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koru_kid
7th Dec 2003, 14:44
Hi there,

I have been a lurker here for a long time and have learnt a lot about the industry here, for which I'm grateful.

Having read widely about the tragedy of TE901, I would like to hear the opinion of people on this forum regarding the true underlying cause of the disaster.

For a long time I thought it was an open and shut case - the disaster was fully caused by the actions of NZ in changing the flight plan. However, awhile ago, I was interested to see a thread on pprune about this subject, and a number of responses that indicated even airline pilots themselves are divided as to whether Captain Collins was ultimately responsible.

I realise this is a touchy topic and truly hope this doesn't devolve into a flame war or other such forms of abuse. While not wishing to appear a thread Nazi, I would prefer responses from airline pilots only and other qualified observers.

A couple of specific questions I would like to ask.

1) In your view, was the Flight Engineer concerned about the operation of the flight immediately prior to the crash?

2) What are your comments on this quote from the accident report?

"..the decision of the pilot in command ... to descend below MSA was in contravention of company restrictions and basic good airmanship "

3) Would you say that Captain Collins was guilty of being too relaxed or too complacent, when compared to the rest of the technical crew, who appeared to be concerned about the operation of the flight and decision to descend?

To all those who respond to this thread, thank you for allowing me to expand my knowledge on this tragic accident.

Disco Stu
7th Dec 2003, 17:41
Kid

I do not know the answers to your questions as I was not there. I certainly remember the day it happened and then watching the events around the original investigation and finally the Royal Commission unfold.

As nobody from those investigations were there either, the resultant reports are nothing more than educated guess's based on what facts were known.

Dredging over old news is a good academic excercise but I believe this one has been done to death and has been superceded by more relevant later accident/incident investigations.

Certainly get the book on the Royal Commission or the report itself and have a good read. Beware of applying todays cockpit or corporate processes to the way things were done 25+ years ago, they do not often stand up to scrutiny through todays eyes were as they were the norm at that time.

Good luck with the research, I was lucky enough to pick up Justice Mahons book at a second hand bookshop for $5 earlier this year.

Sorry, but I will make no comment on any of the crews activities

Disco Stu

Pimp Daddy
7th Dec 2003, 19:15
Another thing to look out for is the video/doco I think called also verdict on Erebus.

Has a very good demonstration of the visual effects caused by whiteout and the expected and actual visual cues experienced by the crew.

geoffrey thomas
7th Dec 2003, 20:48
Dear Koru;

I am not a pilot but the Senior Editor of Air Transport World and like many, have followed this tragedy closely. Allow me to pick up on your point 2 and 3 as under;

2) What are your comments on this quote from the accident report?

"..the decision of the pilot in command ... to descend below MSA was in contravention of company restrictions and basic good airmanship "

This point from the accident report was found to be seriously flawed as while company instructions were for a certain safe altitude the reality was that even check and training captains were flying well below company minimums on these flights and its was even written up in an article and circulated to every New Zealand household.

3) Would you say that Captain Collins was guilty of being too relaxed or too complacent, when compared to the rest of the technical crew, who appeared to be concerned about the operation of the flight and decision to descend?

I feel it was well established at the Royal Commission that Captain Collins was an excellent pilot.

Strongly suggest that you get the late Royal Commissioner's report which has now been accepted as one of the finest pieces of investigative work into an air accident

Best
Geoffrey Thomas

Islander Jock
7th Dec 2003, 22:45
Geoffrey,

Congrats on your aviation reporting award.:ok:

BTW is the book referred to by Justice Mahon titled "Impact Erebus"? I remember reading it many years ago. Very sobering stuff.

forget
8th Dec 2003, 02:02
Much like, where were you when Kennedy died, I remember exactly where I was when ANZ reported ‘loss of contact’ with their DC-10.

