The worst accident: “We’re going!” — Forrest Consulting
Why did Tenerife happen?
The massive investigation of and subsequent reports on the Tenerife airport disaster offer deep insight into what happened and what went wrong. As a result, aviation authorities and airlines worldwide changed procedures.
The “what” of the disaster, in retrospect, is obvious, including fog, no centerline lights, language and radio transmission problems, airport overcrowding, delays, a fuel-heavy aircraft and more. But they are insufficient to explain why the KLM 747 collided with the Pan Am 747.
Explaining the “why” of the disaster leads us to our great concern, bad decisions and what to do to avoid them when making a good decision is imperative for a mission-critical outcome.
The “why” questions
Asking “why” with an understanding that people are not perfectly rational beings raises questions about the human factors that led to:
An airport being sited in a place with a prevalence of bad weather.
A ground controller whose English was poor.
Controllers listening to a soccer game while on duty.
Controllers allowing flight operations – indeed, multiple planes – on a runway covered with fog and without centerlights.
Controllers issuing confusing instructions.
Controllers directing the Pan Am aircraft to a taxiway with a sharp turn nearly impossible for the plane to execute.
Controllers not taking more care to assure safe operations in a chaotic situation.
The Pan Am crew’s seeming lack of haste in exiting the runway.
The Pan Am crew’s continuing uncertainty about the correct runway exit taxiway.
Controllers not stopping the KLM 747 when it was clear the Pan Am 747 was lost.
The time pressure on the KLM crew.
KLM’s head pilot seemingly putting economics ahead of safety.
That expert pilot adding the risk of taking off with a full fuel load.
Crew members interpreting route clearance also as takeoff clearance.
The KLM pilot starting takeoff without clear authorization to do so.
That pilot ignoring the concerns of his crew mates.
Crew members who were unclear if takeoff authorization had been issued and worried that the Pan Am flight could still be on the runway but not pressing the point with their captain.
The overall lack of attention to the whole situation rather than immediate details.
My upcoming book, tentatively titled Big Decisions: Why we make decisions that matter so poorly. How we can make them better, will offer answers to most of these questions, through a deep exploration of mental biases, traps, flaws and shortcuts that lead to bad decisions.
At this juncture, just listing the traps and biases that likely enmeshed the actors in the Tenerife disaster gives us a startling sense of the extent to which we are subject to mental traps and biases, most often without any conscious awareness. The many pitfalls that can betray us underscore how important it is for us to dig deeper to understand why we make bad decisions and learn what we can do to make better decisions when it really counts. Without such understanding, the risk of disasters, perhaps lesser but maybe even the equivalent of Tenerife or even greater, will continue to loom in our personal and organizational lives.
Six categories of mental traps and biases
In research for Big Decisions, I have unearthed hundreds of mental traps and biases that skew decision making and, for better understanding, have catalogued them in six major categories:
Psychological. “Processing problems” – Errors occurring as a result of our cognitive biases and mental shortcuts that can lead to systematic deviations from logic, probability or rational choice.
Perception. “Input problems” – Effects and errors in the organization, identification, and interpretation of sensory information that we use to represent and understand the environment around us.
Memory. “Storage and recall problems” – Errors from the process in which information is encoded, stored and retrieved from our brain.
Logical. “Reasoning problems” – Errors arising from making fallacious arguments that are deductively invalid or inductively weak or that contain an unjustified premise or ignore relevant evidence.
Physiological. “Limbic system problems” – Mental processing and judgment shortfalls caused by physical factors that affect the function of our brain, such as arousal, depression and fatigue.
Social. “Interpersonal problems” – Biases and errors stemming from how we view and interact with the people around us, with causes including social categorization, in-group favoritism, prejudice, discrimination and stereotyping.
How the Tenerife actors were swayed
In the Tenerife disaster, initial analysis suggests that the individuals with a role in the horrible outcome were enmeshed by as many as 68 mental traps and biases, in all categories.
