Beaufort Island
The links posted yesterday by Desert Dingo demonstrate the point: The 3D diagram is at page 103 of the Chippendale Report. At the position marked "P" on the track, the flight commentator says: “There you go. There’s some land ahead.”
Mahon Report, page 154: These are two photos taken by passengers seated on the right-hand side of the plane. They must have been taken just after the completion of the final 180 degree orbit. The scanned versions of the photos shown in the link posted yesterday are not as quite as good as those shown in the original Mahon Report, but they demonstrate the point. This is not an anonymous rock in the middle of the ocean. (In fact, it is about 4 nautical miles long and its maximum height above sea level is 2428 feet.)
It has to be assumed that the crew saw what the passengers and the flight commentator saw. The sighting of this island should have resulted in an appreciation that things were not quite right. If the McMurdo Sound nav track had been plotted on a map/chart, then the plain fact is that there should not have been an island of significant size and height in that position. If this had been appreciated, it would have been a simple matter to check the current coordinates being generated by the AINS, at which point, the appreciation of the things being not quite right would have become an appreciation of things being very wrong. The crew would then have done a 180 degree turn, climbed back to 18000 feet, and then tried to figure things out.
It appears that the crew saw the island but never appreciated that it wasn’t supposed to there. That failure in itself is not necessarily pilot error. However, the failure supports Chippendale’s finding that the crew did not attempt to verify their position before commencing their descent to McMurdo Station. It is useful, in my opinion, to ask what the situation would have been if it was intended to land at McMurdo Station. In that event, verification of the aircraft’s position independently of the AINS would have been an absolute requirement. There could have been no landing approach unless and until the position had been verified. The approach that the crew were about to commence was similar to a landing approach. It is reasonable to expect the crew to have taken similar precautions, before commencing their descent from 18000 feet. There were only two available methods to verify their position: (1) Visually, using a chart, or: (2) By ground radar. (Although McMurdo Station had an NDB and a TACAN, the NDB wasn’t working and the TACAN only provided the distance from the TACAN to the aircraft, not the distance and bearing.) Visual verification from 18000 feet was difficult, given the cloud cover. And the crew had not been advised that Air Traffic Control had located the aircraft on radar. In those circumstances, the aircraft should have stayed at 18000 feet. (This, of course, would have meant that the passengers would not see McMurdo Station, because no cloud-break procedure was available, because the NDB wasn’t working. So there was an obvious temptation to take the opportunity presented by the hole in the cloud cover.)
Several contributors cite the alleged prohibition against descent below 18000 feet before passing Erebus, as did Ron Chippendale. But if you plough through Mahon’s Report, it’s difficult to see an unequivocal prohibition against descent below 18000 feet in VMC. When the issue is pilot error, however, does there have to be a breach of an express rule? You can’t have a rule for every conceivable situation. Where the rules are silent, you are left with the rules of good airmanship, and the pilots are to be judged against the standard of the average pilot - not the best, and not the worst. If the crew of TE901 were guilty of pilot error at any point, it was when they commenced their descent from 18000 feet before verifying their position. The crew might have thought that they could obtain a visual fix once below the cloud, or that they would be picked up on radar. But at the time they began the descent, the only positional information they had was from the AINS, yet they were going to descent to an altitude that was below the height of an obvious hazard. If they made an error, that was it.
Mahon, and his legal lapdogs, such as Stuart Macfarlane, have devoted hundreds of words to the reliability of the AINS. From this, they conclude that the crew was entitled to descend from 18000 feet, because their position did not need to be verified, because the AINS is never wrong. Yet they make these statements in the context of an accident where the AINS directed the aircraft into the side of a mountain. Of course the AINS can be wrong. It requires human input. Humans make mistakes. In the case of TE901, a print-out of the waypoints was provided before take-off. Wasn’t it possible that the Navigation Section might have made an error? The waypoints on the print-out were then entered into the AINS by one of the crew. Wasn’t it possible for a typing error to have been made and not picked up in the cross-checks? It is always possible for the AINS to be wrong, which is why the position had to be verified before descending. If that basic principle had been adhered to, the accident would not have occurred.
So the crew has to bear a share of the responsibility. How much? Although Mahon was a one-man band, he had an experienced aviator to assist him: Sir Rochford Hughes. After the report was published, Sir Rochford said that although he agreed with much of the report, he believed that the crew had to bear a share of the blame, and he put that share at 10%. If Mahon had said the same thing, this argument would have been over decades ago.
On the topic of Messrs Mahon and MacFarlane, anyone reading MacFarlane’s book will note the constant attempts to find contradictions between what someone said on one occasion and what they said on another. (His attempts usually fail. On the rare occasions that he succeeds, it’s to a nitpicking degree.) Yet MacFarlane never puts Mahon under his forensic microscope. If he had done so, he might have noted something a little strange about Mahon’s statements concerning Beaufort Island.
