New Zealand has failed to learn from disasters such as Cave Creek and Mt Erebus in preventing tragedies, the Pike River inquiry has heard.

The accusation came on the eve of today's first anniversary of the deaths of 29 men after the fatal explosion at the underground West Coast coalmine.

"Sadly, but of crucial relevance for future safety, Pike River proves that we have failed to learn from previous accidents," Auckland University's human factors group director, Dr Kathleen Callaghan, told the inquiry yesterday.

THIS WOMAN KNOWS ALL ABOUT AIRCRAFT?
SHE TOOK OVER 25 HOURS TO GO SOLO IN A TOMAHAWK, AND HAS THE AUDACITY TO SAY AIR NEW ZEALAND LEARNT NOTHING FROM LOOSING ZK-NZP AT MT EREBUS.
HOW DO THESE PEOPLE GET HEARD ON THE PUBLIC PURSE.

Begging the question, but what does an explosion in a New Zealand coal mine in 2010 have to do with a DC-10 CFIT into an Antarctic Mountain in 1979?

SHE TOOK OVER 25 HOURS TO GO SOLO IN A TOMAHAWKMaybe she was being instructed by a low-hours PPL who was 'hour-building'? :)

But seriously, point taken....what the heck is the connection with Erebus and Pike River? It is certainly true that almost all accidents (and incidents) are the result of a chain of issues or failures but why bring Erebus into it? Consider a motorway smash....everyone traveling closer than thinking distance (the norm) at speed, a driver overtired gets fazed when hitting a patch of bad viz and loses it. Massive smash-up like you get on the Po valley regularly. Cause: Dopey driver, tailgating, bad viz. It's a combination and sequence.

Absolutely nothing, but callaghan made a reference to mt erebus as an expert witness.
She was once the pmo of nzcaa and successfully grounded nearly every pilot over 60 by applying a heart foundation table to the older pilot group.
I understand that she once had ambitions of getting into nasa!:*
Her flight instructor was a B cat on a CPL (NZ Ratings) and was a very experienced instructor.

I think the phrase "clutching at straws" applies here.

For what it is worth, the enquiry into the Pike Rive mine disaster is revealing an apparently serious set of failures in the systems for ensuring mine safety. Her claim would be that Mt Erebus revealed similar system failure. The link would be that both events caused major loss of life in New Zealand arguably as a result of deficiencies in safety management. I don't know how valid her claim is: NZ has changed a lot between the two events, and any failures in the Erebus case were likely caused by amateurish mateship the sense everyone knows everyone and we're all good blokes and don't need to be bureaucratic. The mine explosion, if the allegations prove to be true, was caused by single-minded following of market forces, self- or de-regulation, and a distrust of civil servants. Similar, actually, but with different ideologies.

Believe it or not, but pilots are human. Just as mine workers are. Their errors are the same. Even if you've flown solo after just 15 mn of dual flight, you're just a human (and you should be warned about the dangers of overconfidence).

So it makes sense to study human errors globally, and not just to stick to aviation. You learn from others' errors.

Interestingly two of the key people running the Pike River Mine were previosuly very senior inspectors within the Queensland Department of Mines and as such perhaps should have been a little more aware of the risks and diligent in their provision of advice regarding the safe operarion of this mine.

However I fail to see how "lessons learned" re Mt Erebus can be related to the Pike River disaster:confused:

SHE TOOK OVER 25 HOURS TO GO SOLO IN A TOMAHAWK


Your point? That it's better for people to have fewer hours before being left in sole charge of an aircraft? :hmm:

"Your point? That it's better for people to have fewer hours before being left in sole charge of an aircraft? "

The point would appear to be that there is no evidence of any natural talent in piloting a small aircraft. Of that points relevance to any enquiry is a bit harder to understand.

It is however easy to connect the lack of oversight by the regulatory bodies who were supposed to oversee that the required regulations are being complied with were as absent in Pike River as they were in the Mt Erebus disaster.

Erebus has been in the public eye in NZ again recently, following the release of a book by that merdia aviation 'expert' ( see below ) Paul Holmes, a one time NZ TV news presenter, and Stearman pilot who had to land said Stearman once - to enquire exactly where he was !

I haven't,and won't, read the book, but those who have reckons he champions the crew and rubbishes the opinions of the Chief Inspector of Accidents and the Judge presiding over the Court of Enquiry. Not having read it I can't comment on the opinion of others of course.

As a result, it has been suggested to me that the widow of the, then, aforementioned Chief Inspector of Accidents might well have a case for libel against P.H.

Not for me to judge whether he is right or wrong, but dredging it all up again for personal publishing profit is a bit tasteless in my opinon, a publication entitled The Erebus Papers (which I have read ) contains everything that was published at the time, make your own mind up.

