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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

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

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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

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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

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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?

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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.

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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

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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

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THANK YOU