For those not au fait with the accident, CVR transcripts etc at

http://www.taic.org.nz/aviation/79-139_annex_a-c.pdf

prospector
8th Dec 2003, 02:38
Koro Kid,
You are correct, it is still a very touchy subject. However there was, and still is, many people who disagreed with the findings of Mr Mahon. One question you can ask yourself,"would you be flying a DC10 at 1500ft, not below 250 kts, in an area that you had never been and in questionable weather conditions??". In your research you may have read a book by Capt Maurice McGreal who was Deputy Director of Civil Aviation at the time. The book is titled "A Noble Chance" and the relevant page is 186. He states that the Dept's DC10 inspector was rostered to fly on the accident flight, but due to a family illness his flight was postponed till the next flight a week later. The relevance of this is explained by the staement "that if the inspector was on board the disaster would not have taken place, why? because no pilot would have displayed before a Civil Aviation Inspector such a poor level of airmanship". It was stated that some pilots did go below the stated altitude minimums on previous flights, the difference was they did not hit the ground, if you break the rules you must be very sure no mistakes are made. In my opinion, the answers to your questions,
1. Yes
2. Yes
3. No, all appeared to be in agreement with the decisions till very late in the sequence of events.

Prospector

Jet_A_Knight
8th Dec 2003, 04:46
I seem to remember a TV program that was about a friend of the said ANZ captain (another ANZ captain) doing his own investigation about the 'poor airmanship' conclusion and trying to clear his friends'name.

Unfortunately, I can't remember the name of the program nor the name of the captain - maybe others could shed some more light.

I do remember that it was quite interesting.

Pimp Daddy
8th Dec 2003, 04:58
I seem to remember a TV program that was about a friend of the said ANZ captain (another ANZ captain) doing his own investigation about the 'poor airmanship' conclusion and trying to clear his friends'name.

Capt Gordon Vette was a C & T Capt and carried out his own investigation into the accident.

His book is called "Impact Erebus"

henry crun
8th Dec 2003, 05:42
I read justice Mahon's book and one impression I got from it was that although he thought he understood everything that was presented to him, there were a number of pieces of evidence and witness statements which clearly showed he did not.

dogcharlietree
8th Dec 2003, 05:50
Hi Guys, 3 books that are very good;
1) "Impact Erebus" by Gordon Vette with John Macdonald 1983 ISBN 0 340 320249.
2) "The Erebus Papers" by Stuart Macfarlane 1991 ISBN 0-473-00844-0 and
3) "Verdict on Erebus" by Peter Mahon 1984 ISBN 0 00 636976 6

The video is also titled "Impact Erebus"
All extremely sobering!

Rongotai
8th Dec 2003, 08:57
The posts so far highlight all the pertinent factors. I am a consultant and researcher who works in part in the area of human error in aviation. This paper:

http://www.webresearch.co.nz/docs_public/CaveCreekPaper.pdf

compares Erebus with the (Canadian) Dryden accident and a significant non aviation disaster in New Zealand.

Since writing that paper I would want to add an analysis of what it was that Captain Collins actually saw. The problem is that he was in sector whiteout - that is the whiteout only applied when looking forward. Landmarks on either side of the aircraft were clearly visible. Thus Captain Collins did not know that the weather conditions were as they were because he had not been trained in whiteout flying. the flight crew were suffering from the visual illusion that they were flying in clear air.

This initial problem was compounded by the fact that the changes to the navigation track in the INS that were done without his knowledge encouraged the crew to believe that the landmarks they could see were those they were expecting to see along the track they thought they were flying.

For the three reasons above a cognitive illusions was created in the minds of the flight crew. Perception research suggests that almost anyone not specifically trained in whiteout flying would be likely to have been deceived by the same illusion.

It is my personal view that Captain Collins ALSO contributed (contributed to - not 'was solely responsible for') the accident because the crew descended below 15,000' not having positively sighted Erebus (that they believed to be off their port side).

