Mount Erebus/Air New Zealand Accident
PEOPLE
MANAGEMENT
Chief Pilot- Ultimately made the decision to fly below 6000 feet and overall decision maker in plane safety. Likely he felt obliged to provide amazing experience for passengers.
First Officer- Was not focusing on position of aircraft. Distracted by lack of VHF radio transmissions from Mcmurdo Centre.
Navigation Department personnel- made the decision not to communicate changes to flight path to Flight Crew.
Mcmurdo Centre personnel granted permission for TE 901 to descend below 6000 feet. Radar assisted descent was not practical (Erebus 2021).
WORKPLACES
EQUIPMENT DESIGN/EASE OF USE
Navigational equipment- difficult to use, first officer struggled to try and utilise radio and keep a check on co ordinates
Ground proximity warning system- did not warn of impending collision until it was too late to avoid (Wikipedia 2021).
WORK ENVIRONMENT
Poor visibility- pilots dealing with cloud at 2000 feet (Wikipedia 2021).
Snow everywhere- on the slopes and in the air
White out phenomenon- causing pilots to struggle to differentiate between vertical and horizontal planes that are snow covered (Ministry of Transport 1980).
Casual workplace- flight was unusual in that it was a pleasure flight and not a journey. According to Ministry of Transport (1980) recordings were difficult to decipher because of passengers in cockpit.
Flight crew had very limited experience flying in snow conditions (Ministry of Transport 1980).
Not 2 pilots on flight- original conditions imposed were 2 Captains to be on the flights, airline decided to send 1 Captain and 1 first mate on this flight (Ministry of Transport 1980).
Created culture of allowing pilots leeway to create the best experience for passengers
Flights were regularly flying below the 6000 feet limit
Advertising brochures showed photos taken at low altitude (Wikipedia 2021).
Appropriate charts not provided to pilots (New Zealand History 2019)
No appropriate procedure for checking flight path accurateness (New Zealand History 2019)
DC 10-30 fit for purpose long range aircraft
Allowed flight coordinates mistake to run for 14 months
Mistake was not rectified accurately, changes not communicated
Early ground proximity radars looked did not look forward, just down (Honeywell Aerospace Engineering 2019)
Human Factor Tools to aid investigation
Hierarchical Task Analysis (HTA)
Link Analysis
Timeline Analysis
Why-Because Analysis
Human Error Reduction in ATM (HERA)
Human Factors Investigation Tool (HFIT)
CIVIL AVIATION DEPARTMENT (CAD)
Unclear stipulations and rules regarding flight ceilings (Mahon 1980).
Lack of consulting Antarctic experienced New Zealand Air force when developing flight paths (Mahon 1980).
Lack of communication and consultation between US authorities at Mcmurdo and CAD (Mahon 1980).
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Requirement not met that chief pilot to have flown route Antarctic route prior to commanding (Mahon 1980).
LIST OF REFERENCES
Erebus 2021, United states policy regarding aviation in antarctica, 1968, viewed 12 September 2021, https://www.erebus.co.nz/Background/Antarctic-Experience/US-Policy-Regarding-Aviation-in-Antarctica-1968
Mahon, P 1980, Royal Commission to inquire into and report upon the crash of Mount Erebus, Antarctica, of a DC 10 aircraft operated by Air New Zealand Limited, viewed 12 September, https://www.erebus.co.nz/Portals/4/Documents/Reports/Mahon/Mahon%20Report_web.pdf
Ministry of Transport 1980, Aircraft accident report no. 79 – 139, viewed 19 August 2021, https://reports.aviation-safety.net/1979/19791128-0_DC10_ZK-NZP.pdf
New Zealand History 2019, The Erebus inquiry by peter mahon, viewed 19 August 2021, https://nzhistory.govt.nz/media/photo/erebus-inquiry-peter-mahon
Wikipedia 2021, Mount Erebus disaster, viewed 22 August 2021, https://en.wikipedia.org/wiki/Mount_Erebus_disaster
CRAIG MALLINSON, HUMAN FACTORS INVESTIGATION, MOUNT EREBUS/AIR NEW ZEALAND DISASTER, MINDMAP, ASSESSMENT ONE