planeposting

Antarctica is the closest Earth comes to Hell, in my opinion. A vast desert wasteland gripped by unbearable cold year round, so inhospitable that upon discovering it the Polynesians decided it wasn't worth ever going back. Mt. Erebus, a name taken from the personification of darkness in Greek mythology, is a 3,700m active volcano on Ross Island, which also houses McMurdo Station and Scott Base. Even more grim, it was not named directly after the god of darkness- it was named after the HMS Erebus, which would go on to wreck alongside the HMS terror in the infamous third Franklin expedition. Perhaps a grim omen for what would follow on the mountain that bore her name 134 years later.

Due to its inhospitable nature, Antarctica has proven a lasting problem for modern capitalism- how, exactly, do we profit off of it? Nowadays, if you want that real Titanic experience of being trapped in an open-topped lifeboat in freezing water while your ship sinks after colliding with an iceberg, you can pay a company thousands of dollars to go on an Antarctic cruise! But if you were in the groovy 70s, your best bet was to fly to Australia or New Zealand and take a sightseeing flight. Air New Zealand (formerly Tasman Empire Airways Limited or TEAL, which is why the flight number of the accident flight was actually TE901) began offering these flights in 1977, and they were a hit- and no wonder, when you hear when they were like.

The DC-10s would be deliberately underbooked to allow passengers the best view of the windows. Fancy meals and champagne would be served throughout, with the screening of Antarctic-themed movies on the way there. Once you arrived, the sights would be narrated over the PA by a real famous explorer like Sir Edmund Hillary or Peter Mulgrew. This luxurious full-day experience would cost you a total of $359 NZ. These flights were proving incredibly popular, and were scheduled year after year- though rising gas prices meant TE901 may have been the last of its kind.

Of course, these exclusive flights were popular for both passengers and crew, so Captain Jim Collins was surprised and delighted when he was selected to head the final flight of the season. Neither he or his First Officer, Greg Cassin, had flown to Antarctica before. They were briefed on the route, and according to Collins' widow and kids, he'd mediculously plotted it on an atlas the day before the flight to prepare.

The typical flight path of the Antarctic flights called for them to fly next to Beaufort Island, past Cape Bird, and down McMurdo Sound to offer passengers a beautiful view of Ross Island to their left. This makes a lot of sense for a sightseeing flight, as one can descend much lower over open ocean than land, allowing the pilots to visually navigate down the Sound at only a few thousand feet of altitude.

We need to take a detour for a moment to talk about how, exactly, planes navigate. Nowadays, we can follow made up GPS coordinates with our fancy high-accuracy computers and hundreds of sattelites, but way back in ye olden days it was a little more rudimentary. Planes would fly along imaginary routes defined by beacons. For example, a plane might fly towards a named VOR (VHF omnidirectional range) beacon, then turn to fly towards an NDB (non-directional beacon), to put them on course to land. If you're in military airspace, you might even get to tune into a TACAN (tactical air navigation) or VORTAC (VOR and also TAC) beacon. All of these are essentially just radio beacons that go "BEEP BEEP!" and tell your plane where they are, the differences don't matter. If you're an aviation professional, pretend I didn't say that.

But how do you navigate if you've got a really big distance to cover? That's where the fancy newfangled Inertial Navigation System comes in. You could enter the coordinates of your parking spot, boot the machine up, and it would track exactly where your plane is by measuring each movement you made in every direction. By programming it with the coordinates of the beacons you want to hit, the INS could make automatic corrections and fly all by itself. There's a margin of error, of course, which is why the coordinates used would be real radio beacons and not random points in space- so you could correct if your INS was getting a little off course.

On this day, the crew was dealing with some unfortunate cloud cover at around 2,000-3,000ft that was making it hard to spot Beaufort Island. US Air Traffic Controllers based at McMurdo offered a radar service that could get them down to 1,500ft, but Collins realized it wouldn't be necessary, as he spotted a large area clear of clouds. When a plane is under Instrument Flight Rules (IFR), which airliner traffic now always is, they must follow ATC instructions and use their instruments for navigation at all times. While under Visual Flight Rules (VFR), however, planes are free to amble around in clear skies while navigating with their good ol' eyes. Collins' plan was to do a couple of orbits in a figure eight pattern within this area of clear air, which would allow them to get below the cloud cover and continue on visually. While we have learned the hard way that airliners should basically never operate under VFR, in this very specific situation (over the water, in clear skies, while on a sightseeing flight, in an area with zero traffic) it was perfect.

After performing the orbits, they continued on, but since they still hadn't managed to spot any landmarks they could navigate by, they kept following the INS track. They followed it all the way into the side of the looming Mt. Erebus. A sightseers camera caught this ominous final photo at the moment of impact.

McMurdo Station's ATC informed Air New Zealand that they had lost contact with the sightseeing flight. Nervous executives waited for news that wasn't coming. At 6pm, the flight missed its stopover in Christchurch. Families waiting to pick up their loved ones at the airport were told the flight was delayed. As hypothetical fuel supplies dwindled, the worst was confirmed. At 9pm, Air New Zealand informed the nation that the plane, and the 257 people on it, were lost. Around midnight, a US Navy aircraft identified wreckage on the slope of Mt. Erebus. They confirmed there were no survivors.

The expedition to the site, which was named Operation Overdue, was undertaken the next day and lasted nearly a month. Mountain rescue workers and police were flown out to the site to work grueling 12 hour shifts sifting through wreckage, locating body parts and important pieces of wreckage, and preparing them to be shipped back to New Zealand. 44 passengers were never identified, and there were likely remains left at the site of the crash, which has since been designated a gravesite. Many of those involved in the operation suffered from post traumatic stress.

Enter the two main characters of this story. On the left, Ron Chippindale, who is not a 70s-themed male stripper, but rather was appointed the Chief Inspector of Air Accidents in charge of the Office of Air Accidents Investigations in 1975. Much maligned in retellings of this story, I have a soft spot for Chippindale, not least because he shows up in basically every New Zealand air accident case I've ever read about (and several that have nothing to do with New Zealand) and feels like kind of a recurring character. While he'd go on to have a very respectable career, he was ill prepared for this investigation just five years after becoming an investigator.

Chippindale's report would draw from a transcript of the CVR as well as the recovered data from the FDR to put together a cause. All flight systems were functioning normally, and the plane was on track, with the INS coordinates following the flight plan perfectly. He rather incredulously pointed out that the Minimum Safe Altitude (MSA) in the area was 6,000ft. According to the CVR transcript, the pilots were uncertain of their location, descending far too low, and in cloud. Clearly, this was a case of pilot error.

This did not sit well with some people- especially fellow pilots. The idea that these experienced pilots were somehow incompetent enough to fly directly into a mountain without some unknown complicating factor was confusing at best, not to mention that the CVR transcript being used to prove it was questionable. Initially, Air New Zealand pilots had been brought in to help make the transcript, as they could recognize their colleagues' voices. However, Chippindale was not happy with the amount of the transcript that couldn't be deciphered. He shipped the CVR recording off to be analyzed by separate experts, but this version of the transcript introduced massive errors, and all of the evidence of the pilots being unaware of their position was drawn from these sections. One particularly ridiculous line used in defense of this argument had one of the Flight Engineers in the back of the cockpit say "Bit thick there, eh Bert?" despite the fact that nobody on the flight deck was named Bert.

This controvercy led to a Royal Commission of Inquiry being set up, led by the gentleman on the right, Justice Peter Mahon. The longer the investigation got, the more witnesses he interviewed, and the more evidence he uncovered, the more Mahon concluded something unsettling. Air New Zealand knew exactly why the plane crashed, and they had intentionally hidden this fact from the investigators.