The low flying part is contentious. The whole point of those flights was to give passengers a good view of Antarctica. Flying at that height had become a normal expectation and there was considerable company pressure on flight crew that had taken on the dimensions of a cultural norm. I still get irritated at the hypocrisy of the aviation authorities in New Zealand who to this day say that if they had known about the low level flying they would have stopped it, when just four weeks before Erebus they published an edition of their house magazine with a cover photograph of an Air New Zealand DC10 flying obver Scott Base at about 5000 feet.

Pharknose
8th Dec 2003, 09:34
Wasn't this the investigation that prompted the "orchestrated Litany of lies" statement.

prospector
8th Dec 2003, 12:00
Rongotai,
Yes, the low flying had been carried out prior to the accident flight, there can be no doubt about that. But all previous flights had positively identified their position before indulging in this practice. But why was it necessary? the vis is so good down there that a few thousand feet of altitude was not going to improve the scenic value such that the disregard of CAA regs, company rules was justified surely?. The sector whiteout explains why the crew never saw the mountain granted, but it does not explain why they were at 1500ft. Whiteout problems had not been covered in any briefing because at the altitude that the flights were legally allowed to descend to it would not have been a problem. It is very disturbing if what you say about the blatant disregard of Company and CAA rules can be attributed to "company pressure" and "dimensions of a cultural norm". Especially with the experience level of AntArctic operations that this Captain and First Officer crew had, namely nil, and this was in itself a contravention of requirements laid down by CAA.
Pharknose.
Yes this is the case that generated that statement, but to keep it in context you must also read what Mr Mahons peers in the Appeal Court,(High Court??)and the Privy Council had to say about it.

Prospector

Continental-520
8th Dec 2003, 12:31
Wasn't Gordon Vette the ANZ Capt. that bailed out that C188 that got lost in the pacific ocean from his B767?


520.

Felix Lighter
8th Dec 2003, 17:04
Like others I am loathed to make personal comments about the actions of the crew involved. I have to however make what I believe to be a significant point about one comment above:

I have a couple of hundred hours flying around Sott Base and McMurdo. I have been to the crash site, paid my respects, and have flown the route to impact of flight 901 at 1500ft. I also studied this particular crash investigation at university a dozen years ago.

Rongatai: Very nice, concise comments.

Prospector: Valid points too and I can appreciate your point that ultimately the descent below company MSA was a significant causal factor. (No matter whether is was considered amongst ANZ pilots as standard) but please read #2 below.

But please keep in mind:

1. Sector Whiteout was only internationally recognised AFTER this investigation. Yes, whiteout was known and understood but the anomlies of diffuse light sector whiteout were not widely acknowledged and most definitely not understood. (Photographs recovered from the wreckage accurately show Bird Island clearly visible -in approx 20Nm visibilty - only 2 minutes prior to impact]).

2. The aircraft in fact impacts Mt Terror. The summit of Mt Erebus is high and a few miles right of the impact site. As Capt Collins asked for climb power he started a right hand turn. (Consistent with the theory that the crew thought Erebus was to their left.) It has never been proven that the DC10, so close to the summit and turning towards it, could have outclimbed Mt Erebus....EVEN IF IT WAS AT COMPANY MSA when the GPWS sounded. This possibility was not investigated thoroughly.

Lastly I concur wholeheartedly with Disco Stu......please try not to apply modern practise and thought in reliving this tragedy. Times were certainly not the same.

Brgds Felix

amos2
8th Dec 2003, 17:29
Why not just let sleeping dogs lie?

This thread is unneccesary!

The info is in the library's for anyone interested.

Rongotai
9th Dec 2003, 02:43
Amos - Continued discussion Erebus is still valuable - see below.

Prospector - your points are valid, but........


For me the issue of Erebus - still unresolved in attitudes to attribution of cause in aviation accidents - is that a simple 'pilot error' conclusion is frequently used to let everybody else of the hook despite a false premise.

