Aircraft Accident Report

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Aircraft Accident Report AIRCRAFT ACCIDENT REPORT PAN AMERICAN WORLD AIRWAYS BOEING 747, N 737 PA KLM ROYAL DUTCH AIRLINES BOEING 747, PH-BUF TENERIFE, CANARY ISLANDS MARCH 27, 1977 AIR LINE PILOTS ASSOCIATION ENGINEERING AND AIR SAFETY WASHINGTON, D.C. i iIIIIImini• iiiin ?**m ma EMBRY-RIDDLE PfCB co/>y Rb\T5C ?'L£Me, ftsrvA*/ ,<cxa<L, I'fom*' Cb A/o+ DbC«xr(4 l°J u( Q(, INTRODUCTION AND FINDINGS This wafTlT^a^tially survivable accident. Although the decelerative forces were well within t&i^rable limits, the'^integrity of the airframe was compromised by the collision^ The environment of the cabin after the accident rapidly became lethaT because of the high-intensity fire that developed, A summary^.of injuries according to thepo^itions of crew members and passengers is provided in Table I. TABLE I. INJURIES TO THE 396-PERSONS ABOARD THE PAN AM FLIGHT Injuries Crew Members Pas sengers Others Fatal 9 316 0 Non-fatal 7 62* 2** None 0 0 0 * 9 of these passengers subsequently died as a result of accident-related injuries. **Company employees riding ii\ cockpit jump seats. Examination of remains was done to facilitate identification. Cause of death was determined on the b&sis of the presence or absence of soot in the trachea. For a body in which the trachea showed signs of burning and/or the presence of soot, death was assumed to have"resulted from thermal injury. A /' *\ _.,_ ..... _ . / body in which the trachea did~not show evidence of^soot or burning was assumed to have met death as a^result of trauma• The cause of death could not-be determined for bodies without tracheas. Of-326-bodies***-examined from the Includes 1 passenger who died in a hospital following the crash, in addition to 9 crew members and 316 passengers who died in the crash. Pan American aircraft, 212 were positively identified as being one of-the- passengers or crew members of the American aircraft. Five bodies were sub­ sequently identified as belonging to persons manifested as assigned to the KLM aircraft. Four passengers manifested on board the Pan American airplane were subsequently identified among the regains of those persons thought to be traveling on board the KLM airplane. Table II summarizes these results. / TABLE II. ^ - SUMMARY OF ANALYSIS OF CAUSE OF DEATH I. Identified A. Traumatic death (includes 2 crew members) 55 B. Ther. 1 death (includes 4 crew members) 96 C. No determination possible 61 D. Pan American bodies identified by Dutch authorities 4 Subtotal 216 II. Unidentified A. Traumatic death 5 B. Thermal death 22 C. No determination possible 83 Subtotal 110 TOTAL 326 Seating charts were prepared based on the passenger manifest and associated seating assignments provided by Pan American. Seven seating charts were prepared showing seating location for: Figure 1. Traumatic deaths. Figure 2. Thermal deaths--soot in trachea. Figure 3. Unknown cause of death. Figure 4. Unidentified. Figure 5. Identified by Dutch authorities. Figure 6. Survivors. Figure 7. Composite chart. Figure 8. Plan view of aircraft impact. 2 mmmm W \ * three crew members in the cockpit are shown as survivors on thetcha'rt (Fig. 6). Two members were in the lounge and are included in the traumatic injury chart. The other members and two company employees riding jump seats in the cockpit are not shown on the charts, since exact location in the aircraft at time of impact was not known. These include two surviving company employees, two surviving flight attendants, and seven flight attendants who died in the accident (4 identified died from thermal causes and 3 were not identified). The significant findings from..'-these charts which were utilized in making our conclusions are as follows: a. Survivors were clustered in the main deck of the first-class section and in the area at the rear of and behind the left wing root (Figure 6). b. Thermal injuries were clustered in the center (between wings) and in the rear of the aircraft (Figure 2). c. Traumatic injuries were clustered in the first-class lounge, behind and to the right of the mid-ship's section of the aircraft, and in the rear of the tourist section (Figure 1). d. There were no traumatic deaths in the center, between wing positions (Figure 1). e. Seventy-eight percent of the passengers on the right side of the aircraft (impact side—seats H and J from row 20. to rear of aircraft) died from traumatic causes or unknown causes or were unidentified, as compared to 54.5% for passengers on the left side of the aircraft (seats A, B, and C from row 20 I < BOEINO 747 JET CUPPHRS: Dual Configuration 30/343 Stats (373 Salabla* Main Cabin Flral Claaa: M aaala. Zona A: n aaata. Zona B1: 4 aaata. Main Cabin Economy Class: MJ Mala Zona 82: 44 laats Zona C: 99 aaata. Zona D: 82 aaata. Zona E: 114 saata. O C ^ W O • o TRAUMA--N0 SOOT IS TRACHFA ^^^ °oo C, CL — CIOMI 0 O. OAL - Gailay •• • *> UV — Lavatory T - Tabic a»> > -wcNtuom«»pif* *owi it if 5iAis MJH Mov«t i« tsiCAtsoca Ail »H«Of 0 »IAT« MITRlCtfOOfl HO MOVif VISION -NON»MOHia »«» MOW »siAt« A aa FT^=^ IflilliSwmmn* 1-llglslliisjSi . llg^tld feBbS^alQ^aaiHtid isjifsiiaa. , riPST CI A5S J LJS-MIJ L J l_. Armed Forces Institute Qt Pathology V/asMnoton 0 C. BOEING T47 JET CLIPPERS: H Dual Configuration 30/343 Saats (373 S*f*bl*)c O Main Cabin First Clata: » —*. Zor»a A: M MH w Zona 01i 4 *•*)• Main Cabin Economy Claaa: aat a*** Zona B2: «a aaata. Zon% C: n Matt. Zon% Cfc a? aaata. Zona E: 114 aaata. pla, w SOOT IN TRACHEA H C Ct - Ctoaat O. GAL - Galley w LAV - Lavatory c/3 T - Tabla en O O NO* ftMOMN *»«l* - MOM tMOMM Aftf A H RCMS it if MA?«HJK AOWi • «4 AU NAT« "W»IM IS MAT* 01*4 AU BMAMO le*T« NfSr»CT{0 0*MO z MOVI« VISION > O lillllj<rQii§[email protected]§§eiiiiii w iefllSillBl!lllillieg§l§lilHlliIllllll§i§iiie I KT*i I I WMI t% J | gowi w Armed Forces Institute Of Pathology . Washington D. C. Assigned seating positions of those individuals identified and in whom the death could not be determined. FIGURE 3. UNKNOWN CAUSE OF DEATH BOEING 747 JET CLIPPERS: Dual Configuration 30/343 Saata (373 Salabla* Main Cabin Flral Ctatt: *>••••* Zono A: If taata. Zona B1: 4 •*•(•. Main Cabin Economy Claaa: %4*~** CAIISF OF OFATH UNKNOWN WmmWt 4a mil ZonoC: W Mala. Ztawtfc 1} IMU ZonoE: 114 M«ta UNKNOWN CAUSE OF DEATH CCL -Ctoaat o. OAL - o«i»n LAV - Lavatory T -Tabla -woNSMOKCM «ata «o**s n if UAIJ HJ* W»VI u is s»*i$of»a Ul tHAOffO MATt MtTMCTIOOANO MOVIC VtStON iipilpoBliiiiiiiPiill^SliiS liliilililia000Ei 3 fflllillllBlllilllliliillllll'llllllllPigga FIRST CLASS J I JSHJSL i L j ;__. (Cor»l.nu«!J «•«! P«9«l Armed Forces Institute Of Pathology Washington D. C. Assigned seating positions of those individuals not identified. u FIGURE A. UNIDENTIFIED < BOEING 747 JET CLIPPERS Dual Configuration 30AM3 Soils (373 Sotiblo* Main Cabin First Class: is watt Zona A: M •«**. Zono II: 4 Mii Main Cablfi Economy Class: sat aaata. Zono B2: as aaata. Zono C: at taata. Zono D: si Mate. Zono E: IM taata. BBBBa UNIDENTIFIED C.CL -OoMt 0,OAL-OWWy LAV -Lavatory T -Tab*. ra«^Sgllllllli^BIS|BiiBllllS'lllllBIIBiriIlil@lli| 1 fflffl# hF^sNSRl-lPlSiiiiliiiFHJS h r 1111111 IB m i n CIIIHIIB ieiiiiiini iiinein lOaaONMi ««a«t paaaj Arrrsed Forces Institute Of Patliolo WssKi-.gfcon D. C. i »*»m ,*,n» T-lf i " iiiwiMBl nl • • f •••! Assigned seating positions of those individuals discovered among the remains assigned to the KLM aircraft. FIGURE 5. IDENTIFIED BY DUTCH AUTHORITIES BOEINQ 747 JET CUPPERS: Dual Configuration 30/343 Saats (373 Sal.bltjc Main Cabin First Clata: MM««». 1 Zona A: » f*\* 1 ZonaBI: «•«•«• *l 1 Main Cabin Economy Claaa: MlMll HI Zona 82: 4t mil ZonaC: * «•*»•. ZonaD: «•••«» Zonafc 114 Mttfc. Ln W !25 IDENTIFIED WITH DUTCH I I H H CCt -CtoMt *j 0. QAL - 0*U«y H LAV - Uvatory W U W Hi NOM<SMOMfN AMtA *0*S U If SIMS HJK U *>V»S M UStMSOtrO cj H O w WM 'Elllllilillll^lilllllll^iglllllll • <=! H W f Ij^JJ^jgr^U LiblilUyyB^idlJBlaElBaiEiiiyicltiU U UBS He O * H ^ininiiE a@^ni 111118 1111111 H g!»^yyffi*iii M W C/5 _/; » ; J I _JONI J L IConlmue<l C it p*Q«) A»*med rorces Institute Of Pathology Washington D. C. z^&zszaassmt^.. ^^riiiiiinimitfiiiir or Assigned seating positions of those individuals surviving on board the Pan American aircraft. r FIGURE 6. SURVIVORS i *»*?:.?.*?* BOEING 747 JET CLIPPERS: Dual Configuration 30/343 Sttls (373 SatabU* Main Cabin First Clata: » »••<« Zona A: M •»*• Zona Bt: 4 »•*• Main Cabin economy Clata: t«t ••«•* Zona B2: a »Mta. Zona C: M *».U Zona D: u aaata, Zona fc 114 aaata. M O Bn a P J* SURVIVORS CO. -Oo^ 3 0,OAL-0«lWy BBBBOB LAV -UY«1<*> T -TaWa en H <J O cn IlliPP^Qiiiillilieioilllillilio. gllililiglisBBE lEraiiiiBlii^iililU hi tliiii p ililillniiii l MilBiiliL 11—1 Armed Forces Institute Of Pathology Washington D C *3 I i Composite diagram of Figures 1-6. FIGURE 7. COMPOSITE CHART BOEING 747 JET CUPPERS: Dual Configuration 30/343 Saata (373 Salable Main Cabin First Class: Maaata. Zona KL 2* taata. Zona B1: 4 IMll Main Cabin Economy Class: S43 aaata. SURVIVORS Zona 82: 48 taala. Zona C: 99 taata.
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