In his report, at paragraph (i) on page 115, Mahon says:
“It therefore follows that because Captain Collins believed that his nav track was taking him down the centre of McMurdo Sound, no one on the flight deck would ever identify any island on or near their path as being Beaufort Island. They would all be aware that it was far away to the north-east, and I venture to say, that although no direct reference is made to the point in the CVR transcript apart from Mr Mulgrew’s “land ahead”, the five persons on the flight deck undoubtedly saw Beaufort Island, and mistook it for a different island altogether, probably, as Mr Shannon thought, Dunlop Island, which is off the Victoria Land coastline. Anyhow, in the minds of the crew the island they must have seen could not possibly have been Beaufort Island, because as previously indicated, the latter landmark would be many miles away in quite a different location.”
Then, at page 153, while discussing AirNZs failure to ensure that a member of the crew has previous Antarctic experience, Mahon says:
“But a previous flight under supervision would almost certainly have resulted in Captain Collins noting the distinctive feature of Beaufort Island which would have been apparent as the only identifiable island in the area. Figure 16, page 154, consists of prints developed from passengers’ cameras, in which Beaufort Island is clearly visible. The film in each case was slightly damaged, and the actual view of Beaufort Island would have been more distinct than the view displayed on the prints. Had Captain Collins seen Beaufort Island previously, and identified it on the fatal flight, he would certainly have realised that his nav track had been changed.”
In his report, Mahon also refers to his visit to Antarctica, one year after the accident. His report, obviously, was published after that visit and it contains the conclusions he formed as a result of the visit.
It is clear, from the report, that Mahon concluded that Peter Mulgrew was on the flightdeck when Beaufort Island was visible. He says that the five persons on the flightdeck, one of whom was Mulgrew, “undoubtedly” saw the island. And Mahon had no difficulty accepting that when Mulgrew said “land ahead”, Mulgrew was referring to Beaufort Island.
After the report was published, Mahon’s findings concerning Beaufort Island were criticised, deservedly. Then, three years later, Mahon wrote his book, “Verdict on Erebus”. In his book he again describes his visit to Antarctica, and he again describes the conclusions he drew from that visit - and he again refers to Beaufort Island, at pages 199-203 of his book.
At page 199, Mahon begins with
“But, equally significantly, was the view I has seen from the Hercules of Beaufort Island. Again I has seen exactly what the crew of the DC10 had seen and from the same height and angle of vision. And I thought I had discovered why the crew never identified Beaufort Island, and I was now sure now why Peter Mulgrew had not realised that Beaufort Island was on the wrong side of the aircraft.”
Gents, please read these pages in Mahon’s book. There is absolutely no doubt that he is referring to the conclusions he reached during his visit to Antarctica, which visit occurred, obviously, before he wrote his report. And having visited Anarctica and having reached various conclusions as a result of the visit, one would think that Mahon would have included those conclusions in his report, that being the whole point of the taxpayer paying for him to go down there. So he goes down to Antarctica, forms his conclusions, and then writes his report. In that report, he says that Mulgrew saw the island. But in the book, he says that Mulgrew didn’t.
Don’t take my word for this: Read the report, and then read the book that was written three years later. Both describe exactly the same thing, namely, the conclusions that Mahon reached as a result of his visit to Antarctica. Mahon’s report says that Mulgrew saw the island. Mahon’s book says that Mulgrew did not see the island.
In his book, Mahon suggests that Mulgrew was not on the flightdeck when Beaufort Island was visible. Instead, he paints a dramatic picture of Mulgrew struggling up the aisle of the aircraft on his artificial legs, being detained by passengers wanting to chat, and reaching the cockpit two minutes too late. I’m probably labouring the point here, but if Mahon, on his visit to Antarctica, formed the view that Mulgrew was not on the flightdeck when Beaufort Island was visible, then why didn’t he say so in his report? .
So, can any of the d8ckhead lawyers out there in internetland explain this clear and obvious contradiction? The only explanation is that Mahon was just like most others: On occasions, this one in particular, he did not let the truth get in the way of a good story. If ALPA are going to simply shove the Mahon Report onto the website and say that it is the definitive verdict, there should at least be an asterisk referring readers to the passages referred to above.
My fingers are starting to get a bit sore, but the other contentious aspect of Mahon’s report is his finding that the two AirNZ briefing officers lied under oath when they gave evidence that the crew were told that the nav track went over Erebus, not down McMurdo Sound. This finding was not supported in the subsequent litigation, but, as I’ve said before, I don’t care what another load of lawyers might think. AirNZ’s position was that the nav track was always supposed to be direct to McMurdo Station, over Erebus. AirNZ said that errors were made, which caused the final waypoint to be shifted to a position in McMurdo Sound. AirNZ said that the error was discovered as a result of the conversation between Captain S and Captain J that took place about two weeks before the fatal flight, when Captain S told Captain J that the waypoint was not where he expected it to be. AirNZ said that the error was corrected on the morning of the fatal flight and admitted that the crew was not told. AirNZ accepted that a sample flightplan shown at the briefing contained the erroneous track, down McMurdo Sound. So the allegedly-brilliant piece of forensic analysis by Mahon was on the table right from the outset. All of the relevant facts are recorded in Chippendale’s report. Having admitted to an appalling series of blunders, AirNZ still maintained that the two briefing officers had told the crew that the nav track went over Erebus. The two briefing officers attended the hearing, put their hands on the bible, and gave evidence under oath as to what they told the crew: The nav track goes over Erebus. Mahon found that both briefing officers committed perjury.