For me the false assumption in blaming Collins (and many crews since) is that all that is required to avoid human error accidents is for pilots to follow standard operating procedures as documented in their manuals and instilled in their training. This is a false premise for three reasons:

(a) real life situations are invariably more complex than those predicted in manuals and training:
(b) manuals and training never predict every possible situation; and
(c) pilots, just like everybody else, are human beings who can occasionally be put under pressure by contradictory requirements between technical performance and social, cultural and business expectations.

In this case, as in many others, all three were operating at some level. If we want someone to blame then we can choose the crew (Kippenberger) or the company (Mahon) and there is a defensible position in either case. But if we want to reduce accidents then we must recognise that there is a correlation between cultural and business practices of airlines and errors committed by aircrew. If, in such situations, we simply attribute blame to the aircrew without addressing any underlying corporate behaviours or practices that contributed to that error, then we may have cause some sort of emotional catharsis but we have done absolutely nothing to reduce the frequency of critical incidents in that company.

Erebus is one of the first, and still one of the most striking, case studies about such matters. That is why it still merits study and discussion. Everybody acknowledges that Collins was a top class pilot. Everybody recognises that in strict procedural terms he should not have been where he was. If we consider how a pilot of such quality could nevertheless place himself in that situation, we have the possibility of drawing lessons that might make commercial aviation safer in the future. If we simply blame the pilot, we deny ourselves that possibility.

nike
9th Dec 2003, 03:25
It is like I have stumbled into the senior class of PPRUNE.

Some excellent posts, well thought out and easily read.

Thank you.

prospector
9th Dec 2003, 03:31
Rongotai,
Agreed as to the accident causes and aftermath. But as has been shown during this thread many people accept that Mr Mahons findings were correct and indisputable. However, the findings of Mr Chippindale, the Chief Accident Inspector, is still the official account. Mr Mahon conducted a Royal Commission of Inquiry that was limited in its scope and the findings could not be appealed in legal terms. Much has been written since but the following statements to be found in John Kings publication New Zealand Tragedies, Aviation, Page 62, appertaining to Mr Mahons findings, and the reputations he sullied, should also be known more widely. "The court of appeal addressed several aspects that were brought to the commissioners notice during the enquiry but ignored by him. The five judges unaminously quashed the $150,00 costs order, imposed as a punishment for the alleged conspiracy" and from the Privy Council.
"In their judgement, delivered on 20 Oct 1983, the five Law Lords of the Privy Council dismissed the Commissioners appeal and upheld the decision of the Court of Appeal decision, which set aside the costs order against the Airline, on the grounds that Mahon had committed clear breaches of natural justice. They demolished his case item by item, including Exhibit 164 which they said could not"be understood by any experienced pilot to be intended for the purposes of navigation' and went even further, saying there was no clear proof on which to base a finding that a plan of deception, led by the company's chief executive, had ever existed".
The statement "An orchestrated litany of lies" would appear to live on, even after Mr Mahons reasons for making the statement have well and truly been demolished by both the Appeal Court and the Privy Council.

Prospector

Rongotai
9th Dec 2003, 03:48
Hi Prospector,

I am not disputing any of the points you make. But what I do suggest is that there is a difference between attributing blame in order to determine legal liability and analysing an event in order to learn lessons that might prevent futire accidents. Mahon strayed into the fuzzy boundary between the two and suffered the consequences. (It can be argued that it killed him).

We have undertaken research for the New Zealand Law Commission on this subject. It can be found at

http://www.webresearch.co.nz/docs_public/HealthSafetyatWork.pdf

From a purely analytical point of view the value of Erebus is that it is one of the few accidents that has been rigorously investigated from accident investigation, commission of inquiry, appeals court AND an unaccountable professional (Vette) frames. We do not have to totally agree with any one of these in order to gain a lot of understanding about accident prevention.

Far Canard
9th Dec 2003, 04:59
The Captain and crew should never have been blamed.

