EREBUS DISASTER

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By; Noor Emellia Binti Jamaludin 807852 861228-35-5444 Lecturer: Ir Daud Bin Sulaiman1

of incident Root cause analysis 4 categories of causes Lessons learned Pictures / Maps / Graphic / Videos Compensation and penalties Chronological

Date of accident: Airlines: Type: Origin: Destination: Registration: Flight no: First flight:

November 28, 1979 (12:50pm) Air New Zealand Mc Douglas DC 10-30 Auckland International Airport Christchurch International Airport ZK-NZP 901 19743

Passengers and crew:

Fatalities: Aircraft damage:

200 New Zealanders, 24 Japanese, 22 Americans, 6 British, 2 Canadians, 1 Australia, 1 French, 1 Swiss) 257 (all) Destroyed

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Time: What happened? 8:20am 237 passengers & 20 crews onboard. 12:30pm Permission was given by the McMurdo radio to descend to 3050 meters and proceed visually. 12:45pm Collins was dropping further to 610 meters. He locked onto the computerized navigational system, but Flight 901 was not where either McMurdo Center or the crew thought it was.5

Time:

What happened? Change in the two co-ordinates had put Flight 901 on a path not across the flat ground of McMurdo Sound, but across Lewis Sound and towards active volcano. No contrast to show the sloping up of the land (air was clear). 12:49pm Deck altitude device began to blare a warning. No time to save the situation. 6 sec later hit the side Mt Erebus6

Time: What happened? 12:50pm McMurdo Center tried to contact Flight 901. Informed Air New Zealand HQ aircraft had been lost. US search & rescue start. 10:00pm About 30mins after DC-10 would (NZtime) have used the last of its fuel, airline told reporters that it had to be assumed that the aircraft was lost. 1:00am US Navy found some unidentified (NZtime) wreckage on the side of Mt Erebus.

Time: 20 hours after the crash

What happened? Confirm that the wreckage was the remains of Flight 901. 257 died.

Public

released on 19 June 1980 Difficulty finding ultimate cause Main factor: Flew low over min safe altitude Concluded: It would safely if the pilot not descended below min safe altitude (specified by CAD and Air New Zealand). Other factors: Omission and inaccuracies in route qualification briefing

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Royal

Commission of Inquiry: 7 July 1980 Single dominant and effective cause: The airlines who programmed the aircraft to fly directly at Mt Erebus and omitted to tell the aircrew Conclusion: Aircrew being misdirected, and not due to pilot error

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Direct cause Damaged beyond repair Aircraft at Mt Erebus Change path

Aircraft hit and disintegrated

Flew low over

Visual condition Knocked out Force impact

257 died

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1 Damaged beyond repair Aircraft hit and disintegrated

Change 45km to the east Communication breakdown Across Lewis Sound and active volcano Late warning blare

Pilots did not check?

Aircraft at Mt Erebus Change flight path Flew low over

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Omitted to tell aircrew

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GPWS malfunction?

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Visual condition 257 died

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To attract passengers Damaged beyond repair Aircraft hit and disintegrated Both experienced pilot but they ignore

Aircraft at Mt Erebus Change flight path Flew low over

5 Better view 6 Not follow Air Safety Regulation Late warning blare

Visual condition 257 died

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Event Change flight path 45km to the east. Flew low

Consequences Across McMurdo Sound and towards Mt Erebus. Hit Mt Erebus.

Possible cause The airline omitted to tell the aircrew

Reason found Communication breakdown

To give their passenger better view. Authorized to descend to 450meter.

The pilots did not follow Air Safety Regulation.11

over (610 257 died. meters).

Event Late warning signal (GPWS). Visual condition no contrast to show the slop.

Consequences No time to save the situation.

Possible cause

Reason found

Malfunction of GPSW No regular device. maintenance on safety devices.

Hit Mt Erebus.

Whiteout. The cloud blended with white mountain.

No monitoring by McMurdo Center.

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Human Errors

Mechanical Errors

Technical Failure No regular

Environment Condition Whiteout

The airlines omitted Deck altitude tell the aircrew about the changes device (GPWS) malfunction

maintenance (cloud blend for safety devices with the white mountain) Across the McMurdo Sound and towards Mt Erebus 16

(comm. breakdown) (late detection) Flew low over (The pilots did not follow Air Safety Regulation)

Effective

communication

Verbal communication Tools box meeting briefing before departure Regular training refreshing and improve competency Non verbal communication Bulletin, safety alert

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Follow

the SOP provided maintenance

Obey to the regulation Regularly check-up all the safety devices Updates with advanced technology

Regular

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First film of Erebus Disaster

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Erebus Investigation

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Official

report Chippindale (12/6/80)

Cited pilot error as principal cause Blame to the decision of Collins to descend below customary min altitude (below 1830 meters)

Mahon

Inquiry Peter Mahon (28/4/81)

Single, dominant, effective cause reprogramming of aircraft flight by the ground crew but failed to inform the aircrew Conclusion: incompetence administration procedures - aircrew being misdirected, not due to pilot error35

Ordered ANZ and CAD to pay the costs incurred by the consortium, NZALPA, estates of the pilot and co pilot. Ordered airline to pay $150,000 towards governments cost.

Appeal

by Air New Zealand

Against Mahon findings Evidence had been given: diagram has been included in flight crew briefing documentation

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Financial

compensation Lack of communication from ANZ Lack of emotional support from ANZ

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