AIR NEW ZEALAND

DC 10 FLIGHT 901
NOVEMBER 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 I
Date of accident: November 28, 1979
(12:50pm)
Airlines: Air New Zealand
Type: Mc Douglas DC 10-30
Origin: Auckland International
Airport
Destination: Christchurch
International Airport
Registration: ZK-NZP
Flight no: 901
First flight: 1974
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ACCIDENT DATABASE II
Passengers 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 I
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.

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CHRONOLOGICAL II
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 Erebus
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CHRONOLOGICAL III
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.
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CHRONOLOGICAL IV
Time: What happened?
20 hours •Confirm that the wreckage was the
after the remains of Flight 901.
crash •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
Direct cause
Damaged
beyond Aircraft at Mt
repair Erebus

Aircraft hit Change path

and
disintegrated
Flew low over

Visual condition

Knocked out
257 died

Force impact 11
 ROOT CAUSE ANALYSIS: L2 Pilots did
1 not check?
Damaged Change 45km to
beyond the east
repair Aircraft at Mt Omitted to
2
Erebus Communication tell aircrew
breakdown
Aircraft hit
Change flight
and 3 Across Lewis
path GPWS
disintegrated Sound and active
volcano malfunction?
Flew low over 4
Late warning blare

Visual condition

257 died

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 ROOT CAUSE ANALYSIS: L2 To attract
passengers
Damaged
beyond Both
repair 5 experienced
Aircraft at Mt
pilot but
Erebus Better view
they ignore
Aircraft hit
Change flight 6
and Not follow Air
path
disintegrated Safety Regulation

Flew low over

Late warning blare

Visual condition

257 died

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 ROOT CAUSE ANALYSIS I
Event Consequences Possible cause Reason found

Change Across The airline omitted Communication

flight McMurdo to tell the aircrew breakdown
path Sound and
45km to towards Mt
the east. Erebus.

Flew low Hit Mt Erebus. To give their The pilots did

over (610 257 died. passenger better not follow Air
meters). view. Safety
Authorized to Regulation.
descend to 11
 ROOT CAUSE ANALYSIS II
Event Consequences Possible cause Reason found

Late No time to Malfunction of GPSW No regular

warning save the device. maintenance
signal situation. on safety
(GPWS). devices.

Visual Hit Mt Erebus. Whiteout. The cloud No monitoring

condition – blended with white by McMurdo
no contrast mountain. Center.
to show
the slop.

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4 CATEGORIES OF CAUSES
Human Errors Mechanical Technical Environment
Errors Failure Condition

The airlines omitted Deck altitude No regular Whiteout

tell the aircrew device (GPWS) maintenance (cloud blend
about the changes malfunction for safety with the
(comm. breakdown) (late devices white
detection) mountain)

Flew low over (The Across the

pilots did not follow McMurdo
Air Safety Sound and
Regulation) 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

competency
 Non verbal communication
 Bulletin, safety alert

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 Follow the SOP provided
 Obey to the regulation
 Regular maintenance
 Regularlycheck-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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Click icon to add
picture

VIDEO 1
First film of Erebus Disaster

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Click icon to add
picture

VIDEO 2
Erebus Investigation

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PENALTIES
 Official report – Chippindale (12/6/80)
 Citedpilot 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 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
 AgainstMahon 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

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