Wed Dec 02, 2020 5:42 am
instructed Flight JZA603 to line up runway 05, airborne, left turn heading 360
Very ambiguous wording imho.Take-off clearance is implied.

The second part should have been given at the same time as the take-off clearance.
Any implication of a take-off clearance can be ignored - take-off clearances are explicit.
If the implication is that I already received take-off clearance and I think I have forgotten, two things come to my mind:
1. that needs to be verified; and
2. why am I getting a SID amendment after receiving clearance and before getting airborne? I think ATC knows better than to issue those types of instructions during that phase of departure. In fact, receiving that sort of instruction at that time might imply to me that I am not cleared for take-off.

I think it serves as sufficient protection against any misunderstanding of departure instructions. ATC can verify the crew's readback of the amendment before giving take-off clearance.
Canoehead wrote: Wed Dec 02, 2020 9:15 amThe clearance this crew received, along with the "airborne instructions" are normal YYZ ops, especially for a Dash-8.
This is common in the Vancouver FIR too. ATC will give a line up and wait instruction along with any SID amendments. Take-off clearance is then given after the crew acknowledges the amendments.
Canoehead wrote: Wed Dec 02, 2020 9:15 amIn 100% of IFR clearances out of YYZ, they get an RNAV SID. Yet in 95% of takeoff clearances, a heading to fly is given. Inevitably, it can lead to some extra button pushing at the last minute and errors can occur. It's completely unnecessary but Nav Canada and the GTAA have made things way more complex than it needs to be.
One would think that a new SID could be developed instead of modifying or cancelling the assigned one 95% of the time. Not a YYZ exclusive issue either.
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Skythings
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Re: Remember Tenerife

Post by Skythings »

A slightly different but similar situation occurred to me many years ago at YEG flying a C-177. I was cleared to runway 19(now 20) from the ramp via Taxi Bravo to the reverse exit Bravo One for a midfield departure. In those days we did our run-ups on the taxiway holding short of the main runway. I turned the aircraft into wind facing a heading of about 210 degrees and completed the run-up. I turned the aircraft and lined up on the taxiway just before the hold line. I called tower and advised I was ready for departure.

My aircraft was pointing SW just before the hold line. The high wing now blocked the approach of the runway I was about to depart. When the tower responded to my radio call, I heard. "Quebec Zulu India......static static garbled....... position". I hesitated but then assumed he had cleared me to taxi to position on the runway. I started to taxi and about 20 feet across the hold line- a little voice said- you better confirm. I stopped the aircraft and I called the tower and asked- Tower Quebec Zulu India - confirm taxi to posi............tion............." At that second an Air Canada B727 went by me on the runway planted on the mains with the nose just touching down. Tower then said- "Your cleared to position now". I'm sure he mutterd "dumb ass" under his breath at the time. Had I not stopped- well I shiver to think of the consequences.

I could not see that big airplane on the approach and touching down because of the wing of my aircraft and the direction my bird was facing. I would have had to look almost behind me to see that B727. But mostly it was because of the lack of discipline I realized I had at that moment. I assumed the controller told me to taxi to position and I didn't do a proper clear approach check to double check. That would have been a major air accident where I would have died and possibly many others also. I am so fortunate to be alive today to tell this story. I sure learned the importance to check the runway in both directions and if any part of a transmission is not crystal clear, I don't move or I ask for confirmation.
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2112
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Re: Remember Tenerife

Post by 2112 »

Scuderia wrote: Wed Dec 02, 2020 12:34 pm One would think that a new SID could be developed instead of modifying or cancelling the assigned one 95% of the time. Not a YYZ exclusive issue either.
This 100%, Flying out of CYTZ 95% of the time there is an amendment to the SID and it's always the same, after departure left turn 180 maintain 3000'. Peasrson I can understand as they want me out of the way (PC-12) But I can see how expectation Bias could play a role with the line up and wait followed immediately by the SID amendment. Stay vigilant no matter how many times you do something.
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A346Dude
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Re: Remember Tenerife

Post by A346Dude »

TSB report is now out for a very similar incident at YYZ.

https://tsb.gc.ca/eng/rapports-reports/ ... o0117.html
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Canoehead
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Re: Remember Tenerife

Post by Canoehead »

From the report:

"As the flight crew of the CRJ 200 lined up in position on Runway 33R and the FO finished the line-up checklist, the captain asked the FO if they had received a take-off clearance. The FO stated that they had."

That should have been the end of it right there.
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PA32pilot
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Re: Remember Tenerife

Post by PA32pilot »

Certainly affirm clearance before entering any runway, but I do appreciate getting information on heading, or heading changes before getting the takeoff clearance to set heading bugs etc. It can make a big difference if you’re departing in low ceilings.
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pelmet
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Re: Remember Tenerife

Post by pelmet »

Canoehead wrote: Sun Jan 17, 2021 2:06 pm From the report:

"As the flight crew of the CRJ 200 lined up in position on Runway 33R and the FO finished the line-up checklist, the captain asked the FO if they had received a take-off clearance. The FO stated that they had."

That should have been the end of it right there.
My rule is.....if any pilot has any doubt(including does not know)....

.....verify with the controller.
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kevenv
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Re: Remember Tenerife

Post by kevenv »

pelmet wrote: Mon Jan 18, 2021 8:57 pm
Canoehead wrote: Sun Jan 17, 2021 2:06 pm From the report:

"As the flight crew of the CRJ 200 lined up in position on Runway 33R and the FO finished the line-up checklist, the captain asked the FO if they had received a take-off clearance. The FO stated that they had."

That should have been the end of it right there.
My rule is.....if any pilot has any doubt(including does not know)....

.....verify with the controller.
As a controller I always advise pilots it's better to ask me if in doubt about anything. I had a pilot from ACA verify/confirm something 3 times apologizing for asking for the 3rd time (it was really early in the morning). I said "it is always better to ask" to which he replied without missing a beat "unless you are flying into LaGuardia". Made me laugh.
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pelmet
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Re: Remember Tenerife

Post by pelmet »

"During normal operations, without any time constraints, the taxi and line-up checklists could take up to 6 minutes to complete."

Findings as to causes and contributing factors
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence:
1. The number of pre-departure tasks the flight crew was required to complete within a short amount of time increased their workload.


Seems odd. Two of the three most recent aircraft I was on had an After Start Checklist done prior to moving forward to taxi followed by a Before Takeoff Checklist when cleared to line up. About 30 seconds each. Could the airline be making their own more complicated procedures, as some have a tendency to do.
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Montroyal
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Re: Remember Tenerife

Post by Montroyal »

Easy to armchair QB...
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