1. The flight was a visual sight-seeing flight of the area and to believe the pilot would stay at IFR minimum safe heights when encountering visual conditions was nonsense.

2. The pilot studied the flight plan including plotting it and knew the track went nowhere near high terrain.

3. The crew encountered visual conditions and descended.

4. The weather report from the ground station reported good visibility.

5. The pilot had complete faith in the aircraft and its navigational systems and continued expecting to encounter the reported conditions.

The flight path was altered and the rest is history. I personally believe most crews would have ended up in the same situation. It raises one point about the total faith and reliance pilots have in their aircraft and their navigational systems.

The Air NZ 767 that came close to flying into the sea due to the ILS being on test is a similar example. In that case the aircraft commenced descent on the false glideslope and nearly flew itself into the sea. There was no cross-reference made by the crew regarding the DME distance versus the altitude while the aircraft was on the ILS. Only the sea appearing at the last minute saved the day.

Pilots fly thousands of hours where everything works as expected. They get lulled into a false sense of security and begin to become complacent. Altering flight plans or leaving ILS systems on test is downright dangerous and will most likely end in a disaster.

The interesting thing is the authorities rubbished Jim Collins but gave the 767 crew a pat on the back for averting a near disaster. I image if the 767 had crashed the authorities would have rubbished the crew and said their airmanship was appalling.

Finally, if Jim Collins was alive I believe his words would be something like:

“Who changed the @#$%#@$$ flight path?”

prospector
9th Dec 2003, 05:47
Far Canard,
How would you reconcile your statements with the following Company requirements for descent at McMurdo??
1...Vis 20 km plus.
2...No snow showers in the area.
3...Avoid Mt Erebus area by operating in an arc from 120 Grid through 306G to 270G from McMurdo Field, within 20 nm of TACAN CH29
4...Descent to be co-ordinated with local radar as they may have other traffic in the area.
VHF comms were not established with McMurdo, at no time was a DME lockon TACAN CH29 achieved. This alone should have alerted the crew that all was not as it should have been.
Previous flights that had descended below prescribed minima's had established contact and been positively identified by McMurdo Radar prior to descent.
If one can fly into a mountain the size of Erebus without even seeing it then surely, the unique weather phenomena of the area must be taken into consideration, hence the requirement for the MDA's for the flight.
Where the flight planned track went is not really relevant, the requirements to be met prior to descent were clearly laid down by the company, there is no doubt the crew were aware of these requirements, a copy of the requirements was recovered from the cockpit wreckage. If these requirements had have been complied with the accident would not have occured.
Myself I can see no similarity between Erebus and the ILS incident at Faleolo.

Prospector

Rongotai
9th Dec 2003, 05:55
Felix lighter's last two posts brings this discussion to a very important point that is often lost.

In descending below MSA Collins believed himself to be in VMC due to an optical illusion with a cause that was not at that time understood or properly described. Nor had he had any training in flying in whiteout, this not being a requirement for those operations. We cannot therefore say AFTER the event 'the conditions were not VMC and so Collins was at fault." The crew had no doubt that they were in VMC and therefore had no cause to ask further questions.

If the previous paragraph is accepted the only question of culpability still resting with Collins concerns the fact that he made no positive sighting of Erebus before descending. Does this vest culpability in Collins? I believe there are two points that need to be considered here:

1. The unknown (to the crew) changes in the INS and the unknown (to anybody) visual illusion conspired to create the impression in Collins' mind that VMC conditions existed along his track and that his track was well to the west of Erebus.
2. Collins was allowed to descend in VMC.

My conclusion is that Collins exercised prudent airmanship according to the prevailing rules and his 'reality', but that he was deceived by the double whammy of sector whiteout conditions and incorrect instrument readings that correlated to create a false impression of his track.

The only niggling question that remains for me is whether the basic principles of airmanship required him to be extra cautious in the absence of a positive sighting of Erebus/Terror. However I agree that almost all pilots would have done the same thing in those circumstances. Well experienced arctic pilots might not have.

