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The fix for an apparent engineering problem might not be an engineering fix.

On March 27, 1977, a Pan Am 747 was taxiing on the runway of Tenerife North Airport in the Canary Islands as a KLM Airlines 747 attempted to take off. The resulting collision killed 583 people, the most ever in an aviation accident. Numerous physical contributors were identified, including:

1. unusually high traffic due to the temporary closing of a larger airport nearby
2. many airplanes parked on the taxiway, complicating taxiing patterns
3. dense fog that greatly limited visibility
4. no ground radar; controllers had to rely on radio to identify plane positions
5. simultaneous radio transmissions that canceled each other out, causing messages to be unheard or misheard, and leading to unauthorized takeoff by the KLM captain despite concern from the copilot

Among the industry-wide changes after the disaster:

1. The word “takeoff” was forbidden except when the control tower authorizes an aircraft to take off. At all other times, “departure” or another term is to be used.
2. Flight crew across the industry were retrained, with lower-ranking crew encouraged to challenge captains with any concerns, and captains required to consider crew concerns in making all decisions.

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