Here's what I didn't tell you about the sequence of events, and why the mountain seemed to quite literally come out of nowhere.

On the previous Antarctic flight, the captain was checking his position when he noticed something strange. As he flew down McMurdo Sound visually, his position relative to the McMurdo TACAN, which he expected to be relatively close, wasn't quite right. This wasn't an issue, just something to be aware of on future flights, so he sent a memo letting the ground staff know to make pilots aware that they would notice an offset at this point in the flight.

The source of this error, allegedly, was a mixup of data points. See, when the flight plan was approved by the Civil Aviation Division, it followed a track directly from Cape Hallett to the McMurdo NDB, which would take them over the top of Mt. Erebus. When entering the coordinates in the computer, however, a senior pilot "accidentally" entered a value that would bring the planes over McMurdo Sound. Allegedly. This course was, of course, a far better course to follow on a sightseeing flight, so nobody noticed the "error." This is when another "mistake" happened. The member of staff who recieved the memo from the captain on the previous flight allegedly assumed that he was being asked to change the coordinate from the McMurdo NDB to the McMurdo TACAN, a negligible distance, so he simply corrected this the night before the accident flight. Because this change was so negligible, nobody thought to bring it to the attention of the pilots, who had been briefed the day before on a route that brought them down McMurdo Sound.

In other words, the pilots believed they were over open ocean, but the flight plan had been changed at the last minute, and their autopilot was bringing them directly towards a volcano.

In addition, the altitude issue turned out to be far more complicated than Chippindale told it. While the MSA was in fact 6,000ft, the pilots had been told at the briefing that they could descend to whatever level was approved by McMurdo ATC, and these sightseeing flights regularly flew at exactly the same altitude (or even lower). Not only did other crews attest to this, but it was absolutely known by ANZ management- a personal letter to the CEO of ANZ, which described the low altitude of the plane, had been printed in a magazine funded by ANZ and distributed to every household in the country. The CEO claimed he had never read this.

But if they were in clear conditions, how did the pilots not see the mountain? This was caused by a phenomenon called whiteout, where a cloudy overcast sky and snow covered landscape can create an illusion of a flat horizon. This phenomenon was well known at the time, but the pilots had never been briefed on it, let alone provided training to identify it. In fact, US pilots based at McMurdo were dumbfounded by the lack of experience the sightseeing crews had. Among military operations, you had to have hundreds of hours of flight time in Antarctica to be a captain of a flight there, while Collins had been given command of an Antarctic flight with exactly no experience in Antarctica.

In his explosive final report, printings of which flew off the shelves in the country, Mahon accused the management of Air New Zealand of a vast cover-up. His most famous line would forever be associated with the accident: "I am forced reluctantly to say that I had to listen to an orchestrated litany of lies."

Let's get back down to Earth for a moment. We're going to stop talking about an accident, and now we'e going to talk about conspiracy.

The question of whether Mahon was right is a hard one. Certainly he was right about the altitude, right about the coordinates, right about the CVR. Was he right about a cover up? The New Zealand courts certainly thought he wasn't. While they agreed with the basic premise, they shot down this allegation, calling it a "breach of natural justice" as Mahon's mandate was to find the cause of the crash, not allege misconduct.

However, from a historical perspective we need to pick apart this question a little more, because Mahon's exhasperation at being repeatedly lied to was very well founded.

Remember that paragraph where I kept saying "allegedly?" I'm going to be real with you. Air New Zealand's explanation of how the coordinates were changed sounds like complete horseshit to me. The sheer confluence of errors needed to perfectly align are just... ridiculous. Of course, the flight plan was just coincidentally changed to fly on a much more reasonable path down the Sound, and flight crews just never noticed the "mistake!" And of course, it was just a coincidence that the flight plan was changed back right before the Civil Aviation Division was about to do a regular check through Air New Zealand's operations.

In the opinion of Mahon, and also me, all of this mistake business was covering up the rather banal crime of ANZ not bothering to resubmit their flight plan to the CAD when they realized route to the McMurdo NDB wasn't really the best idea. Nobody in their right mind would make a flight plan for a sightseeing flight go directly over an active volcano, so they moved a single coordinate a little, and the rest is history. Whether the consequent story of the last minute switch was also a lie is beyond me, and frankly, doesn't really matter.

This is where I must diverge from, and also question, the conspiratorial mindset. I'd like to introduce a new logical tool you can use to evaluate conspiracy theories that I call JFK's Razor. "Can this seeming conspiracy be explained by a series of unrelated beaurocratic fuckups and people covering their asses regarding said fuckups?"

I don't doubt that Air New Zealand's CEO was straight up lying to Mahon when he claimed he'd never read the reviews. I don't doubt that the random management pilots who had made various data entry errors had decided not to mention them to Chippindale. And I don't doubt that ANZ executives were sighing with relief when the original inquiry was rushed out by a board with barely any experience investigating large air crashes. It's whether this litany of lies was orchestrated that I doubt.

When it comes down to it, conspiracy theories don't exist to uncover the truth- they exist to make it more palatable. What's really a more disquieting reality to live in? Is it the one where a shady organization conspires to cover up a disaster they caused knowingly, or is it the one where 257 people can be left in pieces on a remote Antarctic volcano by a typo, a misunderstanding of a memo, a little change to a coordinate that surely wouldn't be noticed?

Antarctica is the closest Earth comes to Hell, in my opinion. A vast desert wasteland gripped by unbearable cold year round, so inhospitable that upon discovering it the Polynesians decided it wasn't worth ever going back. Mt. Erebus, a name taken from the personification of darkness in Greek mythology, is a 3,700m active volcano on Ross Island, which also houses McMurdo Station and Scott Base. Even more grim, it was not named directly after the god of darkness- it was named after the HMS Erebus, which would go on to wreck alongside the HMS terror in the infamous third Franklin expedition. Perhaps a grim omen for what would follow on the mountain that bore her name 134 years later.

Due to its inhospitable nature, Antarctica has proven a lasting problem for modern capitalism- how, exactly, do we profit off of it? Nowadays, if you want that real Titanic experience of being trapped in an open-topped lifeboat in freezing water while your ship sinks after colliding with an iceberg, you can pay a company thousands of dollars to go on an Antarctic cruise! But if you were in the groovy 70s, your best bet was to fly to Australia or New Zealand and take a sightseeing flight. Air New Zealand (formerly Tasman Empire Airways Limited or TEAL, which is why the flight number of the accident flight was actually TE901) began offering these flights in 1977, and they were a hit- and no wonder, when you hear when they were like.

The DC-10s would be deliberately underbooked to allow passengers the best view of the windows. Fancy meals and champagne would be served throughout, with the screening of Antarctic-themed movies on the way there. Once you arrived, the sights would be narrated over the PA by a real famous explorer like Sir Edmund Hillary or Peter Mulgrew. This luxurious full-day experience would cost you a total of $359 NZ. These flights were proving incredibly popular, and were scheduled year after year- though rising gas prices meant TE901 may have been the last of its kind.

Of course, these exclusive flights were popular for both passengers and crew, so Captain Jim Collins was surprised and delighted when he was selected to head the final flight of the season. Neither he or his First Officer, Greg Cassin, had flown to Antarctica before. They were briefed on the route, and according to Collins' widow and kids, he'd mediculously plotted it on an atlas the day before the flight to prepare.

