Before the Royal Commission was appointed and began its work a statutory
investigation had already been carried out in terms of the Civil
Aviation (Accident Investigation) Regulations 1978. Immediately it was
known that the aircraft had crashed on Mount Erebus the standard
procedures for aircraft accident investigation were invoked by the Chief
Inspector of Air Accidents, Mr R. Chippindale. And he arrived in the
Antarctic with a small team of experts on the day following the
disaster. They included mountaineers, police, surveyors, the chief pilot
of Air New Zealand (Captain Gemmell), and a representative of the
Airline Pilots Association, named in the present proceedings as the
fifth respondent (First Officer Rhodes).
Mr Chippindale conducted intensive inquiries at the site of the crash
and instructed that all reasonable steps were to be taken to recover
equipment that would bear upon the cause of the accident and any
documents which were still accessible before they were blown away into
crevasses or covered with snow. Two important items were soon
discovered: the cockpit voice recorder was found at once and after a
period of systematic digging into the snow the digital flight data
recorder was recovered as well. The first piece of equipment provided a
tape recording of much that was said on the flight deck during a period
of 30 minutes preceding the time of the collision with the ice slope.
The second, often described as the "black box", provided conclusive
information concerning course, altitude, and other data relating to the
flight and functioning of the aircraft at the relevant period of time.
Mr Chippindale continued his investigation in New Zealand where he
inspected records gathered from the airline. He also interviewed pilots
and other officers with relevant information. In addition he travelled
overseas. At that point he prepared an interim report so that he could
give notice of his tentative findings to all those whom he felt might
have some degree of responsibility for the accident. Thus the airline
and representatives of the deceased pilots and others were given an
opportunity to provide any appropriate answer to the chief inspector
before he completed his final report. All this was attended to and his
report, which is dated 31st May 1980, was made available to the Minister
of Transport on 3rd June 1980. The Minister then approved the report for
release as a public document on 12th June 1980. As mentioned, the Royal
Commission was appointed for the purpose of conducting a public inquiry
at that same time.
There is a difference in the two reports upon the cause of the accident.
Mr Chippindale considered the probable cause to have been pilot error.
On the other hand the Royal Commission exonerated the pilots completely
and spoke instead of "incompetent administrative airline procedures".
Since this case is concerned with allegations by the Commissioner that
the affected officers of Air New Zealand had engaged "in a
pre-determined plan of deception ... to conceal a series of disastrous
administrative blunders" (administrative mistakes which he himself had
found to be the real cause of the disaster) it is not unimportant to ask
what relevant information the airline had actually been able to provide
which was not supplied to Mr Chippindale. For that last reason the
material made available for consideration by Mr Chippindale deserves
some examination. An example concerns the change made to the final stage
of the computer flight track to the Antarctic which the Commissioner
regarded as a central reason for the accident. During a period of
fourteen months prior to the fatal flight Air New Zealand's ground
computer had contained an incorrect geographical reference to the
southern waypoint of the journey at McMurdo. Accordingly, in that period
it was shown incorrectly on any computer print-outs of the flight plan.
But a few hours before departure of the DC10 an amendment was made and
the flight crew was not informed that amended co-ordinates (since their
briefing 19 days earlier) had thus been fed into the aircraft's
computer.
In paragraph 44 the Report explains that the chief executive of the
airline was told of this matter on 30th November. Then in paragraph 45
it is said that the chief executive "determined that no word of this
incredible blunder was to become publicly known". There follows a
statement that a direction was thereupon given "that all documents
relating to Antarctic flights, and to this flight in particular, were
to be collected and impounded. They were all to be put on one single
file which would remain in strict custody. Of these documents all those
which were not directly relevant were to be destroyed". The reference in
this context to the amendment to the co-ordinates invites the question
as to whether Mr Chippindale had been given that particular information
by the airline during his own investigation. It is made plain in his own
report that this had been done immediately.
He himself was not uncritical of the administrative work of the airline
as it touched upon the fatal flight and concerning this matter he said:
"3.5 The flight planned route entered in the company's base
computer was varied after the crew's briefing in that the position
for McMurdo on the computer printout used at the briefing, was
incorrect by over 2 degrees of longitude and was subsequently
corrected prior to this flight."
The variation in the computer _after the crew of the DC10 had been
briefed_ (as Mr Chippindale realized) is the matter which is mentioned
by the Commissioner in paragraph 44 and which in paragraph 45 is offered
as the motive for what is there described as an immediate decision by
the chief executive that no word of the matter was to become publicly
known, with documents to be impounded and others destroyed. This
information was given into Mr Chippindale's hands by Air New Zealand in
a written statement on the day following his return from the crash site
in Antarctica.
The Chippindale report then states in paragraph 3.6 that the computer
error had remained in the flight plans for some fourteen months. Then it
is said:
"3.7 Some diagrams and maps issued at the route qualification
briefing could have been misleading in that they depicted a track
which passed to the true west of Ross Island over a sea level ice
shelf, whereas the flight planned track passed to the east over
high ground reaching to 12450 feet AMSL.
3.8 The briefing conducted by Air New Zealand Limited contained
omissions and inaccuracies which had not been detected by either
earlier participating aircrews or the supervising Airline
Inspectors."
So these various matters (also mentioned by the Commissioner) were well
within Mr Chippindale's knowledge. However he came to a final conclusion
that pilot error had been involved as a probable cause of the accident
while the Commissioner (who decided this was an incorrect finding) was
satisfied instead that the cause of the accident was not pilot error at
all. He said:
"393. In my opinion therefore, the single dominant and effective
cause of the disaster was the mistake made by those airline
officials who programmed the aircraft to fly directly at Mt. Erebus
and omitted to tell the aircrew. That mistake is directly
attributable, not so much to the persons who made it, but to the
incompetent administrative airline procedures which made the
mistake possible.
394. In my opinion, neither Captain Collins nor First Officer
Cassin nor the flight engineers made any error which contributed to
the disaster, and were not responsible for its occurrence."