‘All those people … the loss of all those people. I can’t get it out of my mind’: a young woman’s reaction sums up the horror felt by New Zealanders when an Air New Zealand DC10 crashed in Antarctica on 28 November 1979, killing 257 people. 1
Although the risk of dying in an air accident is very small (there is a much greater chance of being killed in a road accident), the public reaction to such events is intense. Loss of confidence in an airline, or in flying generally, is common, whether the accident was fatal or not. Crashes have other serious consequences. The cost of rescue operations, recovering bodies, retrieving aircraft wreckage and investigation can run into millions of dollars.
An air accident is rarely caused by just one event. Usually there are several factors, connected like links in a chain. Often the final link – the pilot’s response to an emergency – is seen as the sole cause of the accident, but investigation usually reveals other causes.
The crash of an Ansett Dash 8 in the foothills of the Tararua Range on 9 June 1995 was the result of a cluster of causes. On the approach to Palmerston North airport, the pilots had difficulty lowering the plane’s undercarriage (it was a design flaw that had been previously identified). Instead of climbing to a safe altitude while fixing the problem, they continued descending on an instrument approach in cloud. While they were distracted the plane collided with a hill; four people died and others were seriously injured.
Human error is the underlying cause in the majority of aircraft accidents. The person at fault may be a pilot, maintenance engineer, ground crew member, manager or supervisor, designer, or someone involved in the manufacture of an aircraft. Errors on the ground can include faulty aircraft construction or maintenance, incorrect instructions to air crew, mistakes in refuelling or securing the aircraft doors, overloading, and excessive stress on staff. In the air, pilots may make navigation errors, or choose to fly in cloudy conditions using visual cues such as landmarks instead of navigational instruments.
Failing to heed up-to-date weather forecasts is unwise in New Zealand, where the elements are particularly changeable and intense due to the mountainous terrain and the prevalence of strong winds and turbulence. Severe weather can test the structural strength of aircraft designed for less rigorous conditions, and the skill of the pilots.
Every year in New Zealand there are dozens of aviation accidents resulting in injuries to people or damage to aircraft, and hundreds of incidents affecting safety, including near-accidents. But only some accidents result in deaths, and few fatal accidents have involved large commercial aircraft. Although there are more aircraft per capita in New Zealand than any other country in the world, the air traffic is very light. And worldwide improvements in navigation and safety equipment, aircraft construction and maintenance, air traffic control, weather forecasting and training have enhanced air safety in New Zealand. Since 1944 New Zealand has complied with International Civil Aviation Organisation (ICAO) air safety standards.
A nationwide network of radio beacons, distance-measuring equipment, and instrument landing systems at airports enables pilots to fly safely to their destinations. Air traffic controllers use radar to provide crucial advice to pilots before and during flight. Large aircraft carry sophisticated navigation equipment, and even light aircraft have some navigation aids. The latest global positioning system (GPS) involves computer conversion of signals from a network of satellites, to provide the pilot with highly accurate information on aircraft position.
New Zealanders take their mobile phones everywhere – in cars, buses, trains and increasingly, on planes. However, CAA rules forbid their use on planes for sending and receiving phone calls, text messages or emails. Cellphone signals can interfere with aircraft navigation and communication systems, with potentially disastrous results. Several incidents in New Zealand skies reinforce these findings.
The Civil Aviation Authority of New Zealand (CAA) sets and monitors civil aviation safety and security standards. It is governed by the Civil Aviation Act 1990 (amended in 1992). The CAA is responsible for almost every aspect of civil aviation safety, including:
A commercial company, Airways New Zealand, manages all domestic and international air traffic. In 2003 it was recognised as one of the best operations of its type in the world.
In line with ICAO standards, New Zealand formally investigates all air accidents as a first step in prevention of future disasters. The Transport Accident Investigation Commission, established in 1990, examines all aviation, rail or marine accidents, or incidents which have significant implications for transport safety. The CAA also investigates accidents and incidents.
The development of aviation in New Zealand has inevitably been accompanied by accidents, from which tragic but necessary lessons have been learned.
Nineteenth-century balloonist David Mahoney (alias Captain Charles Lorraine) was the first New Zealander to die in an air accident, drowning after his balloon came down in the sea beyond the entrance to Lyttelton Harbour in 1899. Balloons gave way to aeroplanes before the First World War, and the pioneering phase of aviation stretched into the 1930s. During these years aerial displays and tours were popular, and there were numerous mishaps. The first aircraft fatality occurred in 1919 when a biplane crashed during an aerobatic display over a race meeting at Christchurch, killing pilot Cecil Hill. Such accidents brought home the hazardous nature of flying.
Formation flying is risky – the slightest error of judgement can lead to disaster. A miscalculation led to the fatal crash of a Skyhawk in the RNZAF formation flying team, Kiwi Red, in 1989. The plane clipped another as it attempted a roll, and crashed into the ground. Subsequently, the team disbanded.