If the foregoing is accepted then the question becomes 'Was the trap avoidable, even though sector whiteout was an ill-understood phenomenon at the time?"

My answer is 'Yes'. It could have been avoided if any of the following conditions applied:

1. The NZ CAA had required that civilian operations in the vicinity of Scott Base must not descend below the height of Mount Erebus in ANY circumstances (in which case I doubt that the operations would have attracted paying customers).
2. Aircrew flying these operations had been required to undertake arctic flying training along the lines of those undertaken by military pilots flying to the ice. (In which case AirNZ may have decided that the flights weren't worth the investment).
3. Air New Zealand flight operations were required to inform aircrew of any changes to the programmed track in the INS.

If you believe that it is astounding that the last one did not happen, then to that extent at least you must accept that Air New Zealand failed systemically, and that the accident could have been avoided if the crew had had that information.

In the case of the other two conditions it is at least arguable that the New Zealand authorities and Air New Zealand inadequately assessed what was required to conduct safe commercial operations of this kind. If you argue this then, once again, you are arguing for systemic failures.

Mahon muddied the waters because he reached these conclusions and then overstated the case - he himself being under enormous systemic pressures from the New Zealand public and government (led by a Prime Minister who wanted Air NZ whitewashed at all costs). As Prospector has laid out, higher courts concluded that Mahon's conclusions were deficient in law and in procedure. That does not mean they were wrong in fact.

I agree that what Mahon ended up saying impugned the reputations of a lot of innocent people, and that they breached the principles of natural justice in giving those people no chance to refute the accusations. But that does not mean that there were no systemic failings. For me the second Erebus tragedy is that the emotional responses from the supporters of the aircrew on the one hand, and those unjustly smeared by Mahon on the other, led us to to take longer than we ought to learn the systemic lessons of Erebus, and that during that delay other, similar, fatal accidents occured.

At te beginning of my last post I cited felix lighter. I meant far canard

prospector
9th Dec 2003, 06:29
Rongotai,
There was no room for any leeway by the Captain. The company requirement for the descent was clearly laid down.
"Delete all reference in brie fing dated 23/10/79. Note that the only let- down procedure is VMC below FL16,000feet (16,000ft)
to 6,000 ft as follows: thence the requirements as laid down in my last post.
This is all adequately explained in the official accident report compiled by Mr Chippendale. The change in the flight plan that Mr Mahon laboured over for so long was indeed sloppy operating, but it was not the cause of the accident. If the descent was not commenced until the company requirements for that descent were met, then the accident would not have happened.
That was why there was no training in whiteout conditions given, at the altitudes approve for the operation, whiteout would not have been a problem.
Exercising prudent airmanship would have been to comply with the Company orders, the conditions for descent were clearly laid down,all in VMC but only in the area specified, especially on your first trip to the ice.
As you say "well experienced Arctic pilots might not have" It was to cover this lack of experience that these seemingly excessive descent retrictions were imposed surely?.
It was laid down that no descent take place any where near Mt Erebus in the company requirements for descent.

Prospector

Rongotai
9th Dec 2003, 08:38
Hi Prospector. In the light of your posts I have re-read the CVR transcript and this leads me to want to re-read some of the other evidence before responding. My silence overnight does not mean that I have withdrawn from this discussion! I just want to re-interrogate the data from your perspective.

Casper
9th Dec 2003, 08:51
Is there any truth in the claims that, after the accident, the homes of both pilots were broken into and "certain items" taken? If so and no cover-up, then why??

Also, what about all the pages missing from Collins' diary recovered from the wreckage - despite the fact that the diary cover was in normal condition?

Just wondering?

Rongotai
10th Dec 2003, 02:55
It is five years since I last reviewed the data on Erebus. At this distance from the actual disaster I am no longer much interested in the conspiracy stuff. But I remain very interested in the implications of the whole event for aviation safety.

