Commission Effects and Outcomes

The unshakeable reluctance of the Prime Minister and the airline's chief executive to accept systemic or organisational error played a causative role in the accident that was so absolute that it eventually led the early retirements of Captain Vette and Justice Mahon, and to the shelving of judge's "Mahon Report". It has been commented that the death of Justice Mahon (1923-1986) may have been “hastened by the pressures associated with his stand for truth and justice, (and) deprived New Zealand of ten productive years of a jurist capable of providing much needed social, cultural and commercial leadership” (Auckland Faculty of Law Annual 2006 - 2007)

 

In 1983, Captain Vette published “Impact Erebus” and in 1999 he published, along with John MacDonald, “Impact Erebus II” accompanied by an introductory DVD. From an interview with Ian Johnston in 1984, shown on the DVD, Justice Mahon said the following about Captain Vette when answering the question about whether Vette had helped make a similar sort of accident less likely to happen again: “I think that Captain Vette succeeded to an unprecedented degree. When he gave evidence at the inquiry he produced written material which demonstrated this “flat light phenomenon”. He produced from overseas a man acknowledged as a world expert in the field who confirmed the existence of this illusion and this in turn set me on the track of overseas inquiries which I made in the United States, in Canada and in England from top class experts. They all confirmed what I had been told at the inquiry through Vette’s efforts and finally I went to Antarctica and there the thesis was again confirmed especially when I was taken for a flight myself in white out conditions and saw with my own eyes the flat terrain of ice and snow stretching forth for more than forty miles when in fact right in front of us there was a snow ridge several hundred feet high….An overseas expert in jet training and jet operations has said that this report has made the world a safer place to fly in.. Well if that is so, that is due to the persistence of Gordon Vette and the evidence he produced which directed me and counsel of the Royal Commission onto the right path.”

 

In July 1998, in recognition of his important contributions to flight safety, Captain Vette received an Honorary Doctorate of Engineering from Glasgow University, Scotland. During the presentation, the university representative had the following to say about Vette: “Today we honour a man of undoubted integrity, a highly trained and gifted pilot, with an inquisitive deductive brain, of high intellect. His selfless actions have the respect of us all and he is an outstanding role model for today’s graduates” ( Impact Erebus II DVD).

It is of great significance that Captain Vette’s extensive work and ground-breaking hypotheses on the Erebus accident have changed the way accident investigators think about commercial accidents of all kinds. The investigations of the Erebus accident have taken two distinct directions:

the first is the example of some people’s tendency to make the evidence fit pre-determined views and therefore learn nothing new to prevent further accidents;

the second is developing a scientific explanation about how the apparently inexplicable can happen and, through knowing the full facts of an “organisational” accident, prevent the same accident occurring again.

Today, because of Gordon Vette’s efforts, determination and dedication, the International Civil Aviation Organisation (ICAO) uses the Erebus crash to demonstrate how latent and active failures combined to cause an “organisational” accident. “The Erebus Report was probably 10 years ahead of its time……In retrospect, if the aviation community and the safety community at large had grasped the message from Antarctica and applied its prevention lessons, Chernobyl, Bhopal, Clapham Junction, King’s Cross and certainly the Dryden Report would not have existed”( ICAO Human Factors Digest No 10).

The report from Chief Accident Inspector Ron Chippindale remains the official state report on the Erebus accident at ICAO. However, since 1999, when then Transport Minister Maurice Williamson presented Justice Mahon’s Erebus Report to Parliament, there is a second version of events in the ICAO records of Erebus for the world to consider.

NZALPA encourages you to read “Impact Erebus” or view the DVD to gain some understanding of the human factors science, visual illusions produced by sector whiteout and systemic or organisational errors. NZALPA encourages you to delve deeper into the tragedy of TE901 and the extraordinary efforts of Gordon Vette to uncover the comprehensive story of the accident, thereby making flying safer for crew and passengers.

NZALPA sincerely thanks Captain A. Gordon Vette ONZM D.Eng (Glasgow) for the many references used in the article from “Impact Erebus” and his DVD “Impact Erebus II”.