The typical flight path of the Antarctic flights called for them to fly next to Beaufort Island, past Cape Bird, and down McMurdo Sound to offer passengers a beautiful view of Ross Island to their left. This makes a lot of sense for a sightseeing flight, as one can descend much lower over open ocean than land, allowing the pilots to visually navigate down the Sound at only a few thousand feet of altitude.

We need to take a detour for a moment to talk about how, exactly, planes navigate. Nowadays, we can follow made up GPS coordinates with our fancy high-accuracy computers and hundreds of sattelites, but way back in ye olden days it was a little more rudimentary. Planes would fly along imaginary routes defined by beacons. For example, a plane might fly towards a named VOR (VHF omnidirectional range) beacon, then turn to fly towards an NDB (non-directional beacon), to put them on course to land. If you're in military airspace, you might even get to tune into a TACAN (tactical air navigation) or VORTAC (VOR and also TAC) beacon. All of these are essentially just radio beacons that go "BEEP BEEP!" and tell your plane where they are, the differences don't matter. If you're an aviation professional, pretend I didn't say that.

But how do you navigate if you've got a really big distance to cover? That's where the fancy newfangled Inertial Navigation System comes in. You could enter the coordinates of your parking spot, boot the machine up, and it would track exactly where your plane is by measuring each movement you made in every direction. By programming it with the coordinates of the beacons you want to hit, the INS could make automatic corrections and fly all by itself. There's a margin of error, of course, which is why the coordinates used would be real radio beacons and not random points in space- so you could correct if your INS was getting a little off course.

On this day, the crew was dealing with some unfortunate cloud cover at around 2,000-3,000ft that was making it hard to spot Beaufort Island. US Air Traffic Controllers based at McMurdo offered a radar service that could get them down to 1,500ft, but Collins realized it wouldn't be necessary, as he spotted a large area clear of clouds. When a plane is under Instrument Flight Rules (IFR), which airliner traffic now always is, they must follow ATC instructions and use their instruments for navigation at all times. While under Visual Flight Rules (VFR), however, planes are free to amble around in clear skies while navigating with their good ol' eyes. Collins' plan was to do a couple of orbits in a figure eight pattern within this area of clear air, which would allow them to get below the cloud cover and continue on visually. While we have learned the hard way that airliners should basically never operate under VFR, in this very specific situation (over the water, in clear skies, while on a sightseeing flight, in an area with zero traffic) it was perfect.

After performing the orbits, they continued on, but since they still hadn't managed to spot any landmarks they could navigate by, they kept following the INS track. They followed it all the way into the side of the looming Mt. Erebus. A sightseers camera caught this ominous final photo at the moment of impact.

McMurdo Station's ATC informed Air New Zealand that they had lost contact with the sightseeing flight. Nervous executives waited for news that wasn't coming. At 6pm, the flight missed its stopover in Christchurch. Families waiting to pick up their loved ones at the airport were told the flight was delayed. As hypothetical fuel supplies dwindled, the worst was confirmed. At 9pm, Air New Zealand informed the nation that the plane, and the 257 people on it, were lost. Around midnight, a US Navy aircraft identified wreckage on the slope of Mt. Erebus. They confirmed there were no survivors.

The expedition to the site, which was named Operation Overdue, was undertaken the next day and lasted nearly a month. Mountain rescue workers and police were flown out to the site to work grueling 12 hour shifts sifting through wreckage, locating body parts and important pieces of wreckage, and preparing them to be shipped back to New Zealand. 44 passengers were never identified, and there were likely remains left at the site of the crash, which has since been designated a gravesite. Many of those involved in the operation suffered from post traumatic stress.

Enter the two main characters of this story. On the left, Ron Chippindale, who is not a 70s-themed male stripper, but rather was appointed the Chief Inspector of Air Accidents in charge of the Office of Air Accidents Investigations in 1975. Much maligned in retellings of this story, I have a soft spot for Chippindale, not least because he shows up in basically every New Zealand air accident case I've ever read about (and several that have nothing to do with New Zealand) and feels like kind of a recurring character. While he'd go on to have a very respectable career, he was ill prepared for this investigation just five years after becoming an investigator.

Chippindale's report would draw from a transcript of the CVR as well as the recovered data from the FDR to put together a cause. All flight systems were functioning normally, and the plane was on track, with the INS coordinates following the flight plan perfectly. He rather incredulously pointed out that the Minimum Safe Altitude (MSA) in the area was 6,000ft. According to the CVR transcript, the pilots were uncertain of their location, descending far too low, and in cloud. Clearly, this was a case of pilot error.

This did not sit well with some people- especially fellow pilots. The idea that these experienced pilots were somehow incompetent enough to fly directly into a mountain without some unknown complicating factor was confusing at best, not to mention that the CVR transcript being used to prove it was questionable. Initially, Air New Zealand pilots had been brought in to help make the transcript, as they could recognize their colleagues' voices. However, Chippindale was not happy with the amount of the transcript that couldn't be deciphered. He shipped the CVR recording off to be analyzed by separate experts, but this version of the transcript introduced massive errors, and all of the evidence of the pilots being unaware of their position was drawn from these sections. One particularly ridiculous line used in defense of this argument had one of the Flight Engineers in the back of the cockpit say "Bit thick there, eh Bert?" despite the fact that nobody on the flight deck was named Bert.

This controvercy led to a Royal Commission of Inquiry being set up, led by the gentleman on the right, Justice Peter Mahon. The longer the investigation got, the more witnesses he interviewed, and the more evidence he uncovered, the more Mahon concluded something unsettling. Air New Zealand knew exactly why the plane crashed, and they had intentionally hidden this fact from the investigators.

Here's what I didn't tell you about the sequence of events, and why the mountain seemed to quite literally come out of nowhere.

On the previous Antarctic flight, the captain was checking his position when he noticed something strange. As he flew down McMurdo Sound visually, his position relative to the McMurdo TACAN, which he expected to be relatively close, wasn't quite right. This wasn't an issue, just something to be aware of on future flights, so he sent a memo letting the ground staff know to make pilots aware that they would notice an offset at this point in the flight.

The source of this error, allegedly, was a mixup of data points. See, when the flight plan was approved by the Civil Aviation Division, it followed a track directly from Cape Hallett to the McMurdo NDB, which would take them over the top of Mt. Erebus. When entering the coordinates in the computer, however, a senior pilot "accidentally" entered a value that would bring the planes over McMurdo Sound. Allegedly. This course was, of course, a far better course to follow on a sightseeing flight, so nobody noticed the "error." This is when another "mistake" happened. The member of staff who recieved the memo from the captain on the previous flight allegedly assumed that he was being asked to change the coordinate from the McMurdo NDB to the McMurdo TACAN, a negligible distance, so he simply corrected this the night before the accident flight. Because this change was so negligible, nobody thought to bring it to the attention of the pilots, who had been briefed the day before on a route that brought them down McMurdo Sound.

In other words, the pilots believed they were over open ocean, but the flight plan had been changed at the last minute, and their autopilot was bringing them directly towards a volcano.

In addition, the altitude issue turned out to be far more complicated than Chippindale told it. While the MSA was in fact 6,000ft, the pilots had been told at the briefing that they could descend to whatever level was approved by McMurdo ATC, and these sightseeing flights regularly flew at exactly the same altitude (or even lower). Not only did other crews attest to this, but it was absolutely known by ANZ management- a personal letter to the CEO of ANZ, which described the low altitude of the plane, had been printed in a magazine funded by ANZ and distributed to every household in the country. The CEO claimed he had never read this.