Prospector - I agree that Captain Collins did not meet the fourth of your conditions for the flight. It is also evident from the transcript that one of the FE's was deeply concerned, and that in a modern CRM environment is likely to have been more forceful in expressing those concerns.

But what I do not agree with is your statement that 'the change in flight plan was not the cause'. I believe that in order to optimise safe operations we have to accept that almost every accident is multi-causal, and that every contributing factor needs to be acknowledged. The trouble is that this approach is in tension with the need to know who was to BLAME. 'Accountability' is an appallingly dangerous word in my view because it allows for an abrogation of responsibility.

Here is my position on all this. I have never observed a transport operation in any transport mode where the mandated procedures were rigidly adhered to throughout the operation. Never. There are a number main reasons for this:

1. There are always conflicting pressures on the crew - 'keep to time', 'give them a comfortable ride', 'I want to get home, it's my daughter's birthday'.
2. Mandated procedures are drafted theoretically. Reality always produces ambiguous scenarios eventually.
3. Sometimes reality produces situations where salvation lies in NOT following the mandated procedures, or in improvising in the absence of advice from the procedures (UA 821, Sioux City)
4. Because of 1-3 standard procedures always become subject to judgements by the crew. That becomes the norm of actual operational behaviour.

Because the above is the inevitable actual operational situation in all transport operations there are unavoidable implications for organisational processes in transport operations. To simplify these are back up, fail-safe and mitigating processes. If an airline (or railway, or shipping company) does not have robust processes of this kind, then it is equally responsible (note the word - not 'to blame', not 'accountable', but 'responsible') for any accident to the extent that its corporate processes failed.

The crew of NZ901 committed a number of operational errors when confronted with a unique set of circumstances at the very edge of acceptable operations. Some of those errors were compounded or encouraged by failed corporate processes. Some of those errors were not slips or lapses, but exercises of judgement that turned out to be based on inadequate data. If we 'blame' the crew and let the corporate processes off, then we lose the opportunity to learn how to make operations safer.

In short I believe that the crew's actions were a causal factor, and so were were the company's. I am prepared to agree that 'the change in flight plan was not THE cause', but I do not accept that the change in flight plan was not A cause.

prospector
10th Dec 2003, 04:55
Rongotai,

The following is from Capt Derek Ellis, an ex BA Concorde Capt and the after retirement from BA , Capt for SIA on 747. When with BALPA he had been involved in investigations into airline accidents and investigations.
"The effect of reading Gordon Vette's book, which is dedicated to supporting the views of the Commissioner, has in fact been to convince me that the findings of the New Zealand Office of Air Accident Investigation are infinitely more realistic"
From the accident report compiled by Mr Chippendale.
"initiated a descent to an altitude below both the IMC (16000ft) and VMC (6000ft) minima for the area in a cloud free area but in contravention of the operator's briefing and outside the sector approved for the descent to 6000ft by DCA and the company.
The probable cause of this accident was the decision of the Capt to continue the flight at low level toward an area of poor surface and horizon definition when the crew was not certain of their position and the subsequent inability to detect the rising terrain which intercepted the aircrafts flight path".
From the CVR a few moments before impact
"I still cant see very much at the moment-as soon as I see something that gives me a clue as to where we are I'll let you know"
If the descent had been initiated in the designated area there was no possibility of impacting Erebus, that was why it was the designated area. If the flight had carried on even on the so called wrong track, overhead Erebus, as per the the "Wrong" flight plan, to the designated descent area, and met the required conditions for descent, the accident would not have happened.
From the US district Court hearing in Washington DC, Judge Harold H.Greene ruled "It is clearly established that, when the pilot told MAC centre he wished to descend VMC, he effectively informed the controllers that he could see where he was going. In so doing, he took sole responsibility for separating the airplane from other aircraft and the terrain, and he was on his own."
The American court got involved because an attempt was made to push the blame onto the duty Air Traffic Controllers at McMurdo
There were mistakes made by the Company ground staff, but none which should have ended up with aircraft crashing.
In the interests of Aviation Safety surely this accident should not be seen as caused for the most part by a computer programmer in Head Office as the main instigator, as Mr Mahon and his council would try to have us believe??