Commercial aviation began before the Second World War, flourishing after 1945 when a state airline, the National Airways Corporation (NAC), was established. In just under 11 years from 1938 there were five major fatal accidents. The two crew members of a Union Airways Electra that crashed at Māngere, Auckland, in May 1938 were the first people to die on a scheduled air service in New Zealand. In May 1942 another Union Airways Electra collided with Mt Richmond on a flight from Wellington to Nelson, killing five people. An NAC DC3 freighter carrying two crew hit a ridge overlooking Tory Channel in August 1948, and then in October 13 people died when an NAC Electra flew into Mt Ruapehu on a flight from Palmerston North to Hamilton. In March 1949 NAC suffered another calamity when a Lodestar flying from Auckland crashed only minutes from landing at Paraparaumu, killing all 15 on board.
While there were various causes, these disasters highlighted the need for industry regulation – including more rigorous in-flight safety procedures for commercial pilots – and revealed deficiencies in both aircraft and ground navigation aids. At that stage navigation beacons were not available everywhere in the country, and aircraft instruments were often unreliable. Influenced by recent events, in 1948 a government commission recommended restructuring civil aviation.
‘In the unlikely event of an emergency, follow the instructions of your crew – they know what to do.’ These words are familiar to New Zealand air travellers, but before the mid-1950s cabin crew were carried on only a few flights. After the crash of a DC3 near Raumati in 1954, some surviving passengers suggested that a flight attendant might have helped save the lives of the three children who died. In 1956 NAC began employing flight attendants, and from 1960 attendants were mandatory on aircraft seating more than 14 passengers. They are trained in first-aid and emergency procedures and play an important safety role.
The 1963 crash of an NAC DC3, with the loss of 23 people, remains the worst air accident within New Zealand. On 3 July the flight departed from Auckland, bound for Wellington via Tauranga, Gisborne and Napier. The weather was stormy, but forecasts underestimated the force of the wind. As the plane began its descent towards Tauranga it was caught in a downdraught and slammed into a ridge on the Kaimai Range. Insufficient altitude and navigational problems contributed to the crash, but the ferocious winds were the deciding factor. It took two days for rescuers to locate and reach the crash site.
The inquiry noted that there was no distance-measuring equipment at Tauranga airport, which would have given the pilot an accurate indication of how far he was from his destination. One recommendation was that this equipment be installed at all airports served by commercial flights. It also suggested a review of minimum safe altitudes for flights, taking into account terrain and weather conditions, and the provision of locator beacons for aircraft so they could quickly be found in the event of a crash. These were finally made mandatory in all passenger planes after several light aircraft were lost without trace in the early 1980s. Digital data flight recorders were gradually introduced to help determine the cause of accidents. Since 1989 they have been required on all multi-engined turbine-powered planes.
The New Zealand government regulated the aviation industry from 1918, when it passed an act to control civil aviation. The Air Board was established in 1920. Licensing of air services began in 1934, and from 1951 was administered by the Air Services Licensing Authority. In 1937 the Air Department was established to administer both military and civil aviation, and in 1964 a separate Department of Civil Aviation was set up. It became a division of the Department of Transport in 1968.
Restructuring and funding cuts in the 1980s reduced the government’s involvement in aviation. The much-reduced Air Transport Division, responsible for policing the industry, and the profit-making Airways Corporation, which managed air traffic control, were both established in 1987. Another development was the deregulation of the aviation industry, which led to a proliferation of new, mostly small, airlines. In 1990, air services licensing was abolished.
The diminished government role overseeing an expanding industry is widely believed to have contributed to deteriorating air safety. 1989 was a particularly bad year for accidents. Although there have been further changes, notably the establishment of the Civil Aviation Authority in the early 1990s, the monitoring of air traffic control and airline operations draws criticism into the 2000s.
Small aircraft are used for recreation and in work that underpins the New Zealand economy. Yet they are particularly accident-prone. A 2004 study of accidents between 1990 and 2002 found that New Zealand had five times the rate of small aircraft crashes than the US, and four times that of the UK. The accident rate was similar to Australia’s, but New Zealand crashes killed twice as many people. These grim statistics are partly explained by the profusion of light aircraft in New Zealand. From the 1950s they became more affordable to small airlines, aero clubs and private owners, and numbers soared.
Caution is an important quality for a pilot, as this old aviation saying warns:
‘There are old pilots, and there are bold pilots;
But there are no old, bold pilots.’
Experiments using aircraft to spread fertiliser onto inaccessible country took place during and after the Second World War. The benefits to agriculture were immediately obvious, and an industry developed using the skills of hundreds of former military pilots, often flying ex-air force Tiger Moths. But lax safety standards, bad pilot habits and the inherent dangers of flying near to the ground led to many crashes. The Fletcher FU24, a specialised topdressing plane, made the task easier. From the 1960s, pilot training, farmer education, improved aircraft design, and regular safety bulletins were all aimed at reducing accidents, but the high crash rate continued into the 1970s.