But if they were in clear conditions, how did the pilots not see the mountain? This was caused by a phenomenon called whiteout, where a cloudy overcast sky and snow covered landscape can create an illusion of a flat horizon. This phenomenon was well known at the time, but the pilots had never been briefed on it, let alone provided training to identify it. In fact, US pilots based at McMurdo were dumbfounded by the lack of experience the sightseeing crews had. Among military operations, you had to have hundreds of hours of flight time in Antarctica to be a captain of a flight there, while Collins had been given command of an Antarctic flight with exactly no experience in Antarctica.

In his explosive final report, printings of which flew off the shelves in the country, Mahon accused the management of Air New Zealand of a vast cover-up. His most famous line would forever be associated with the accident: "I am forced reluctantly to say that I had to listen to an orchestrated litany of lies."

Let's get back down to Earth for a moment. We're going to stop talking about an accident, and now we'e going to talk about conspiracy.

The question of whether Mahon was right is a hard one. Certainly he was right about the altitude, right about the coordinates, right about the CVR. Was he right about a cover up? The New Zealand courts certainly thought he wasn't. While they agreed with the basic premise, they shot down this allegation, calling it a "breach of natural justice" as Mahon's mandate was to find the cause of the crash, not allege misconduct.

However, from a historical perspective we need to pick apart this question a little more, because Mahon's exhasperation at being repeatedly lied to was very well founded.

Remember that paragraph where I kept saying "allegedly?" I'm going to be real with you. Air New Zealand's explanation of how the coordinates were changed sounds like complete horseshit to me. The sheer confluence of errors needed to perfectly align are just... ridiculous. Of course, the flight plan was just coincidentally changed to fly on a much more reasonable path down the Sound, and flight crews just never noticed the "mistake!" And of course, it was just a coincidence that the flight plan was changed back right before the Civil Aviation Division was about to do a regular check through Air New Zealand's operations.

In the opinion of Mahon, and also me, all of this mistake business was covering up the rather banal crime of ANZ not bothering to resubmit their flight plan to the CAD when they realized route to the McMurdo NDB wasn't really the best idea. Nobody in their right mind would make a flight plan for a sightseeing flight go directly over an active volcano, so they moved a single coordinate a little, and the rest is history. Whether the consequent story of the last minute switch was also a lie is beyond me, and frankly, doesn't really matter.

This is where I must diverge from, and also question, the conspiratorial mindset. I'd like to introduce a new logical tool you can use to evaluate conspiracy theories that I call JFK's Razor. "Can this seeming conspiracy be explained by a series of unrelated beaurocratic fuckups and people covering their asses regarding said fuckups?"

I don't doubt that Air New Zealand's CEO was straight up lying to Mahon when he claimed he'd never read the reviews. I don't doubt that the random management pilots who had made various data entry errors had decided not to mention them to Chippindale. And I don't doubt that ANZ executives were sighing with relief when the original inquiry was rushed out by a board with barely any experience investigating large air crashes. It's whether this litany of lies was orchestrated that I doubt.

When it comes down to it, conspiracy theories don't exist to uncover the truth- they exist to make it more palatable. What's really a more disquieting reality to live in? Is it the one where a shady organization conspires to cover up a disaster they caused knowingly, or is it the one where 257 people can be left in pieces on a remote Antarctic volcano by a typo, a misunderstanding of a memo, a little change to a coordinate that surely wouldn't be noticed?

Antarctica is the closest Earth comes to Hell, in my opinion. A vast desert wasteland gripped by unbearable cold year round, so inhospitable that upon discovering it the Polynesians decided it wasn't worth ever going back. Mt. Erebus, a name taken from the personification of darkness in Greek mythology, is a 3,700m active volcano on Ross Island, which also houses McMurdo Station and Scott Base. Even more grim, it was not named directly after the god of darkness- it was named after the HMS Erebus, which would go on to wreck alongside the HMS terror in the infamous third Franklin expedition. Perhaps a grim omen for what would follow on the mountain that bore her name 134 years later.

Due to its inhospitable nature, Antarctica has proven a lasting problem for modern capitalism- how, exactly, do we profit off of it? Nowadays, if you want that real Titanic experience of being trapped in an open-topped lifeboat in freezing water while your ship sinks after colliding with an iceberg, you can pay a company thousands of dollars to go on an Antarctic cruise! But if you were in the groovy 70s, your best bet was to fly to Australia or New Zealand and take a sightseeing flight. Air New Zealand (formerly Tasman Empire Airways Limited or TEAL, which is why the flight number of the accident flight was actually TE901) began offering these flights in 1977, and they were a hit- and no wonder, when you hear when they were like.

The DC-10s would be deliberately underbooked to allow passengers the best view of the windows. Fancy meals and champagne would be served throughout, with the screening of Antarctic-themed movies on the way there. Once you arrived, the sights would be narrated over the PA by a real famous explorer like Sir Edmund Hillary or Peter Mulgrew. This luxurious full-day experience would cost you a total of $359 NZ. These flights were proving incredibly popular, and were scheduled year after year- though rising gas prices meant TE901 may have been the last of its kind.

Of course, these exclusive flights were popular for both passengers and crew, so Captain Jim Collins was surprised and delighted when he was selected to head the final flight of the season. Neither he or his First Officer, Greg Cassin, had flown to Antarctica before. They were briefed on the route, and according to Collins' widow and kids, he'd mediculously plotted it on an atlas the day before the flight to prepare.

The typical flight path of the Antarctic flights called for them to fly next to Beaufort Island, past Cape Bird, and down McMurdo Sound to offer passengers a beautiful view of Ross Island to their left. This makes a lot of sense for a sightseeing flight, as one can descend much lower over open ocean than land, allowing the pilots to visually navigate down the Sound at only a few thousand feet of altitude.

We need to take a detour for a moment to talk about how, exactly, planes navigate. Nowadays, we can follow made up GPS coordinates with our fancy high-accuracy computers and hundreds of sattelites, but way back in ye olden days it was a little more rudimentary. Planes would fly along imaginary routes defined by beacons. For example, a plane might fly towards a named VOR (VHF omnidirectional range) beacon, then turn to fly towards an NDB (non-directional beacon), to put them on course to land. If you're in military airspace, you might even get to tune into a TACAN (tactical air navigation) or VORTAC (VOR and also TAC) beacon. All of these are essentially just radio beacons that go "BEEP BEEP!" and tell your plane where they are, the differences don't matter. If you're an aviation professional, pretend I didn't say that.

But how do you navigate if you've got a really big distance to cover? That's where the fancy newfangled Inertial Navigation System comes in. You could enter the coordinates of your parking spot, boot the machine up, and it would track exactly where your plane is by measuring each movement you made in every direction. By programming it with the coordinates of the beacons you want to hit, the INS could make automatic corrections and fly all by itself. There's a margin of error, of course, which is why the coordinates used would be real radio beacons and not random points in space- so you could correct if your INS was getting a little off course.

On this day, the crew was dealing with some unfortunate cloud cover at around 2,000-3,000ft that was making it hard to spot Beaufort Island. US Air Traffic Controllers based at McMurdo offered a radar service that could get them down to 1,500ft, but Collins realized it wouldn't be necessary, as he spotted a large area clear of clouds. When a plane is under Instrument Flight Rules (IFR), which airliner traffic now always is, they must follow ATC instructions and use their instruments for navigation at all times. While under Visual Flight Rules (VFR), however, planes are free to amble around in clear skies while navigating with their good ol' eyes. Collins' plan was to do a couple of orbits in a figure eight pattern within this area of clear air, which would allow them to get below the cloud cover and continue on visually. While we have learned the hard way that airliners should basically never operate under VFR, in this very specific situation (over the water, in clear skies, while on a sightseeing flight, in an area with zero traffic) it was perfect.