The “why” factors that were likely at work that led to the Tenerife airport disaster included at least 36 psychological biases and traps:
Action-oriented bias
Availability heuristic
Backfire effect
Bad news avoidance
Bald man fallacy
Bayesian conservatism
Cognitive dissonance avoidance
Commitment heuristic
Confirmation bias
Emotion
Epistemic arrogance
Escalation of commitment
Familiarity heuristic
Hyperbolic discounting
Illusion of control
Impulsivity
Isolated problem trap
Loss avoidance
Narrow framing
Normalcy bias
Observer effects
Optimism bias
Overconfidence effect
Power
Primacy effects
Priming effects
Probability neglect
Regret aversion
Restraint bias
Risk blindness
Risk compensation
Selective perception
Semmelweis reflex
Serial position effects
Single-effect trap
Subjective validation
The “why” factors also likely included at least six perception traps and biases:
Change blindness
Contrast effect
Fundamental cognitive error
Inattention blindness
Platonicity error
Salience biases
Three memory traps may also help explain the “why” of the Tenerife disaster:
Conservatism or regressive bias
Illusion of truth effect
Suggestibility
The “why” factors also likely involved at least eight logic traps and biases:
Black Swan blindness
Certainty bias
Conjunction fallacy
Hasty generalization
Irrational escalation
Jumping to conclusions
Narrative fallacy
Rule-based decisions
In addition, very likely at work to explain the “why” of the disaster were four physiological effects:
Decision fatigue
High stress
Sleep deprivation
Stimulated limbic system
Lastly, the “why” of the Tenerife airport disaster likely can also be attributed to at least 11 social traps and biases:
Availability cascade
Bandwagon effect
False consensus effect
Group think
Halo effect
Illusion of explanatory depth
Projection bias
Reactance
Reciprocation
Shared information bias
Sunflower management
How we make decisions matters
This telling of the Tenerife disaster story will anchor the introduction of Big Decisions. It serves as an attention-getting account showing why we ought to give great thought to our decision-making process and how to make the big decisions better.
The chapters of Big Decisions that will follow will explore the origins of our mental traps, biases and shortcuts (“Smartphones on the Savannah”), our inability to make rational, optimal decision amidst undecidability and unknowability (“The madness of not knowing”), what leads us to irrational decisions (“Like a lost shepherd, we lead ourselves astray”), and how so many specific traps, biases, errors and shortcuts plague our decision making.
Then Big Decisions will reveal decision-making best practices discovered through research, examine what constitutes a big decision and how to recognize when one is needed, and give examples of some really good decisions. Finally, I will offer an evidence-based process built on best practices that, hopefully, we can consciously use when the necessity for a big decision confronts us or our organization.
Throughout Big Decisions, I will tell many more stories about individuals and organizations whose decision making went off the rails and led to detrimental and even ruinous results. These real-world cases teem with examples of the pernicious effects of mental traps, biases, errors and shortcuts on decision making. Subjects for the stories I intend to tell and analyze include:
Bank of America – Countrywide
Bernie Madoff
Brian Cullinan
Brutus
Cuban Missile Crisis
Custer
Donald Trump
FedEx
Firestone
Flight 370
The French Panama Canal
Fukushima
Galileo
Gettysburg
Google
The Great Powers before World War I
Henry Ford
Hillary Clinton
Kodak
Lehman Brothers
Marissa Meyer
NASA
Rob Hall
Samsung
Uber
The U.S. Panama Canal
Volkswagen
Wells Fargo
Yahoo
Throughout Big Decisions, as the exploration of bad decision making and what to do about it proceeds, I will unfold yet another story. Even compared with Tenerife aircraft disaster, this story scales up the actors and the consequences of bad decisions. You will have to wait for the book to read about and learn from this saga of incredibly bad decision making and ensuring personal and societal damage.
Note: All images are believed to be in the public domain unless otherwise indicated.
