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Conclusion

Upon consideration of all the evidence,[82] the Court finds as a fact that the disaster at Mt. Erebus on November 28, 1979, was caused by a combination of (1) the careless attitude of the New Zealand airline in switching flight plans for Flight 901 as and when it did, without a thorough briefing of the flight crew regarding the switch and its implications, and (2) the careless performance of the crew which did not avail itself of several available fail-safe systems, any one of which would have enabled it to discover in ample time that it was not on a proper course and would have permitted it to alter that course without significant difficulty. The air traffic controllers at McMurdo Station had no reason to suspect that these errors in the most fundamental principles of planning and airmanship had occurred, and that they had profoundly altered what would otherwise have been a safe and uneventful flight. Absent such knowledge, they had no basis for suspecting that Flight 901 was in mortal peril, or for taking extraordinary measures that even the flight crew never requested them to take.

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The air traffic controllers at McMurdo Station had no reason to suspect that these errors in the most fundamental principles of planning and airmanship had occurred, and that they had profoundly altered what would otherwise have been a safe and uneventful flight. Absent such knowledge, they had no basis for suspecting that Flight 901 was in mortal peril, or for taking extraordinary measures that even the flight crew never requested them to take.

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Sorry, cannot answer that, even with theory.

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It did, but only very briefly.
How was this established?

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It was entirely reasonable of the air traffic controllers to expect that that was the option Flight 901 would exercise. The air traffic controllers could not possibly assume that the crew, which was proceeding visually, did not have the high terrain in the area, specifically Mt. Erebus, in sight. Alternatively, the controllers could not be expected to assume that the crew would choose to descend below the known elevation of the terrain if it could not see where the flight was going.[56] According to the expert witnesses, a pilot should first fix his position, particularly if he is in uncontrolled airspace, and then, and only then, after he has determined that it is safe, make his descent.[57] This rule holds true whether or not radar assistance is anticipated. The evidence at trial also showed that, for Flight 901 to descend below 16,000 feet while lost would have been contrary to the most basic tenets of good airmanship and stated company policy.

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......for Flight 901 to descend below 16,000 feet while lost

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According to the expert witnesses,

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Unable to answer what exactly? The fact that other crews did not comply with SOPs? If that is the case, you're being just a little too cute, and you take the position of the gal in your video.

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Professor Diane Vaughan developed the “Normalisation of Deviance” theory

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Someone who doesn't know where they are is "lost" but so to is someone who thinks they know where they are but are wrong. I would venture to suggest that the latter person is the more lost, which describes Captain Collins situation from Cape Hallett into jaws of Lewis Bay on Ross Island. At that point he moved into the former situation, in that he didn't know where he was.

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I see and hear of many cars going through red traffic lights. I decide to do the same, however I collide with another car going through a green light.

Would Professor Diane Vaughan theory be a credible defence??

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I found it interesting that it pointed out that the McMurdo controllers would only be available if they had Deep Freeze aircraft operating. So it was entirely feasible that the sight seeing flights would have no one to talk to. Puts their cloud break procedure in the trash can, and once again points out the lack of planning by the airline.

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In the early hours of 28 November a navigational coordinate in the flight plan presented at the briefing was changed. The airline’s navigation section believed it was making a minor adjustment to the flight’s longstanding destination point, but a typing error some 14 months earlier meant it had actually shifted this point some 27 nautical miles to the east. Instead of the IFR route taking Flight TE901 over flat sea ice, as Collins and Cassin had been briefed, it would take them directly over Mt Erebus, a 3794-metre-high active volcano. The flight crew were not alerted to the change. On the morning of 28 November they received the adjusted 'correct' flight plan and entered these coordinates into the on board computer.

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If Collins and the rest of his crew knew where they were, they wouldn't have flown into a mountain now, would they?

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I see and hear of many cars going through red traffic lights. I decide to do the same, however I collide with another car going through a green light.

Would Professor Diane Vaughan theory be a credible defence??
According to Megan, yes.

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Everyone left that briefing under the assumption that the waypoint was at McMurdo Station. It was only Captain Collins private preparatio0ns the night before that led him to believe otherwise.

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Two of the three pilots had received the specially devised audio visual, written and simulator route qualification briefing. F/O Lucas had not.

An examination of this briefing revealed certain significant items were not included;

c. The way in which the airline route varied from the normal military route, which followed the reporting points depicted on the RNC, particularly on the leg from Cape Hallett south to McMurdo.

d. Topographical maps for the flight. With the exception of a photostat copy of a small inset enlargement of a map of Ross Island (1:1,000,000), these were not issued to the crew until the day of the flight, and were of a relatively small scale (1:3,000,000 and 1:5,000,000) Although topographical charts for the area were available on the day of the flight the only “charts” of the area below the flight planned track from Cape Hallett to McMurdo available at the initial briefing were:

The passenger information map
(an overprint on a 1:16,000.000 chart)
The RNC chart and
A slide depicting a schematic diagram taken from the rear of a passenger brochure

All of which showed a track proceeding o the true west of Mt Erebus down the McMurdo Sound. While these “charts” were not intended to be used for navigation the track shown was not that to be followed by TE 901. Several members of earlier crews were of the opinion that the inbound track to McMurdo was intended to be on an alignment which was over the sea level ice to a point adjacent to McMurdo but to the west of that base. (The dialogue which accompanied the audio visual briefing referred to the RNC chart when discussing the appropriate flight levels for the flight.)

