PPRuNe Forums - View Single Post - Erebus 25 years on
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Old 19th Jun 2016, 07:10
  #813 (permalink)  
3 Holer
Whispering "T" Jet
 
Join Date: Jun 2001
Location: Melbourne.
Age: 68
Posts: 655
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Excellent post megan and most aircrew with even a miniscule amount of training in the subject of Human Factors/Crew Resource Management will comprehend and appreciate it's content.

Can you imagine the mountain Justice Peter Mahon and Captain Gordon Vette had to climb all those years ago trying to educate the establishment it was not correct to immediately assume "pilot error" in aircraft accidents.

Justice Mahon – by investigating those “standing conditions” and naming them as a latent failure that contributed to the disaster – helped to shift the focus of accident investigation from apportioning blame to “identify[ing] those systemic failures which either foster and enable human error, or which fail to contain and negate its consequences.” The far more worthy aim of this sort of accident investigation is to preclude a similar recurrence.
There is no doubt, in my mind, that the change of route was the cause of the Erebus accident. No amount of gobbledygook about MSA's,radar letdowns, VMC conditions and chatter extracted from the CVR will convince me otherwise. The crew thought they were flying over a flat sea bed and the rest is history.
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