After performing the orbits, they continued on, but since they still hadn't managed to spot any landmarks they could navigate by, they kept following the INS track. They followed it all the way into the side of the looming Mt. Erebus. A sightseers camera caught this ominous final photo at the moment of impact.

McMurdo Station's ATC informed Air New Zealand that they had lost contact with the sightseeing flight. Nervous executives waited for news that wasn't coming. At 6pm, the flight missed its stopover in Christchurch. Families waiting to pick up their loved ones at the airport were told the flight was delayed. As hypothetical fuel supplies dwindled, the worst was confirmed. At 9pm, Air New Zealand informed the nation that the plane, and the 257 people on it, were lost. Around midnight, a US Navy aircraft identified wreckage on the slope of Mt. Erebus. They confirmed there were no survivors.

The expedition to the site, which was named Operation Overdue, was undertaken the next day and lasted nearly a month. Mountain rescue workers and police were flown out to the site to work grueling 12 hour shifts sifting through wreckage, locating body parts and important pieces of wreckage, and preparing them to be shipped back to New Zealand. 44 passengers were never identified, and there were likely remains left at the site of the crash, which has since been designated a gravesite. Many of those involved in the operation suffered from post traumatic stress.

Enter the two main characters of this story. On the left, Ron Chippindale, who is not a 70s-themed male stripper, but rather was appointed the Chief Inspector of Air Accidents in charge of the Office of Air Accidents Investigations in 1975. Much maligned in retellings of this story, I have a soft spot for Chippindale, not least because he shows up in basically every New Zealand air accident case I've ever read about (and several that have nothing to do with New Zealand) and feels like kind of a recurring character. While he'd go on to have a very respectable career, he was ill prepared for this investigation just five years after becoming an investigator.

Chippindale's report would draw from a transcript of the CVR as well as the recovered data from the FDR to put together a cause. All flight systems were functioning normally, and the plane was on track, with the INS coordinates following the flight plan perfectly. He rather incredulously pointed out that the Minimum Safe Altitude (MSA) in the area was 6,000ft. According to the CVR transcript, the pilots were uncertain of their location, descending far too low, and in cloud. Clearly, this was a case of pilot error.

This did not sit well with some people- especially fellow pilots. The idea that these experienced pilots were somehow incompetent enough to fly directly into a mountain without some unknown complicating factor was confusing at best, not to mention that the CVR transcript being used to prove it was questionable. Initially, Air New Zealand pilots had been brought in to help make the transcript, as they could recognize their colleagues' voices. However, Chippindale was not happy with the amount of the transcript that couldn't be deciphered. He shipped the CVR recording off to be analyzed by separate experts, but this version of the transcript introduced massive errors, and all of the evidence of the pilots being unaware of their position was drawn from these sections. One particularly ridiculous line used in defense of this argument had one of the Flight Engineers in the back of the cockpit say "Bit thick there, eh Bert?" despite the fact that nobody on the flight deck was named Bert.

This controvercy led to a Royal Commission of Inquiry being set up, led by the gentleman on the right, Justice Peter Mahon. The longer the investigation got, the more witnesses he interviewed, and the more evidence he uncovered, the more Mahon concluded something unsettling. Air New Zealand knew exactly why the plane crashed, and they had intentionally hidden this fact from the investigators.

Here's what I didn't tell you about the sequence of events, and why the mountain seemed to quite literally come out of nowhere.

On the previous Antarctic flight, the captain was checking his position when he noticed something strange. As he flew down McMurdo Sound visually, his position relative to the McMurdo TACAN, which he expected to be relatively close, wasn't quite right. This wasn't an issue, just something to be aware of on future flights, so he sent a memo letting the ground staff know to make pilots aware that they would notice an offset at this point in the flight.

The source of this error, allegedly, was a mixup of data points. See, when the flight plan was approved by the Civil Aviation Division, it followed a track directly from Cape Hallett to the McMurdo NDB, which would take them over the top of Mt. Erebus. When entering the coordinates in the computer, however, a senior pilot "accidentally" entered a value that would bring the planes over McMurdo Sound. Allegedly. This course was, of course, a far better course to follow on a sightseeing flight, so nobody noticed the "error." This is when another "mistake" happened. The member of staff who recieved the memo from the captain on the previous flight allegedly assumed that he was being asked to change the coordinate from the McMurdo NDB to the McMurdo TACAN, a negligible distance, so he simply corrected this the night before the accident flight. Because this change was so negligible, nobody thought to bring it to the attention of the pilots, who had been briefed the day before on a route that brought them down McMurdo Sound.

In other words, the pilots believed they were over open ocean, but the flight plan had been changed at the last minute, and their autopilot was bringing them directly towards a volcano.

In addition, the altitude issue turned out to be far more complicated than Chippindale told it. While the MSA was in fact 6,000ft, the pilots had been told at the briefing that they could descend to whatever level was approved by McMurdo ATC, and these sightseeing flights regularly flew at exactly the same altitude (or even lower). Not only did other crews attest to this, but it was absolutely known by ANZ management- a personal letter to the CEO of ANZ, which described the low altitude of the plane, had been printed in a magazine funded by ANZ and distributed to every household in the country. The CEO claimed he had never read this.

But if they were in clear conditions, how did the pilots not see the mountain? This was caused by a phenomenon called whiteout, where a cloudy overcast sky and snow covered landscape can create an illusion of a flat horizon. This phenomenon was well known at the time, but the pilots had never been briefed on it, let alone provided training to identify it. In fact, US pilots based at McMurdo were dumbfounded by the lack of experience the sightseeing crews had. Among military operations, you had to have hundreds of hours of flight time in Antarctica to be a captain of a flight there, while Collins had been given command of an Antarctic flight with exactly no experience in Antarctica.

In his explosive final report, printings of which flew off the shelves in the country, Mahon accused the management of Air New Zealand of a vast cover-up. His most famous line would forever be associated with the accident: "I am forced reluctantly to say that I had to listen to an orchestrated litany of lies."

Let's get back down to Earth for a moment. We're going to stop talking about an accident, and now we'e going to talk about conspiracy.

The question of whether Mahon was right is a hard one. Certainly he was right about the altitude, right about the coordinates, right about the CVR. Was he right about a cover up? The New Zealand courts certainly thought he wasn't. While they agreed with the basic premise, they shot down this allegation, calling it a "breach of natural justice" as Mahon's mandate was to find the cause of the crash, not allege misconduct.

However, from a historical perspective we need to pick apart this question a little more, because Mahon's exhasperation at being repeatedly lied to was very well founded.

Remember that paragraph where I kept saying "allegedly?" I'm going to be real with you. Air New Zealand's explanation of how the coordinates were changed sounds like complete horseshit to me. The sheer confluence of errors needed to perfectly align are just... ridiculous. Of course, the flight plan was just coincidentally changed to fly on a much more reasonable path down the Sound, and flight crews just never noticed the "mistake!" And of course, it was just a coincidence that the flight plan was changed back right before the Civil Aviation Division was about to do a regular check through Air New Zealand's operations.

In the opinion of Mahon, and also me, all of this mistake business was covering up the rather banal crime of ANZ not bothering to resubmit their flight plan to the CAD when they realized route to the McMurdo NDB wasn't really the best idea. Nobody in their right mind would make a flight plan for a sightseeing flight go directly over an active volcano, so they moved a single coordinate a little, and the rest is history. Whether the consequent story of the last minute switch was also a lie is beyond me, and frankly, doesn't really matter.