Nb. X is the unknown quantity, and a spurt is a drip under pressure.

Paul Holmes made a major contribution to flight safety in NZ by giving up flying !

<<You cannot libel the dead, although it is possible that a comment about someone no longer living may be libellous of that person’s relatives, colleagues or friends.>>

Why did ANZ almost immediately dump DC-10s for B747s after Erebus?

Hi Folks,

I've read PH's book & as a pure read I found it mostly quite good. The content of course will always be contentious, as there were so many parties involved, Flight Crew, Air Accident Investigation Branch, Air New Zealand etc.
I did think at the time of the tragedy though, that it would have been advisable, eventhough the Flight Deck Crew had been given a verbal briefing, as this was the Pilots first Antarctic flight, they should have had a Training Captain with them on the day.
I operated the DC10 for six years, lovely aircraft & it took me to some great destinations along the way
Long time ago for Erebus though & I appreciate their are many views held by many people on this accident. God Bless all those on board that day, their families, colleagues & friends. Best to let rest I think.

"Sadly, but of crucial relevance for future safety, Pike River proves that we have failed to learn from previous accidents," Auckland University's human factors group director, Dr Kathleen Callaghan, told the inquiry yesterday.

THIS WOMAN KNOWS ALL ABOUT AIRCRAFT?
SHE TOOK OVER 25 HOURS TO GO SOLO IN A TOMAHAWK, AND HAS THE AUDACITY TO SAY AIR NEW ZEALAND LEARNT NOTHING FROM LOOSING ZK-NZP AT MT EREBUS.
HOW DO THESE PEOPLE GET HEARD ON THE PUBLIC PURSE.

I would suggest you are viewing her statement from entirely the wrong perspective.

She is not commenting specifically about aviation nor is she commenting specifically about mining. I would guess she mentioned Cave Creek and Erebus because these are two classic examples of systematic failure (ergo the reason model) all kiwi's know about.

I recently had a lengthy discussion with a chap about safety in the power industry. Turn's out they rely heavily on the reason model too (no real surprise). I knew nothing about the power industry, he knew nothing about aviation but the model transcends the industries and we had an interesting discussion.

Dr Callaghan's evidence to the Pike River enquiry (Commission Hearings - pikeriver.royalcommission.govt.nz (http://pikeriver.royalcommission.govt.nz/Commission-Hearings)) concerned basic Human Factors matters and their influence on events. The Phase three evidence thus far gives the strongest possible indication that the Swiss Cheese theory came into play at Pike; all the holes eventually lined up and the tragic outcome was an explosion.

As with many accidents in aviation, industrial and other processes and activities had the "chain"of events been broken (by regulation, inspection, training or otherwise) the disaster might have been avoided.

That's what Callaghan specialises in; how long she took to solo an aircraft has absolutely nothing to do with it!

Why did ANZ almost immediately dump DC-10s for B747s after Erebus?

The accident had nothing to do with the 'type' of aircraft, in that era both DC-10's and 747's used INS as their primary navigation aid, tho' in this accident the Mark 1 eyeball was supposed to make the final decision i.e. they had to be visual before descending to the lower level. ( I'm not making a judgement, read it all for yourself. )

A Cessna 152 fitted with INS and with waypoints programmed as that DC-10 had been - and flown by the same crew responsible for decisions and actions taken - would have had the same result.

This is not a Boeing / Douglas / Airbus thing, but maybe Air NZ felt that the " image " of the DC-10 being a " dangerous " aircraft as a result of Erebus, was likely to influence ticket sales, just as Lockerbie gave PanAm an image of being a dangerous airline to fly with, and the public had a choice, albeit misguided, after Lockerbie PanAm would probably have been the safest ! ( but try telling that to the travelling public, " image " is everything, stuff the "facts". )

The Fickle Finger of Fate.

This is not a Boeing / Douglas / Airbus thing, but maybe Air NZ felt that the " image " of the DC-10 being a " dangerous " aircraft as a result of Erebus, was likely to influence ticket sales, just as Lockerbie gave PanAm an image of being a dangerous airline to fly with, and the public had a choice, albeit misguided, after Lockerbie PanAm would probably have been the safest ! ( but try telling that to the travelling public, " image " is everything, stuff the "facts". ) I totally agree. Similar story with the de Havilland Comet and metal fatigue which wasn't properly understood or factored-into designs until the first Comet disasters. Interesting that Nevil Shute (designer R100 and founder/designer Airspeed Ltd) predicted the consequences of fatigue in 'No Highway' -- which might have a different title in the USA? The fictional 'Reindeer' and the wonderful eccentric RAE Farnborough boffin, Mr Theodore Honey. Also true of the airships R101/R100. Shute tells the story in his autobiography, Slide Rule.

