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conducted an eighteen-month, three-country
investigation of this accident, with an emphasis on
the human factors of flight crew performance.2
ALPA found that the KLM crew had strong concerns related to duty time, specifically that they would be able to
return to Amsterdam that evening and remain within their duty time regulations. They also expressed concern
about the weather and its potential to delay the impending takeoff — the cockpit voice recorder indicates the KLM
Captain said, “Hurry, or else it [the weather] will close again completely.”
Pan Am’s crew was equally concerned with potential weather delays. They were detained for more than an hour
due to the KLM flight crew’s decision to refuel — the KLM aircraft and fuel trucks blocked the taxiway, thus
preventing Pan Am’s departure. These schedule-related problems set the stage for the catastrophe that followed.
Hurry-Up Study
This review of the Hurry-Up Syndrome is an adaptation of a research study in which we examined 125 ASRS
incident records that involved time-related problems.3 We define Hurry-Up Syndrome as any situation where a
pilot’s human performance is degraded by a perceived or actual need to hurry or rush tasks or duties for any reason.
These time-related pressures include the need of a company agent or ground personnel to open a gate for another
aircraft, pressure from ATC to expedite taxi for takeoff or to meet a restriction in clearance time, the pressure to
keep on schedule when delays have occurred due to maintenance or weather, or the inclination to hurry to avoid
exceeding duty time regulations.
1 Two Boeing 747s, one operated by KLM and the other by Pan Am, collided when the KLM flight was taking off and the Pan Am
flight was taxiing on the runway. Both aircraft caught fire and were destroyed — there were 583 fatalities and only 61 survivors.
2 Airline Accident Report, Pan American 747, KLM Boeing 747, Canary Islands, 03/27/77, Air Line Pilots Association.
3 The study, titled “Hurry-Up Syndrome — Time Pressure as a Causal Factor in Aviation Safety Incidents” was presented at The Ohio
State University 7th International Symposium on Aviation Psychology, April 1993.
20 Issue Number 5
Hurry-Up Syndrome
Errors and Incidents
Each time-pressure incident
had a point where the error
occurred (Point of Error Occurrence),
and another point,
either immediately or further
downstream, where the
result(s) of the error(s) actually
manifested themselves
(Point of Incident Occurrence).
Figure 1 shows the relationship
between the error and
incident occurrence for various
flight phases.
Point of Error
A large majority of incidents
(63 percent) had their origins
in the pre-flight phase of operations.
For example:
✍ “…Inbound flight was
late and we were rushed because
of the scheduled out time report card mentality…It
turns out that the clearance I got on ACARS was for the
inbound flight. The squawk was incorrect, the altitude was
wrong and so was the departure frequency…” (ACN 200800)
The taxi-out phase accounted for the second highest number of
error occurrences, while all other operational phases combined
amounted to less than 10 percent.
Point of Incident Occurrence
The errors made in pre-flight and taxi-out often manifested
themselves later, during takeoff and departure. One reporter
writes:
✍ “…we were busy with checklists and passenger announcements,
while changing to Tower frequency. [The] Tower
cleared us for immediate takeoff, and even though we had not
finished our checklists, I taxied our aircraft into position and
started to advance the power for takeoff…After about 1,000
feet of takeoff roll, Tower canceled our takeoff clearance…
[we] asked the Tower why we had our takeoff clearance
canceled…the F/O said [that] we’re not on the runway. At
that point I realized we had started our takeoff roll on an
active taxiway.” (ACN 134919)
The next most common category for incident
occurrence was the taxi-out phase with 22 percent
of all reports:
✍ “Aircraft expediting taxi after an extended
maintenance delay, failed to follow
cleared routing and ended [up] on the active
runway…F/O busy with checklist…Captain
rushed due to schedule pressure…”
(ACN 55009)
Who Made The Error?
Errors can be made by one individual, or they
can be made by the flight crew as a collective
unit. The majority (68 percent) of errors appeared
to be collective. Collective error on the
　
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