This is where I must diverge from, and also question, the conspiratorial mindset. I'd like to introduce a new logical tool you can use to evaluate conspiracy theories that I call JFK's Razor. "Can this seeming conspiracy be explained by a series of unrelated beaurocratic fuckups and people covering their asses regarding said fuckups?"

I don't doubt that Air New Zealand's CEO was straight up lying to Mahon when he claimed he'd never read the reviews. I don't doubt that the random management pilots who had made various data entry errors had decided not to mention them to Chippindale. And I don't doubt that ANZ executives were sighing with relief when the original inquiry was rushed out by a board with barely any experience investigating large air crashes. It's whether this litany of lies was orchestrated that I doubt.

When it comes down to it, conspiracy theories don't exist to uncover the truth- they exist to make it more palatable. What's really a more disquieting reality to live in? Is it the one where a shady organization conspires to cover up a disaster they caused knowingly, or is it the one where 257 people can be left in pieces on a remote Antarctic volcano by a typo, a misunderstanding of a memo, a little change to a coordinate that surely wouldn't be noticed?

It was July 7th, 2017, at around midnight local time in San Francisco. The Air Canada pilots had been working a grueling schedule, with the Captain reportedly having been awake for 19 straight hours. They were cleared for a visual approach to Runway 28R. While San Francisco's airspace is notoriously busy, there were few flights coming in this late- only one controller was working, and he reported his workload was perfectly normal. Four flights, three United Airlines planes and a Phillipine Airlines plane, were lined up on taxiway C waiting for their chance to take off.

Now, SFO's runway 28L/10R was undergoing some resurfacing work in 2017, projected to take about 10 months. The runway wasn't always closed, but it would be closed during the nights to accomodate that work. When a runway is closed, there are strict guidelines- the normal lighting must be shut off, while a large flashing X must be placed at the threshold to show it is not in use. All of this was in place. The closure was listed in the airport's NOTAMs, or Notice to Airmen, a huge list of operational information the pilots are required to review before leaving. It can be hard to pick out which NOTAMs will actually impact the flight, and on this day, the Air Canada pilots had missed or glossed over the runway closure NOTAM.

As the approach was visual, the pilots needed to manually line up with the runway- but visual approaches are still standardized. In this case, they were using Air Canada's FMS Bridge approach, which was the only Air Canada approach that required the pilots to manually tune the Instrument Landing System frequency- a step that the First Officer missed. While the ILS would obviously not be used, having it tuned would provide the pilots with extra information, and seeing their offset from the localizer would surely have alerted them of a potential issue.

And finally, Air Canada had the Enchanced Ground Proximity Warning System in their aircraft, but didn't have the optional Runway Alerting and Awareness System installed. The RAAS helps pilots out by alerting them to which runways they're lined up with. Without it, the pilots were expected to figure this out by... y'now. Following the approach correctly and not making a huge mistake.

With no knowledge of the closure of Runway 28L, the pilots were expecting to see two runway-like lines of lights next to each other and line up with the rightmost set. So they did. While the lighting on a taxiway doesn't really resemble the lighting on a runway at all, as shown above, the several planes lined up with lights on their wings and bodies active may have given the illusion of edge lighting.

As you can hear in the video, the Air Canada pilots noticed something strange about the lighting and checked in with the controller. Their first thought, clouded by confirmation bias, was that this strange lighting indicated somebody was on the runway trying to take off. As they got closer, however, it became clear to everyone involved that something was incredibly wrong. In quick succession, a pilot in one of the planes on the ground expressed disbelief at the Air Canada's position, the Captain initiated a go-around, the First Officer called for a go-around, and the tower controller called for a go-around. While this is sometimes described as the United pilots averting catastrophe, it seems both the Air Canada pilots and the controller independently identified the problem on their own. Three different people directly called for a go-around based on their own assessment and all three of those commands would have been in time to avert disaster, so the system really did its job here. But man, does it feel like that???

The NTSB report recommended that aircraft be required to be equipped with systems like RAAS that would alert pilots to taxiway landings, control towers be equipped with alerting systems capable of detecting possible taxiway landings, 25 hour CVRs being mandated on all aircraft, as well as rest requirements in Canada being improved. The response has been mixed, but overall decently positive? Canada's rest requirements were amended swiftly, but according to the pilot's union, the new requirements still aren't strict enough. The FAA has since equipped 43 major airports with the described alerting systems, a rare FAA W. They also claimed that doing this meant they didn't need to mandate RAAS, which is like, kind of missing the point given that the planes are also flying to places that aren't those 43 US airports... but the NTSB called this one "Open- Acceptable Response." I assume the NTSB's bar is so low that the FAA reading their recommendations within a 3 year time span is considered Open- Acceptable Response.

Overall, it's hard to quanlify this one. In some ways, having read the report and seeing concrete steps that could be taken to avoid this makes me feel a bit more reassured. On the other hand, I still wonder... if this was possible in the first place, with so many layers of swiss cheese being breached, how do we know these next few layers are gonna help? My throughts are drawn to incidents like the Singapore Airways runway collision, where it feels like such obvious signs could be missed out of the sheer random obliviousness of the human mind. Are we just one stupid moment away from a second Tenerife at all moments?

The eponymous airport on the island of Gran Canaria was the main hub for travel in and out of the colonized African archipelago. That made it a logical target for the Fuerzas Armadas Guanches, the armed division of the MPAIAC, fighting for an end to Spanish colonial rule. That day, a man placed a bomb in a duffel bag inside the airport terminal. The group called in to alert the authorities, but the building wasn't quite evacuated in time, leading to one airport worker being injured in the explosion. Knowing that multiple bombs may have been placed, local authorities shut the airport down to do a thorough search. As the terrorists intended, traffic in and out of the island ceased, and the planes en route to Gran Canaria were diverted to the nearby island of Tenerife.

Los Rodeos Airport was well enough equipped for landings and takeoffs by the occasional large jet, but its capacity could not possibly keep up with the demand that day. Aircraft filled the small apron and spilled out into the taxiways as exhausted tourists disembarked and roamed the small terminal building. Just minutes away from their destination, the pilots had no idea how long it would take for the airport in Gran Canaria to reopen, and their duty times were slowly ticking away.

Limits on how long a pilot is allowed to work are pretty self explanatory. If you wouldn't drive to the convenience store at 3am on 2 hours of sleep from the previous night, you probably wouldn't want your pilot doing that either. However, the Netherlands had recently enacted a pretty questionable law which could charge pilots with a felony if they exceeded these limits, which was weighing hard on the mind of the very senior pilot behind the controls of a KLM 747.

Captain Jacob van Zanten was, by all accounts, an excellent pilot. He headed the airline's training program and spent more of his time mentoring other pilots in the simulator than flying passengers these days. This duty was almost a formality, as pilots must have a minimum number of real flight hours to maintain their licenses. The flight to Gran Canaria and back would fill this requirement for him, but with this extra delay and the frankly bullshit law that his home country had put in place, it could also land him in jail. He made a strategic decision to disembark the passengers and begin refuelling for the trip back while at Los Rodeos, to cut down on turnover times later.

This decision was certainly not appreciated by the pilots of a Pan Am 747 parked on the taxiway behind him. When the airport at Gran Canaria reopened and jets began streaming out, Captain Victor Grubbs on the Pan Am flight found himself trapped by the refuelling KLM. He and his First Officer actually climbed out of the plane to evaluate the distance on foot just in case they could barely maneuver around the other aircraft, but to no avail- they were meters short of the clearance needed on the small taxiways at Tenerife.

