Originally Posted by
3 Holer
I notice you have left out two important IF(s).
- if the Navigation Section hadn't changed the final waypoint to a position directly behind high terrain.
- if after making this change, had advised the operating crew about it.
I notice the tone of the posts now are softening a little in respect to blame versus contributing factors. It's a pity Ron Chippendale didn't apply that sentiment when he drew up his final report. The findings of his report (Pilot Error) was what ignited the search for truth.
There has always been three camps in this debate. The Chippendale, Mahon and Moderates.
The Mahon report contained overwhelming evidence it was not pilot error that caused this accident. That finding upset the Chippendale/Air New Zealand and NZ Government so began years of trying to overturn that conclusion. To no avail. In fact, the compensation paid out to victims by the Air NZ insurers and NZ government, the failure of the appeal to the Privy Council to overturn the findings in the Mahon inquiry and finally an apology by both these parties to the families of the flight crew, further crystallized the Mahon findings. They have never been overturned on appeal.
I have no doubt this debate will continue but The Honourable Justice Mahon got it right and the findings in his inquiry still stand today.
India Four Two, a very nice touch and prudent post to end (until the next chapter) this debate.
I think you will find that I repeatedly state in all of my posts that I consider the contributing factors and systemic failures associated with AIR NZ are incontrovertible fact and as you state without the navigation bungle the crash would not have happened. I am just pointing out that you can not alleviate the crew of ALL responsibility either as to do so means that many learnings from this accident will be lost. I agree there are major flaws with Chippendale's report as even though he identified some relevant issues he totally ignored the part that the company played, the Mahon review did the total opposite, he identified the company errors and totally disregarded some errors made by the crew. I personally like to learn from these incidents and have been involved with Safety and Accident investigation for many years for mainly selfish reasons. Because of accidents like this one if I am flying into an airfield or environment with high terrain that I am unfamiliar with I will carry out full procedural arrivals over a visual approach every time even in CAVOK conditions until I have gained some local knowledge as I have read way to many reports of CFIT where a loss of situational awareness of position and terrain lead to loss of life. I can't hand on heart say that I would have done anything different on the day to the crew onboard TE901, we should be in an industry though that accepts the errors that get made and do our best to learn from them. Having a 'blameless' culture is detrimental to a good safety system as ignored errors are errors that will happen again.