New Zealand’s magnificent scenery attracts many tourists. Some of the most spectacular areas are best viewed from on high. Air tourism caught on during the Second World War, when American troops stationed in New Zealand chartered planes to view South Island beauty spots. Scenic flights continued in the 1950s and became more popular from the 1960s. But the density of traffic in some areas, and the need for pilots to fly low over rugged terrain, often while giving a commentary, have contributed to some serious accidents. The repercussions have extended beyond New Zealand: in 1989 the death of six Japanese tourists in a mid-air collision above Milford Sound is estimated to have cost the tourism industry $30 million in lost revenue.
When not using navigation systems, pilots must adhere to visual flight rules. This means avoiding cloud or darkness and keeping to prescribed heights. The life expectancy of pilots who enter cloud without navigational instruments is somewhere around 19 seconds. Either they will fly into solid ground concealed by cloud (dubbed ‘cumulogranite’), or they will become disorientated and lose control of their aircraft.
Helicopters began to appear in New Zealand skies from the 1950s and were widely used from the 1970s. In forestry, construction work, deer recovery, sightseeing, traffic monitoring, police work, air ambulance services and search and rescue they have become indispensable. However, such flights often require pilots to fly at low altitudes, closer to hazards such as cables. Some 95% of helicopter operations are carried out within 300 metres of the ground and 80% within 150 metres, which helps explain their high accident rate.
Although it did not occur on New Zealand territory, the crash of an Air New Zealand DC10 on Mt Erebus, Antarctica, in 1979 with the loss of 257 lives is widely regarded as New Zealand’s worst air accident.
Air New Zealand’s one-day sightseeing flights to Antarctica began in 1977. Leaving Auckland, the aircraft headed for Antarctica, where passengers were treated to low-level views of the Ross Dependency before returning, with a brief refuelling stop at Christchurch. The flights had always operated smoothly and were popular with adventurous Kiwis and tourists. But when Flight TE901 failed to arrive at Christchurch on schedule on 28 November 1979, there was a great sense of foreboding. It was clear that the plane, if still airborne, would soon run out of fuel. Search and rescue operations began, and the following day wreckage was spotted on the slopes of Mt Erebus; no-one could have survived the impact when the DC10 ploughed into its slopes.
More than 60 people were involved in the gruelling tasks of recovering bodies from the crevasse-riven site and inspecting the wreckage to determine the cause of the disaster. These operations took several weeks. Against heavy odds, all the bodies were retrieved and eventually 214 were identified. An air accident investigation began, using information from the aircraft’s flight recorders and other sources.
All large and some small aircraft carry two ‘black boxes’: a digital flight data recorder, which monitors altitude, speed, direction and engine function, and a cockpit voice recorder (CVR). They can help determine the cause of accidents. The content and significance of the first transcript of the CVR from the Erebus DC10 is still hotly debated. Access to the original tape has been barred until 2049. Until then, speculation will continue.
The official report by Chief Air Accident Inspector Ron Chippindale was published in June 1980. It explained that at the time of the crash, the aircraft was flying at about 450 metres above sea level in whiteout atmospheric conditions – where the sun is filtered through cloud and reflects light from the snow, making it impossible to distinguish ground from air. The plane flew into the icy mountainside in level flight soon after the ground proximity warning had sounded. Mechanical problems were ruled out. The report found fault with the airline for inadequate pilot briefings and procedures, including a late flight-path alteration that was not mentioned to the crew. It also reprimanded the Civil Aviation Division for not monitoring Antarctic flights more rigorously. However, the main blame was reserved for the pilots, especially the captain, who was criticised for descending to a low altitude when he was unsure of his position and unable to see the terrain. This conclusion was strongly opposed by some, who saw it as a slur on the professionalism of the dead pilots.
Meanwhile, a royal commission of inquiry, headed by High Court Judge Peter Mahon, was appointed to look into the circumstances surrounding the disaster. Judge Mahon’s report, released in 1981, reached a different conclusion. It found that the state-owned airline was primarily to blame in changing the flight plan without telling the crew, with the result that the plane flew towards Mt Erebus instead of down McMurdo Sound. The report stirred up further controversy, particularly in its condemnation of Air New Zealand. Mahon asserted that the airline had intentionally misled the inquiry through an ‘orchestrated litany of lies’.
The airline sought a judicial review of the judgement. A Court of Appeal judgement in December 1981 decided that Mahon had exceeded his terms of reference in suggesting criminal conspiracy, and in October 1983 the Privy Council upheld this decision.
Today, the argument over what really caused the Erebus crash continues. There were clearly a number of contributing factors. But which of them was the most significant, and whether the pilots or the airline were ultimately responsible, remains a matter of intense debate.
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Guerin, Michael. Dash 8 down: the inside story of Ansett flight 703. Auckland: Random House, 2001.
King, John. New Zealand tragedies: aviation accidents and disasters. Wellington: Grantham House, 1995.
McGreal, Maurice E. A history of civil aviation in New Zealand. Auckland: David Bateman, 2003.
Myles, Sarah. Towards the mountain: a story of grief and hope forty years on from Erebus. Auckland: Allen & Unwin, 2019.