That day, the overworked ground controller was struggling to manage all of the unexpected traffic and sequence them for takeoff. Since the taxiways were already filled with parked aircraft, he had to instruct some to back-taxi down the whole length of the runway and turn around in order to take off. To make things worse, fog was rolling over the airport- at times there was okay visibility, but most of the time he couldn't see the planes he was directing. Without radar, he had to track them all using rudimentary flight strips and a mental map.

Once all the passengers had been wrangled back to the KLM, the controller instructed them to taxi to the end of the runway and into the takeoff position. In the meantime, he intended to have the waiting Pan Am taxi most of the way down the runway and exit onto taxiway three to wait for their chance.

As they taxied slowly down the runway engulfed in fog, the mood in the cockpit of the Pan Am was sour. They been waiting far longer than they needed, and now they were moving down an occupied runway while barely able to see the exits as they passed. When they spotted the exit to taxiway 3, they were puzzled- by their judgement, the steep acute angle they'd have to turn to enter it wasn't possible. Perhaps the controller had meant the third taxiway from their position, which would be taxiway four? Of course, he had not meant this- he had no radar to tell where the Pan Am flight was. He simply was not familiar enough with the 747 to know it could not accomodate such a tight turn.

While the Pan Am crawled down the runway, the KLM had made its turn and the pilots were rushing through the takeoff checklist. In fact, Captain van Zanten increased the throttles and was reminded they had yet to recieve clearance. Of course. He instructed the First Officer to ask for it now.

At this point in the story, the exact wordings start to become very, very important. Pay attention.

KLM F/O: "The KLM four eight zero five is now ready for take-off and we are waiting for our ATC clearance."

TOWER: "KLM eight seven zero five you are cleared to the Papa beacon, climb to and maintain flight level nine zero, right turn after takeoff, proceed with heading four zero until intercepting the three two five radial from Las Palmas VOR."

...did you catch that? The mental models have started diverging. "ATC clearance" is the route the plane is cleared to follow after getting airborne, but it is not takeoff clearance. However, these clearances are often provided at the same time. Because the controller used the word "takeoff" in his route instructions, the pilots on board the KLM flight mistakenly believed he was providing takeoff clearance. This may seem like a difficult mistake to make, but after a long work day with an unplanned stopover and with the threat of jail time or a logistical nightmare if you delay, it's a mistake you might make too.

After reading back the clearance, the KLM First Officer says a line that nobody can quite decipher- either "We are at takeoff" or "We are, uh, taking off." Whatever he said, this raised the attention of both the controller and the Pan Am crew, who each sought to clear up the confusion.

TOWER: "Okay.... Stand by for takeoff, I will call you."

PAN AM F/O: "And we're still taxiing down the runway, the clipper one seven three six."

However, a tragic coincidence sealed their fate. Since the controller hesitated slightly after saying "okay," the Pan Am First Officer transmitted his message before the controller was finished. On traditional radio systems, if you are transmitting, you can't hear any other transmissions, so neither party realized they had been speaking at the same time. In the cockpit of the KLM, already starting the roll, the crew heard this:

TOWER: "Okay."

[Unintelligible static]

PAN AM F/O: "Clipper one seven three six."

There was one last chance to realize their mistake, although by this point it may not have saved them.

TOWER: "Ah, Papa Alpha one seven three six, report the runway clear."

PAN AM F/O: "Okay, we'll report when clear."

While the Pan Am pilots complained about the KLM's sudden rush after they'd held up the line so long, the flight engineer on the KLM posed a question in Dutch- is he not clear then, that Pan American? Captain van Zanten reassured him in a way the transcript deacribes as "emphatic."

When the Pan Am pilots caught sight of the lights through the fog, they tried to taxi off the runway into the grass to no avail. Meanwhile, spotting the Pan Am, Captain van Zanten made the fateful (yet possibly correct) decision to attempt to take off early. The tail struck the runway and the engine smashed into the Pan Am's upper deck, leading the damaged KLM to stall and slam back into the runway, where the fuel exploded. While much of the Pan Am was damaged and engulfed by flames, 61 survivors managed to escape. The decision to attempt a takeoff may have killed the KLM crew, but if they hadn't, there may have been no survivors.

This is where our story leaves the realm of objective fact and becomes one of conjecture. After all, 583 people were now dead. Whose fault was it?

The punitive mindset pervades our modern world. We are animals, after all, and our advancement has only given us more complex ways to justify our love of cruelty. Hell, our instinctive need to punish taboo or anti-social behaviours probably kept us alive in the days when taking the proverbial last slice of pizza meant risking the lives of your whole band of hunter gatherers. We demand punishment be doled out, regardless of intention.

Captain van Zanten, the arrogant pilot who took off without clearance, is dead. He likely died instantly, never realizing what his mistake was. Or maybe in the last moments he realized his engineer had been right, and he knew exactly what he had done to cause his own horrid, painful death. Is that justice?

In the aftermath, Spain's official investigation placed the blame squarely on the KLM crew. They took off without clearance. While the Dutch investigators agreed, they argued that the lack of radar and the controller's confusing transmissions were what led to the error. History has proven that they were correct. Controllers are now never allowed to use the word 'takeoff' in transmissions unless it is for a takeoff clearance. Confirmation bias, the way we seek information that confirms our mental model while unconsciously discarding evidence against it, is now far better understood.

Still, load up any video on Tenerife and it is a flip of a coin whether the presenter understands this. Whether Captain van Zanten was a reckless and controlling man who broke the rules on purpose or a frazzled pilot trying to get home during an incredibly stressful shift is in the eye of the beholder, because it is ultimately not a question about him at all. It's a question about how you make sense of blame.

Personally, I'm a safety enthusiast (and a hedonist, in the classical sense). I believe in whatever maximizes safety. So here's my argument to you.

Blaming the individual who makes a mistake, absent any evidence it was intentional, is not a safe mindset. A punitive approach to mistakes causes people to feel ashamed of them and fear retribution. A mistake that is not admitted early can snowball. Think about it... if Captain van Zanten had been taught the value of questioning his decisions, listening to his subordinates, and admitting to his mistakes, would he have been a little less likely to take off the brakes that day?

What makes safety so intriguing to me is its utopian aims. That every accident can be learned from, every death can be prevented, and every mistake shared openly without shame can be a tragedy avoided. It's not always the perfect lens to view the world through- I can agree that punitive justice feels pretty good when negligence leads to horrible suffering. But sometimes being human is about setting aside our emotions and doing not what feels right, but what works.

The eponymous airport on the island of Gran Canaria was the main hub for travel in and out of the colonized African archipelago. That made it a logical target for the Fuerzas Armadas Guanches, the armed division of the MPAIAC, fighting for an end to Spanish colonial rule. That day, a man placed a bomb in a duffel bag inside the airport terminal. The group called in to alert the authorities, but the building wasn't quite evacuated in time, leading to one airport worker being injured in the explosion. Knowing that multiple bombs may have been placed, local authorities shut the airport down to do a thorough search. As the terrorists intended, traffic in and out of the island ceased, and the planes en route to Gran Canaria were diverted to the nearby island of Tenerife.

Los Rodeos Airport was well enough equipped for landings and takeoffs by the occasional large jet, but its capacity could not possibly keep up with the demand that day. Aircraft filled the small apron and spilled out into the taxiways as exhausted tourists disembarked and roamed the small terminal building. Just minutes away from their destination, the pilots had no idea how long it would take for the airport in Gran Canaria to reopen, and their duty times were slowly ticking away.

Limits on how long a pilot is allowed to work are pretty self explanatory. If you wouldn't drive to the convenience store at 3am on 2 hours of sleep from the previous night, you probably wouldn't want your pilot doing that either. However, the Netherlands had recently enacted a pretty questionable law which could charge pilots with a felony if they exceeded these limits, which was weighing hard on the mind of the very senior pilot behind the controls of a KLM 747.