As a result, it has been suggested to me that the widow of the, then, aforementioned Chief Inspector of Accidents might well have a case for libel against P.H.

That's as maybe, but let's face it - some of the things he did were woefully naive. Re-editing a CVR transcript alone with a management representative from the airline present? Without notifying a single member of the group who had agreed on the CVR transcript only days before? Such things would not be accepted in this day and age, and rightly so. As a pilot and investigator he may have been a top-drawer example of the time, but there's no way that his methods would be accepted today.

This is not a Boeing / Douglas / Airbus thing, but maybe Air NZ felt that the " image " of the DC-10 being a " dangerous " aircraft as a result of Erebus, was likely to influence ticket sales...

I always had it as a simple matter of economics. As far as ANZ at the time was concerned, their primary competitor was Qantas and Qantas used 747s, which on paper at least made more sense than the DC-10.

I always had it as a simple matter of economics. As far as ANZ at the time was concerned, their primary competitor was Qantas and Qantas used 747s, which on paper at least made more sense than the DC-10.

So why buy the DC-10 in the first place ? Maybe 'cos they were already a 'Douglas' airline, better the devil you know ?

History now, anyway.

ExSp33db1rd:The accident had nothing to do with the 'type' of aircraft, in that era both DC-10's and 747's used INS as their primary navigation aid, tho' in this accident the Mark 1 eyeball was supposed Arriving to the scene of the accident would have been the same, regardless of airframe, as they were depending on Lat/long entries in the 3 inertials. The difference was in the aftermath.

The ANZ DC-10 fleet had the Collins AINS-70, Area Inertial Navigation System that was 20 years in advance of the competition. Its dual NCU, Navigation Computer Units, were fed by 3 Litton ISU, Inertial Sensor Units, and mixed/averaged their outputs for navigation. One of the NCUs was recovered from the wreckage, and its two 8K(!) magnetic core modules were read out at Collins in Iowa, USA. They revealed the waypoints entered by the crew, and the aircraft's track for its last half hour.

That data exonerated the Litton ISU, the Collins AINS-70, and the DC-10 in its tragic year of the AAL crash in Chicago and a WAL crash in Mexico City. Without that data, the DC-10 would have no doubt been relegated to cargo service much sooner.

INUs of that era had only last position in their memory. They would have had to recover all 3 INUs to exonerate the INUs in the 747, and still, they would have had no evidence the wrong lat/long had been entered for the intended McMurdo reporting point over the Ross ice shelf. ANZ staff would have got away with blaming the airplane, or maybe even the pilots, while shirking their own responsibility.

GB

Thank you, interesting.

Paul Holmes book has been rubbished by a professional pilot

The man who's written an article criticising Paul Holmes' book on the Erebus disaster says he's been inundated with support.
Airline commentator and former pilot advocate Derek Ellis says the book was extremely biased.
He says Paul Holmes' admits in his prologue he'd only talked to people he knew would agree with his preconceived intention to exonerate Captain Collins.
Mr Ellis says he's had a mass of phone calls and online responses to the article, all of which support his article.
"Such things as, 'a breath of fresh air, at last the true story is being told'."


Support flows for Erebus book critic - Yahoo! New Zealand News (http://nz.news.yahoo.com/a/-/mp/13162441/support-flows-for-erebus-book-critic/)

:D

Mr Ellis says he's had a mass of phone calls and online responses to the article,

try ......

New Zealand Herald (http://www.nzherald.co.nz/erebus/search/results.cfm?kw1=Erebus&kw2=&st=gsa)

if this link doesn't work, do the www bit for the NZHerald with the .co and .nz after it, and when you get into the site type Erebus into the search box at the top.

When I tried to type it as a regular URL it all went weird here !!

The call by Paul Holmes and Peter Dunne for exoneration of the pilots of the Air New Zealand DC10 aircraft which crashed into Mt Erebus is not appropriate.


It is the prime duty of an airline captain to deliver his passengers safely to their destination. Captain Jim Collins failed in this duty.

I say this as a professional airline pilot with no connection to any person affected by the accident, which probably makes mine unique among the opinions expressed on this tragedy.

We all have absolute sympathy for the relatives of those tragically killed in the Erebus accident. There is no similar sympathy on the part of Peter Dunne and Paul Holmes for those Air New Zealand personnel, and their families, unfairly and incorrectly blamed by the late Peter Mahon for the DC10 accident on Mt Erebus. Peter Mahon's allegation that they had lied under oath when giving evidence was successfully appealed by Judicial Review to the New Zealand Court of Appeal. This caused the resignation of Peter Mahon as a judge. His subsequent appeal to the Privy Council supported the finding of the New Zealand Court of Appeal.