It is important to examine what happened immediately after the accident. Ron Chippendale was obviously involved right from the outset. In his evidence to the Royal Commission, Chippendale said he was aware of the change in co-ordinates at a very early stage, but he didn’t know whether it was a cause. So he spoke with the crew who attended the same briefing as the crew of the fatal flight. According to Chippendale, these crew-members told him that they believed that the nav track went over Erebus. Although Mahon does not mention it, Ron Chippendale gave evidence to the Royal Commission that the crew-members who attended the same briefing as the crew on the fatal flight told him that they believed that the nav track went over Erebus. As a result, Chippendale found that the change in co-ordinates was not a cause of the accident, because the crew were told at the briefing that the nav track went over Erebus.
Mr MacFarlane babbles on about Chippendale’s failure to take formal written statements from the pilots he spoke with. In hindsight, that might have been a good idea – but Chippendale didn’t know that this accident would be the subject of 30 years worth of books and articles and internet postings. His job was to investigate the accident and the first thing he had to decide was where he should look. The change in co-ordinates was an obvious avenue if inquiry, so he spoke with the briefing officers and with the surviving pilots who attended the briefing. According to Chippendale, there was no significant dispute. The two briefing officers said that they told the pilots that the nav track went over Erebus, and the surviving pilots who attended the briefing agreed. Given that, Chippendale reported that there was no evidence that the change in co-ordinates had misled the crew.
Some months later, at the hearing before the Royal Commission, the surviving pilots who attended the briefing gave evidence. They said, in summary, that they were not told that the nav track went over Erebus. They said that they believed that the nav track went down McMurdo Sound.
Unfortunately, there does not seem to be room for any middle ground here. Either the briefing officers lied as a result of pressure from AirNZ, or the surviving pilots lied as a result of pressure from the union. Mahon decided that the two briefing officers were lying, but his finding to that effect was based on an assumption that the erroneous McMurdo Sound waypoint was, in fact, a deliberate change, known to the briefing officers. If the briefing officers knew that the nav track actually went down McMurdo Sound, they would not have told the crew that the nav track went over Erebus.
Mahon’s conspiracy theory, to the effect that the McMurdo Sound nav track was deliberate was, in my considered opinion, b8llocks. If the Navigation Section had hatched some bizarre plan to change the track to the military route, then they would have selected the waypoint used on the military route, being the Byrd Reporting Point. They did not. The waypoint was down by the Dailey Islands, in no-man’s land. And its co-ordinates were consistent with an error in data-entry.
Mahon got it into his head that the McMurdo Sound route was the obvious route, so much so that he thought that a route over Erebus could never have been intended. His reason for thinking the McMurdo Sound route to be obvious was the high ground on Ross Island. But lets think about this a little bit. In blue sky conditions, the nav track doesn’t really matter, because you can see the high ground on Ross Island. What if Ross Island and McMurdo Station are covered in cloud? In that situation, if you wanted to see McMurdo Station you had to perform a cloud-break manouvre using the NDB. And how are you going to get to the NDB? Via the nav track. So it makes perfect sense to align the nav track from Cape Hallett with the NDB at McMurdo Station, with the track going over Erebus. If I’m wrong about this, I look forward to being corrected.
The point I’m trying to make is that Mahon’s impression of the evidence of the two briefing officers was affected by incorrect conclusions he drew about other evidence. Isn’t it possible that these two gentlemen might have been telling the truth? In other words, isn’t it possible that the crew were, in fact, told that the nav track went over Erebus? It might be said that this could not have happened, given that the aircraft was flown into Erebus in nav mode. It should be noted, however, that the briefing occurred many days before the flight, and that copies of the McMurdo Sound co-ordinates were available and might have been noted by members of the crew. If that occurred, the pilots might have assumed that the written material was correct, rather than the oral material. The making of such an assumption without seeking clarification would be a clear case of pilot error, but it cannot be discounted.
The issue as to what was said at the briefing is directly linked to the issue concerning the final change of the waypoint. There is no dispute as to the initiating cause of the change: It was the result of the communication between Captain S and Captain J. Captain S attended the briefing. He then commanded a flight to Antarctica, during which he noted that the waypoint (then located at the end of McMurdo Sound) was not where he expected it to be. Captain S gave evidence before the Royal Commission and said that the two briefing officers did not say that the nav track went over Erebus. He said that be believed that the nav track went down McMurdo Sound.
Why, then, was the waypoint not where Captain S expected it be. If the briefing officers did not tell Captain S that the track was over Erebus, and if Captain S believed that the nav track went down McMurdo Sound, then Captain S would have expected the waypoint to be at the end of McMurdo Sound – which is where it was.
So was there anything unusual for Captain S. to report? No – as long as his evidence about the briefing was correct.