The strip map of the route from Christchurch to McMurdo issued on the day of the flight also had two tracks printed on it both depicting a passage to the west of Ross Island. A track and distance diagram issued at the route qualification briefing correctly depicted the intended flight plan track from Cape Hallett to the McMurdo TACAN, but this showed no relationship to geographical location or terrain.

The audio visual presentation of the route qualification briefing showed two slides purporting to be of the track between Cape Hallett and the McMurdo TACAN. The first which only showed Cape Adare, 73 miles northwest of the Cape Hallett waypoint, accompanies the statement “We are almost 77° south proceeding from Cape Hallett towards Ross Island at Flight Level 330. Mt Erebus, almost 13000 feet, ahead. McMurdo Station and Scott Base lie 20 miles beyond the mountain in the direction of grid north”. A second slide accompanies the statement “Now approaching Erebus at 16000 feet the minimum sector altitude. In VMC a descent to this minimum altitude up to 50 miles before McMurdo will be found advantageous for viewing”. This slide gave no indication of the relationship of the track to Mt Erebus, as it shows a view of Mt Erebus taken from behind the co-pilot’s seat with the aircraft heading north.

The computer flight plan used at the briefing had been in error for 14 months in that it showed the destination point for McMurdo as two degrees ten minutes of longitude to the west of the intended turning point. This error was not corrected in the computer until the day before the flight. Although it was intended that it be drawn to the attention of the previous crew, immediately prior to their departure this was not done, nor was it mentioned during the preflight dispatch planning for the crew of the accident flight. The crew was shown a copy of the erroneous flight plan with the incorrect co-ordinates at the route qualification briefing but the flight plan issued on the day of the flight was correct.

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As the chief inspector went on to say in a succeeding paragraph, there were provided at these briefings two charts and a slide depicting a schematic diagram which each showed a track proceeding down McMurdo Sound. This was in conflict with a reference in the recorded text of the briefing to the actual latitude and longitude co-ordinates of McMurdo Station as being the destination point of the flight, and in view of the fact that the briefing described a track direct to McMurdo, then these three diagrams were of course, in conflict with the theoretical Cape Hallettto McMurdo track to which the briefing referred.

ln addition to these inadequacies revealed in the report of the chief inspector, there were two other features of the antarctic briefings which were unsatisfactory. In the first place there was no photograph showing pilots a general view of McMurdo Sound and Ross Island as the aircraft approached from the north. This is of particular significance in view ofthe fact that the McMurdo area bears little relationship to what might be expected to be observed from a topographical map of the area. The other
deficiency was that the briefing did not include a topographical map of the area upon which the flight planned track from Cape Hallett to McMurdo had been imposed. Such a map would have indicated to pilots the precise course to which the nav track oi the aircraft would take them.

There were two mistakes in the slides which were shown. One slide purported to show Cape Hallett whereas in fact it was a slide of Cape Adare located 73 miles north·west of the Cape Hallett waypoint. The second slide showed a view of Mt. Erebus and was accompanied by the statement that the aircraft was "Now approaching Erebus at 16,000 feet the minimum sector altitude". However, the photograph of the mountain had been taken from the true south of Mt. Erebus and not from the true north, and the result was that a view of this photograph showed Mt. Erebus over to the left of the direction in which the aircraft was heading. This error accordingly coincided with the McMurdo Sound approach depicted by the three diagrams to which I have previously referred. As to the simulator exercise, this did not give the pilot any view of the terrain to be observed on the flight. It was programmed as if the flight was being made at night time. This is because the airline‘s DC10 flight simulator is only programmed to the night lighting of an aerodrome, and in the case of antarctic briefings the position of the runways at Williams Field were shown in the distance as two intercepting lines of lights. The simulator instruction adequately covered the compass and navigation conversion procedures already referred to. The evidence given by Captain Wilson and by Captain Johnson as to the verbal content of the RCU briefing was not accepted by the majority of the pilots who attended the briefings. Indeed, there was one pilot who said that upon listening to the evidence given before the Commission in relation to the briefing which he had attended, he was led to wonder whether he had been at the same briefing.

The RCU briefing for antarctic flights was primarily inadequate, in my opinion, in that--

(a) The co—ordination of the United States Navy air traffic control system with the proposed overfly was not properly explained.

(b) The pictorial representations showed the observers that the flight path was down McMurdo Sound and these displays would, not unnaturally, take precedence over the spoken words indicating a direct track from Cape Hallett to McMurdo Station and indicating the NDB coordinates as the destination waypoint.

(c] The dangers of flying over uniformly white terrain under an overcast sky were not directly referred to.

(d) The prepared text of the briefing and the constant reference to minimum safe altitudes of 16,000 feet and 6,000 feet were verbally contradicted by Captain Wilson in the 1978 and 1979 flights by indicating to the crews that they were authorised to descend to any altitude approved by the United States Navy Air Traffic Controller, and it is significant to point out that at the time when the chief inspector signed and published his report, he had not been told by Captain Wilson, or by anyone else, that this specific authority was orally given to flight crews during the course of the audio—visual presentation to which I have referred. Captain Wilson admitted this.

[e) Captain Wilson, the supervisor of the RCU briefing procedures, had not flown to McMurdo Sound. He had applied to go on such a flight, so as to improve his knowledge of antarctic conditions, but his application had been declined by Flight Operations Division.

(f] Most important of all, crews were not shown a topographical map with the nav track plotted thereon.

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That was not what I intimated. Neither of you apparently have an understanding of the theory,

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It becomes an instituted practice within the company, until they collect that car coming through on the green.

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