Responsibility for the Erebus tragedy must remain with Captain Collins, as found by the official accident investigation. This finding is still valid.


These extracts are from the recent New Zealand Herald article by Derek Ellis, a retired British Airways captain living in New Zealand.
It strikes me that despite Ellis's undoubted competency and experience as an airline pilot, he is another to join the band waggon of those many who have prejudged the causes of this accident. Perhaps, behind the scenes, the media saw an opportunity to hit back at Paul Holmes, consequently calling upon a man such as Ellis to wade in with the
old claymore, delivering blow after blow to Collins at the same time.

Whether or not this theory holds water, the fact remains that Ellis has out of hand condemned Collins, most regrettably receiving in this attack, wide media coverage under the banner of his expert status. Hence the public yet again are inflamed to believe not only that there were, and possibly still are, maverick airline pilots on the loose, but moreover that Collins, in the case of the Erebus tragedy, must bear the entire blame. This is manifestly absurd. To get to the causal truths is no simple task. It requires much study of the huge file that has amassed since the first enquiry. Yet the partial, inadequate, biased and uninformed execration of Collins and Mahon goes on and on.
(Madame Defarge knitting by the guillotine is not a totally unapposite image.)


Where Ellis gratuitously states that . .. . .
"it is the prime duty of an airline captain to deliver his passengers safely to their destination. Captain Jim Collins failed in this duty" . . .. many will be those who themselves, through their professional lives, know the truth of this injunction, in their water, but who will wince to hear this absolute given trotted out by Ellis with the glib rider that Jim Collins in effect stuffed up. Forgot the creed he held in full trust all his working life. Not good enough Captain Ellis. Please look at every aspect of this very complex accident before you again pass summary judgement.

.........you again pass summary judgement.

Capt. Ellis had articles published in "New Zealand Wings" in the mid 1980's
and the magazine, now renamed Pacific Wings, has seen fit to publish his rebuttal of Holmes' book in their April edition now on the bookshelves.

I suggest that you read it, which ends with a brief C.V. of Capt Ellis's background, he certainly hasn't passed "summary judgment". Whether you agree or not is, of course, your privilege.

Capt. Ellis has been passionately interested in this affair almost from day one, as have I, my having been asked by a lawyer acting for the aviation interests of Lloyds of London, on the morning after the news broke in the UK, what was meant by " Grid Navigation in the Polar regions" which had been mentioned at that time, albeit somewhat irrelevant in view of the fact that that navigational procedure had been superceded by the adoption of INS procedures by then, procedures which Capt. Ellis maintains would have prevented the accident had they been followed as prescribed, i.e. the Lat and Long of the next, and each subsequent, waypoint being checked against a chart as they were overflown.

This would have shown the crew that they were now proceeding over, or near to, Erebus to the - now correct - waypoint, not the previously promulgated incorrect one, which they may well have previously "fixed" in their consciousness, thereby giving them the assurance that they "knew" where they were going, so didn't bother to re-check. Maybe. If so then 'trouble was, it was the wrong one. We'll never know.

Whether or not you agree with Capt. Ellis, or indeed any of the many pronouncements that have appeared attempting to explain this tragedy, the fact remains that a pilot flew a perfectly serviceable aeroplane into a mountain, whatever information, correct or otherwise, persuaded him to do so.

Very early on in my airline career I was told that each and every action that a Captain makes has to be prefaced, albeit subconsciously, with the question - "At the subsequent Court of Enquiry, can I justify what I am doing ?" Capt Collins obviously thought that he could, sadly he was wrong.

You may say that There But For The Grace of God have gone many others that is no defence - The Buck Stops Here.

I agree that exoneration is not appropriate.

Following my comments yesterday - above - I re-read the article in the magazine that I had referred to, and after that another article outlining conditions for being accepted as a pilot by Air New Zealand, which at the very beginning states :~

"The Captain is legally responsible for the conduct of the flight, and for the safety of the aircraft and all its crew and passengers" and goes on " First Officers contribute actively to the decision making PROCESS in flight, but the Captain always has the final decision making AUTHORITY".

QED.

Regrettably, Capt. Collins didn't fulfill that responsibility - for whatever reason or circumstances that others might think had some bearing on his actions; even if you think he was influenced in some way, or ways, by others, ultimately his decisions, and his alone, dictated the eventual conduct of the flight.

No way should exoneration be considered. Sadly.

"The Buck Stops Here "

It was written at the time that the pilots did not have a chart even as good as a National Geographic map in their possession. Whose fault would that be, if true?

Overconfidence in the Collins AINS-70 was certainly a factor.

GB