No Place for an Ego

During my recent sojourn in Germany, I had the ability to command my TiVo digital video recorder at home to save programs for my viewing after I returned. The TiVo is connected to the Internet via a wireless adapter, and sitting in my apartment in Germany I could tell it to save shows I learned about while I was abroad. I didn't do this more than a few times, and it was perhaps as much for the feeling of being connected to my home as anything else. So when I got back there were a few movies and documentaries waiting for me.

Indulging my peculiar fascination with plane crashes, I asked the TiVo to store the PBS/Nova episode "The Deadliest Plane Crash." Airline disasters often combine mystery, physics, profound consequences for slight mistakes or lapses of judgment, and other human frailties into a narrative I find compelling. Despite over 80 years of commercial flight, human nature and regular old nature still find freak ways to interact and cause catastrophe.

Nova's computer-generated portrayal of the Tenerife disaster.

The Nova special concerned what is still the worst plane crash ever. Two Boeing 747s collided on the ground in Tenerife on the Canary Islands in 1977. As with any accident, several rare and unrelated things occurred in close proximity, both temporally and spatially. The full story is complicated, and I recommend clicking on the Nova link above if you're interested in all the details.

I've been most fascinated in this story by the way the pilot of one of the 747s is portrayed. Using a technique now common in documentaries, the Nova special employs actors to re-create key scenes. The actor playing the pilot of the KLM 747, Jacob van Zanten, is shown to be imperious, impatient, concerned less with safety than his reputation for being the airline's best pilot and his prestige in the cockpit. He commences a take-off roll in heavy fog violating standard procedures, and his crew, after weakly challenging him a moment earlier when he had tried the same maneuver, silently allowed him to make the same mistake a second time. A Pan Am 747 was taxiing down the same runway in the fog, looking for the exit onto the taxiway the tower had ordered it to use. Van Zanten ran his plane into the Pan Am machine, killing himself and all the other 247 people on the KLM plane, along with 335 people on the Pan Am plane (there were 61 survivors on the Pan Am 747).

As re-created by Nova, the actor playing KLM First Officer Klaas Meurs casts a questioning glance in the direction of Captain Jacob van Zanten, who is commencing a take-off roll without proper authorization from the tower.

From the documentary, you get the sense that van Zanten was in a hurry to take off because if he didn't get the plane to its intended nearby destination soon, rules would dictate that they would have to spend the night. The airline would have had to pay for hotels for everyone (if rooms could even have been found). As the airline's chief pilot, van Zanten is made to appear very reluctant to endure the loss of face such an expense would mean. But despite Nova's vivid re-creation of the disaster, we'll never know exactly what caused van Zanten to improperly start his take-off roll.

There's a basic conservatism at work in airline safety improvements. They don't generally get made unless there's a clearly demonstrated reason, often involving an actual or a near accident. That means that some passengers and crew members will sacrifice their lives for the safety of all future fliers. Much as I hate to admit it, the approach is probably correct. Routinely tinkering with technology and well-established procedures while only assuming one may be preventing future accidents seems to me to be a good way to introduce lots of potentially deadly unintended consequences, and at huge financial cost, ultimately to be reflected in ticket prices.

For example, after Tenerife, standard terminology was adopted for the first time to describe taxiing procedures (one of the many factors involved in the Tenerife crash was the Pan Am crew's confusion about which exit onto the taxiway the tower had meant for them to use). This may seem like common sense now, but to have mandated such a drastic change throughout the world in how controllers and crews communicate without a reason everyone could readily accept would have been to court resentment, lack of compliance, or outright resistance. No one who has learned about how the two 747s collided could doubt that such new ways of talking were necessary, and as a result there are very probably a lot of people alive today who have been saved from dying in collisions because of the standard terminology.

According to the Nova special, cockpit crew training was also changed after the Tenerife crash. Pilots were supposed to be more open to input from co-pilots (and flight engineers, if they were also on board, as had been the case in van Zanten's plane). This gets back to a lesson generally applicable to every human organization: there needs to be a final authority, but that authority must also insure that it gets the very best information. Those in command must have ways to construct their egos that allow their subordinates to volunteer contradictory facts, interpretations, and points of view. Many other occupations -- teachers, historians, politicians, and generals, just to name a few -- could also benefit from this approach.

An excerpt from Nova's reconstruction of the crash can be viewed here.