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Old 30th Nov 2019, 05:11
  #156 (permalink)  
megan
 
Join Date: Mar 2005
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I know I myself have learned from this that one should never just take someone else's numbers without verifying. Take the 5 minutes then.
To me the key moment was when Collins accepted the new coordinates without rechecking them against his notes at least and thus not realizing the last few numbers were different.
Had he at that point sat down with his notes and compared numbers we would not be chatting today.
The crew should have been alerted to the change of coordinates by an "Ops Flash" contained at the top left of the flight plan, the relevant box contained no message of any sort. The way point had been changed some eight hours prior to departure and the navigation section, in keeping with its previous lack of attention to detail, didn't see fit to notify the change. Captain Collins plotted the route of flight from the coordinates given at the briefing and used by the previous flight undertaken by Captain Simpson two weeks prior. Those same erroneous coordinates for McMURDO had been used by flights on 7/11/78, 14/11/78, 21/11/78, 28/11/78, 7/11/79, 14/11/79. Captain Collins flight had the way point changed to the coordinates of the TACAN.

Flights on the 15/2/77 and 22/2/77 used the coordinates of Williams Field as the McMURDO way point. For the flights on 18/10/77 and 1/11/77 the McMURDO way point was changed to the NDB, about two miles from the Williams Field way point. It should be pointed out that through all the way point changes it was annotated and identified as McMURDO on the flight plan.

The navigation section and crews flying the route on five previous occasions did not detect the anomalous way point position 27 miles away in the sound. It was not until the sixth flight, immediately preceding Captain Collins, that the error was questioned Captain Simpson.

The accident was the culmination of airline culture, lack of training, lack of observance of SOP's by all crews, unclear briefings (the reason for lack of SOP observance, hell, the airline even used the lack of SOP observance as publicity). Captain Collins and crew unfortunately pulled the trigger of a gun manufactured and loaded by many others. A seminal accident for the James Reason Swiss Cheese model. RIP all.

Safety is everyone’s responsibility -“Responsibility lies with those who could act but do not, it lies with those who could learn but do not and for those who evaluate it can add to their capacity to make interventions which might make all our lives the safer”. (Phillip Capper)
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