The Worst Aviation Accident in History is a Case Study for Giving Employees a Voice

Speaking up can help solve problems faster and prevent disaster.
Do your employees feel comfortable speaking up in a constructive manner? Or do they fly blind with disastrous consequences?

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Speaking up isn’t just a matter of speaking out—of challenging others and being adversarial. It’s a critical tool for solving problems as a team, making smarter decisions, and, sometimes, avoiding disaster.

Consider one case study as a cautionary tale.

The fated flight of KLM 4805

Captain Jacob Van Zanten had a problem.

The terrorist bombing of a flower shop on March 27, 1977, had closed the Las Palmas airport on the neighboring island of Grand Canary, forcing KLM flight 4805 to divert mid-flight to Tenerife. The diversion threatened to put him and his crew over the strict duty time limits imposed by the Dutch government. If they weren’t cleared to fly in time, delays would ripple through KLM and Van Zanten’s passengers might be forced to stay overnight in Tenerife, delaying their cruise vacations.

Van Zanten was KLM airline’s top pilot, head of safety, and the chief flight instructor. He spent the majority of his time training the company’s pilots and his face was on KLM’s advertising around the world. Yet, here his plane was, stuck in a motionless traffic jam outside of his control. The huge 747 was parked at the end of a runway at the tiny island airport, surrounded by other 747s. And then a dense fog settled in.

Shortly after the fog arrived, Las Palmas announced that it had reopened. The small size of the Tenerife airport, the plane traffic congestion on the ground, and the fog presented challenges to the air traffic controllers in the tower. They couldn’t see the planes they were directing and the planes had limited room to maneuver.

The controllers decided to get the KLM 747 to taxi down the runway, turn around, and then take off. The next plane to move, a Pan Am 747, would taxi halfway down the runway behind the KLM plane and then turn off and connect to an adjacent runway.

The Pan Am crew missed the recommended turn and kept moving toward the next exit ramp. Meanwhile, the KLM 747 had reached the end of the runway and turned around. At this point, the controllers were trying to determine where each plane was located in the fog. They were unaware that the planes were facing each other on the same runway, a half a mile apart.

The controllers and other pilots had noticed that Van Zanten was irritable in his radio communications. The pending deadline of the crew’s duty time limit was probably weighing on his mind. And the thickening fog had likely raised his fears that the airport would close. Suddenly, the fog lessened, which prompted Van Zanten to comment that visibility had improved enough to be able to take off. First Officer Meurs noted that they didn’t have clearance to take off, and the captain asked him to get it.

What happened next was confusion. Van Zanten thought he heard the tower give them clearance to take off and he said, “We’re going!” The KLM 747 revved its engines and began rolling down the runway. Flight Engineer Willem Schreuder appeared concerned and asked Van Zanten, “Is he not clear then?”
Van Zanten replied, “What do you say?”

Schreuder asked, “Is he not clear, that Pan American?”

The captain replied, “Oh, yes.” But the Pan Am flight was still taxing down the runway.

The KLM plane picked up speed and emerged from the fog just as the Pan Am plane began to turn onto the exit ramp. Realizing his mistake, Van Zanten tried to take off early but was too low. The landing gear ripped off the top of the Pan Am’s fuselage and the KLM plane hit the runway, skidded and burst into flames, killing all 248 people on board. Some people were able to escape the burning Pan Am plane but 335 people died.

In total, 583 people died in the worst aviation accident in history.

How could they have avoided it?

There were multiple failings on many levels but a key cause of the crash was the inability and the unwillingness of Captain Van Zanten’s subordinates to effectively challenge his actions, despite their concerns over whether the Pan Am flight was clear and uncertain whether they had actually received clearance to take off.

This is what can happen under challenging conditions that have life-or-death stakes with top caliber people. The same thing can, and does, occur on a daily basis within companies and groups where the stakes are much lower, yet still important.

Do your employees feel comfortable challenging others, including their superiors, in a constructive manner? Or do they let them fly blind with disastrous consequences? How can you get your employees to speak up and offer their views when you need them to?

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