Endnotes
[1] “Lessons Learned from Civil Aviation Accidents: KLM Flight 4805 collision with Pan Am Flight 1736 at Tenerife,” Federal Aviation Administration. http://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=52&LLTypeID=2
[2] “The Deadliest Plane Crash,” (https://www.pbs.org/wgbh/nova/transcripts/3315_planecra.html), NOVA, PBS, October 17, 2006. http://www.pbs.org/wgbh/nova/space/deadliest-plane-crash.html
[3] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017 http://www.telegraph.co.uk/travel/comment/tenerife-airport-disaster/
[4] Chris Kilroy, “Special Report: Tenerife,” AirDisaster.com, October 18, 2007. https://web.archive.org/web/20071018035500/http://www.airdisaster.com/special/special-pa1736.shtml
[5] “Lessons Learned from Civil Aviation Accidents: KLM Flight 4805 collision with Pan Am Flight 1736 at Tenerife,” Federal Aviation Administration.
[6] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017
[7] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[8] ALPA Study Group, “Human Factors Report on the Tenerife Accident,” Air Line Pilots Association, 9. https://www.webcitation.org/5zRT8z0Rm?url=http://www.project-tenerife.com/engels/PDF/alpa.pdf P. 14.
[9] ALPA Study Group, “Human Factors Report on the Tenerife Accident,” Air Line Pilots Association, 4.
[10] Kathleen Bangs, “Calamity and Coincidence: 40 Years Later Are We at Risk of Another Tenerife?” disciplesofflight.com, March 29. 2017 https://disciplesofflight.com/remembering-tenerife-airport-disaster/
[11] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[12] “Accident description,” Aviation Safety Network, Flight Safety Foundation. https://aviation-safety.net/database/record.php?id=19770327-1
[13] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[14] “Clipper Victor, 27 March 1977,” This Day in Aviation, March 27, 2017. https://www.thisdayinaviation.com/tag/clipper-victor/
[15] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[16] ALPA Study Group, “Human Factors Report on the Tenerife Accident,” Air Line Pilots Association, 8
[17] “Tenerife 1977 – Why 747 Service to Las Palmas?” Airliners.net, July 29, 2015. http://www.airliners.net/forum/viewtopic.php?t=593183&start=50
[18] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017
[19] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017
[20] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[21] Jan U. Hagen, “KLM Flight 4805: The burden of speaking up,” EMST Knowledge. https://knowledge.esmt.org/sites/default/files/11_hagen_book-klm-flight-4805-final-neu.pdf
[22] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[23] ALPA Study Group, “Human Factors Report on the Tenerife Accident,” Air Line Pilots Association, 7.
[24] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[25] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[26] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[27] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource. https://www.theairlinepilots.com/forumarchive/flightsafety/klmpanamdisaster.php
[28] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017
[29] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[30] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[31] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[32] Jan U. Hagen, “KLM Flight 4805: The burden of speaking up,” EMST Knowledge.
[33] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 40. http://www.project-tenerife.com/engels/PDF/Tenerife.pdf
[34] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[35] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 41.
[36] “Lessons Learned from Civil Aviation Accidents: KLM Flight 4805 collision with Pan Am Flight 1736 at Tenerife,” Federal Aviation Administration.
[37] Kathleen Bangs, “Calamity and Coincidence: 40 Years Later Are We at Risk of Another Tenerife?” disciplesofflight.com, March 29. 2017
[38] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[39] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 49.
[40] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 51.
[41] “Lessons Learned from Civil Aviation Accidents: KLM Flight 4805 collision with Pan Am Flight 1736 at Tenerife,” Federal Aviation Administration.
[42] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[43] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[44] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 47.
[45] “27 March 1977 – KLM 4805 & PanAm 1736,” Cockpit Voice Recorder Database. https://www.tailstrike.com/270377.htm
[46] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017
[47] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 57.
[48] “Accident description,” Aviation Safety Network, Flight Safety Foundation.
[49] “27 March 1977 – KLM 4805 & PanAm 1736,” Cockpit Voice Recorder Database.
[50] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[51] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[52] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 45.
[53] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[54] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[55] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[56] “The Deadliest Plane Crash,” NOVA, PBS, October 17, 2006.
[57] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 26.
[58] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[59] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[60] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 5.
