I’ve been doing research on the aviation accident that happened in Tenerife in the Canary Islands, Spain in 1977. This is an absolutely fascinating study in looking at how each element contributed to the fiery crash.

A chain of events is a sequence of events that, occurring consecutively, caused an accident. Had only one or two of these events happened, the accident may not have happened.

It all began with a bomb explosion in the Las Palmas terminal, diverting all flights to Tenerife. The KLM captain opted to let his passengers off the aircraft. Heavy fog rolled in. When it rolled back out, briefly, passengers were not quick to reboard.

From a communications perspective, the dialogue between the air traffic controllers, the KLM pilot, and the Pan Am pilot is a comedy of errors. When people from two aircraft talk on the radio at the same time, squelching occurs. This happened at a critical time when Pam Am stated they were still taxiing down the runway.

We will never know exactly what was rolling through the Captain’s mind … possibly expiring crew duty times, possibly the monies the airline would have to spend if the flight stayed overnight, perhaps “we’ve come this far we need to complete the task” …. was it loss avoidance or a tightly-held commitment?

As in all our lives, it isn’t what you said, it’s what they think they heard.