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1
AIR NEW ZEALAND DC 10
FLIGHT 901NOVEMBER
28,1979(EREBUS
DISASTER)
By;
Noor Emellia Binti Jamaludin
807852
861228-35-5444
Lecturer: Ir Daud Bin Sulaiman
2
CONTENTS Chronological of incident Root cause analysis 4 categories of causes Lessons learned Pictures / Maps / Graphic / Videos Compensation and penalties
3
ACCIDENT DATABASE IDate of accident: November 28, 1979
(12:50pm)Airlines: Air New Zealand Type: Mc Douglas DC 10-
30Origin: Auckland
International AirportDestination: Christchurch
International AirportRegistration: ZK-NZPFlight no: 901First flight: 1974
4
ACCIDENT DATABASE IIPassengers and crew: 200 New
Zealanders, 24 Japanese, 22 Americans, 6 British, 2 Canadians, 1 Australia, 1 French, 1 Swiss)
Fatalities: 257 (all)Aircraft damage: Destroyed
5
CHRONOLOGICAL ITime: 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.
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CHRONOLOGICAL IITime: 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 Erebus
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CHRONOLOGICAL IIITime: 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 (NZtime)
•About 30mins after DC-10 would have used the last of its fuel, airline told reporters that it had to be assumed that the aircraft was lost.
1:00am (NZtime)
•US Navy found some unidentified wreckage on the side of Mt Erebus.
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CHRONOLOGICAL IVTime: What happened?20 hours after the crash
•Confirm that the wreckage was the remains of Flight 901.•257 died.
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CHIPPINDALE REPORT 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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MAHON REPORT 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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ROOT CAUSE ANALYSIS: L1
Aircraft hit and
disintegrated
Damaged
beyond repair
257 died
Aircraft at Mt Erebus
Flew low over
Visual condition
Change path
Force impact
Knocked out
Direct cause
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ROOT CAUSE ANALYSIS: L2
Aircraft hit and
disintegrated
Damaged
beyond repair
257 died
Aircraft at Mt Erebus
Flew low over
Visual condition
Change flight path
Change 45km to the east
Communication breakdown
Late warning blare
Across Lewis Sound and
active volcano
Pilots did not check?
Omitted to tell aircrew
GPWS malfunctio
n?
3
2
1
4
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ROOT CAUSE ANALYSIS: L2
Aircraft hit and
disintegrated
Damaged
beyond repair
257 died
Aircraft at Mt Erebus
Flew low over
Visual condition
Change flight path
Better view
Not follow Air Safety Regulation
Late warning blare
To attract passengers
Both experienced pilot but they ignore
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ROOT CAUSE ANALYSIS IEvent Consequenc
es
Possible cause Reason found
Change
flight
path
45km to
the
east.
Across
McMurdo
Sound and
towards Mt
Erebus.
The airline omitted
to tell the aircrew
Communicati
on
breakdown
Flew low
over
(610
meters).
Hit Mt
Erebus.
257 died.
To give their
passenger better
view.
Authorized to
descend to
450meter.
The pilots did
not follow Air
Safety
Regulation. 11
ROOT CAUSE ANALYSIS IIEvent Consequence
s
Possible cause Reason
found
Late
warning
signal
(GPWS).
No time to
save the
situation.
Malfunction of
GPSW device.
No regular
maintenanc
e on safety
devices.
Visual
condition
– no
contrast
to show
the slop.
Hit Mt
Erebus.
Whiteout. The
cloud blended
with white
mountain.
No
monitoring
by McMurdo
Center.
11
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4 CATEGORIES OF CAUSES Human Errors Mechanical
Errors
Technical
Failure
Environme
nt
Condition
The airlines
omitted tell the
aircrew about the
changes (comm.
breakdown)
Deck altitude
device
(GPWS)
malfunction
(late
detection)
No regular
maintenan
ce for
safety
devices
Whiteout
(cloud
blend with
the white
mountain)
Flew low over
(The pilots did not
follow Air Safety
Regulation)
Across the
McMurdo
Sound and
towards Mt
Erebus
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LESSONS LEARNED FROM OSH ASPECT Effective communication
Verbal communication Tools box meeting – briefing before
departure Regular training – refreshing and improve
competencyNon verbal communication
Bulletin, safety alert
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Follow the SOP providedObey to the regulation
Regular maintenanceRegularly check-up all the safety devices Updates with advanced technology
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MAP
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ANTARCTIC PHAMPLET
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PHOTO: PLANE WRECKAGE
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PHOTO: BODY LOCATION FLAG
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PHOTO: RECOVERY DURING BLIZZARD
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PHOTO: CRASH SITE
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PHOTO: PLANE FUSELAGE
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PHOTO: PLANE’S TAIL
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PHOTO: RECOVERY PARTY ACCOMMODATION
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PHOTO: VICTIM’S PERSONAL EFFECT
29
PHOTO: RETURNING BODIES
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PHOTO: IDENTIFYING VICTIMS
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PHOTO: EREBUS MEMORIAL
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PHOTO: WAKUMETE CEMETERY
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VIDEO 1First film of Erebus Disaster
Click icon to add picture
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VIDEO 2Erebus Investigation
Click icon to add picture
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PENALTIES Official report – Chippindale (12/6/80)
Cited pilot error as principal causeBlame 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 error
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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 government’s 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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COMPENSATION Financial compensation Lack of communication from ANZ Lack of emotional support from ANZ
38
THANK YOU