Captain Jacob van Zanten was, by all accounts, an excellent pilot. He headed the airline's training program and spent more of his time mentoring other pilots in the simulator than flying passengers these days. This duty was almost a formality, as pilots must have a minimum number of real flight hours to maintain their licenses. The flight to Gran Canaria and back would fill this requirement for him, but with this extra delay and the frankly bullshit law that his home country had put in place, it could also land him in jail. He made a strategic decision to disembark the passengers and begin refuelling for the trip back while at Los Rodeos, to cut down on turnover times later.

This decision was certainly not appreciated by the pilots of a Pan Am 747 parked on the taxiway behind him. When the airport at Gran Canaria reopened and jets began streaming out, Captain Victor Grubbs on the Pan Am flight found himself trapped by the refuelling KLM. He and his First Officer actually climbed out of the plane to evaluate the distance on foot just in case they could barely maneuver around the other aircraft, but to no avail- they were meters short of the clearance needed on the small taxiways at Tenerife.

That day, the overworked ground controller was struggling to manage all of the unexpected traffic and sequence them for takeoff. Since the taxiways were already filled with parked aircraft, he had to instruct some to back-taxi down the whole length of the runway and turn around in order to take off. To make things worse, fog was rolling over the airport- at times there was okay visibility, but most of the time he couldn't see the planes he was directing. Without radar, he had to track them all using rudimentary flight strips and a mental map.

Once all the passengers had been wrangled back to the KLM, the controller instructed them to taxi to the end of the runway and into the takeoff position. In the meantime, he intended to have the waiting Pan Am taxi most of the way down the runway and exit onto taxiway three to wait for their chance.

As they taxied slowly down the runway engulfed in fog, the mood in the cockpit of the Pan Am was sour. They been waiting far longer than they needed, and now they were moving down an occupied runway while barely able to see the exits as they passed. When they spotted the exit to taxiway 3, they were puzzled- by their judgement, the steep acute angle they'd have to turn to enter it wasn't possible. Perhaps the controller had meant the third taxiway from their position, which would be taxiway four? Of course, he had not meant this- he had no radar to tell where the Pan Am flight was. He simply was not familiar enough with the 747 to know it could not accomodate such a tight turn.

While the Pan Am crawled down the runway, the KLM had made its turn and the pilots were rushing through the takeoff checklist. In fact, Captain van Zanten increased the throttles and was reminded they had yet to recieve clearance. Of course. He instructed the First Officer to ask for it now.

At this point in the story, the exact wordings start to become very, very important. Pay attention.

KLM F/O: "The KLM four eight zero five is now ready for take-off and we are waiting for our ATC clearance."

TOWER: "KLM eight seven zero five you are cleared to the Papa beacon, climb to and maintain flight level nine zero, right turn after takeoff, proceed with heading four zero until intercepting the three two five radial from Las Palmas VOR."

...did you catch that? The mental models have started diverging. "ATC clearance" is the route the plane is cleared to follow after getting airborne, but it is not takeoff clearance. However, these clearances are often provided at the same time. Because the controller used the word "takeoff" in his route instructions, the pilots on board the KLM flight mistakenly believed he was providing takeoff clearance. This may seem like a difficult mistake to make, but after a long work day with an unplanned stopover and with the threat of jail time or a logistical nightmare if you delay, it's a mistake you might make too.

After reading back the clearance, the KLM First Officer says a line that nobody can quite decipher- either "We are at takeoff" or "We are, uh, taking off." Whatever he said, this raised the attention of both the controller and the Pan Am crew, who each sought to clear up the confusion.

TOWER: "Okay.... Stand by for takeoff, I will call you."

PAN AM F/O: "And we're still taxiing down the runway, the clipper one seven three six."

However, a tragic coincidence sealed their fate. Since the controller hesitated slightly after saying "okay," the Pan Am First Officer transmitted his message before the controller was finished. On traditional radio systems, if you are transmitting, you can't hear any other transmissions, so neither party realized they had been speaking at the same time. In the cockpit of the KLM, already starting the roll, the crew heard this:

TOWER: "Okay."

[Unintelligible static]

PAN AM F/O: "Clipper one seven three six."

There was one last chance to realize their mistake, although by this point it may not have saved them.

TOWER: "Ah, Papa Alpha one seven three six, report the runway clear."

PAN AM F/O: "Okay, we'll report when clear."

While the Pan Am pilots complained about the KLM's sudden rush after they'd held up the line so long, the flight engineer on the KLM posed a question in Dutch- is he not clear then, that Pan American? Captain van Zanten reassured him in a way the transcript deacribes as "emphatic."

When the Pan Am pilots caught sight of the lights through the fog, they tried to taxi off the runway into the grass to no avail. Meanwhile, spotting the Pan Am, Captain van Zanten made the fateful (yet possibly correct) decision to attempt to take off early. The tail struck the runway and the engine smashed into the Pan Am's upper deck, leading the damaged KLM to stall and slam back into the runway, where the fuel exploded. While much of the Pan Am was damaged and engulfed by flames, 61 survivors managed to escape. The decision to attempt a takeoff may have killed the KLM crew, but if they hadn't, there may have been no survivors.

This is where our story leaves the realm of objective fact and becomes one of conjecture. After all, 583 people were now dead. Whose fault was it?

The punitive mindset pervades our modern world. We are animals, after all, and our advancement has only given us more complex ways to justify our love of cruelty. Hell, our instinctive need to punish taboo or anti-social behaviours probably kept us alive in the days when taking the proverbial last slice of pizza meant risking the lives of your whole band of hunter gatherers. We demand punishment be doled out, regardless of intention.

Captain van Zanten, the arrogant pilot who took off without clearance, is dead. He likely died instantly, never realizing what his mistake was. Or maybe in the last moments he realized his engineer had been right, and he knew exactly what he had done to cause his own horrid, painful death. Is that justice?

In the aftermath, Spain's official investigation placed the blame squarely on the KLM crew. They took off without clearance. While the Dutch investigators agreed, they argued that the lack of radar and the controller's confusing transmissions were what led to the error. History has proven that they were correct. Controllers are now never allowed to use the word 'takeoff' in transmissions unless it is for a takeoff clearance. Confirmation bias, the way we seek information that confirms our mental model while unconsciously discarding evidence against it, is now far better understood.

Still, load up any video on Tenerife and it is a flip of a coin whether the presenter understands this. Whether Captain van Zanten was a reckless and controlling man who broke the rules on purpose or a frazzled pilot trying to get home during an incredibly stressful shift is in the eye of the beholder, because it is ultimately not a question about him at all. It's a question about how you make sense of blame.

Personally, I'm a safety enthusiast (and a hedonist, in the classical sense). I believe in whatever maximizes safety. So here's my argument to you.

Blaming the individual who makes a mistake, absent any evidence it was intentional, is not a safe mindset. A punitive approach to mistakes causes people to feel ashamed of them and fear retribution. A mistake that is not admitted early can snowball. Think about it... if Captain van Zanten had been taught the value of questioning his decisions, listening to his subordinates, and admitting to his mistakes, would he have been a little less likely to take off the brakes that day?

What makes safety so intriguing to me is its utopian aims. That every accident can be learned from, every death can be prevented, and every mistake shared openly without shame can be a tragedy avoided. It's not always the perfect lens to view the world through- I can agree that punitive justice feels pretty good when negligence leads to horrible suffering. But sometimes being human is about setting aside our emotions and doing not what feels right, but what works.