Prospector

4Greens
10th Dec 2003, 05:21
Nowhere in the material I have read is there any mention of why the crew did not cross check the loaded route by reference to Lat and Long on the chart. I may have missed this. It is, of course, standard practice in many operations. If this had been done the discrepancy may well have been noticed.

Rongotai
10th Dec 2003, 06:15
Prospector,

I am not 'pro Mahon/Vette' and 'anti Chippendale'. Nor am I the other way round. I think that the greatest barrier to understanding here has been the tendency to push people into taking sides (and I agree that both Vette and Mahon did a disservice by using emotive language). You misunderstand me if you think that I am advocating that a 'computer programmer in Head Office' was the main instigator. But even if I did believe that, your disagreement does not invalidate the generic questions I posed in my previous post.

If a widely respected captain and first officer committed the violations that they undoubtedly did, then a useful question is 'what are the factors that contributed to their decision making?', because it is possible that those factors could contribute to future critical incidents involving other widely respected flight crew.

There have been many gains from Erebus that are non-contentious. Knowledge about whiteout, the rules governing the presence of non crew members on the flight deck and advances in CRM being amongst them.

My basic position on pilot error is 'Shit happens. What can be done to minimise the chances of it happening near fans?' Human beings are just like the machine parts of a socio-technical system - if you exceed their design limitations they have a tendency to malfunction. And pilots are human beings, not gods.

deadhead
10th Dec 2003, 07:33
The Captain’s decision to descend below the route MSA of FL160 was probably flawed, since under an IFR flight plan the only two ways you can do that is by descent under radar (or DME step or similar) OR by conducting a visual approach. (Of course you could cancel IFR as well). None of these things actually occurred, since a descent “VMC” is clearly not the same thing as cancelling IFR and proceeding VFR, and neither is it the same as conducting a visual approach. A descent maintaining own terrain visually still, as I understand it, requires a radar service. You cannot do that in a non-radar environment – you have to formally cancel IFR OR fly a visual approach.

Analysis of the captain’s probable thought processes reveals two fundamental pathways:

Either he decided to descend knowing that such a decision was an improper course of action, or:

He decided to descend knowing that such a decision was a valid and proper course of action.

If the first is true, then the captain was reckless and incompetent. End of story. Most, if not all of the “pilot error and nothing else” theories assume this (in many cases quite unknowingly!). It is now a natural and easy progression to apply the “command responsibility” excuse and go no further.

If the second is true, then a study of all information the captain may have based his decision on is required.

My belief is that the Captain of TE901 elected to make a descent because he knew that such an act was proper. That he was tragically mistaken is history. That this decision was neither challenged nor even queried by the other crew members shows that this misconception was shared by them all. The famous unease expressed by the operating F/E “I don’t like this” did not occur until much later.

Despite the amount of technical support available to him, (far more than what poor Ron Chippindale had) Mahon was probably out of his depth (despite producing a report that was well ahead of its time) and the fault here lies squarely with the then Attorney-General, who was foolish enough to appoint him as a one man band. Tragically the politicians of the time did not see it as "expedient" to use Ron Chippindale to assist the Commission. The political climate that prevailed required blame to be found quickly, in response to so-called "public pressure." Thus what should have been a formality turned out to be a nightmare for Chippindale, whom I recall was cross-examined continuously for seven days, and through little fault of his own, what should have been a report of "substance" has been relegated, in the eyes of many, to the back benches. That is a real tragedy, too. There is no doubt, though, that the Report of the Royal Commission set a precedent for examining systemic causal factors, a line that was taken up by ICAO in the eighties and nineties. Had this state of the art been available prior to 1979, there would have been no pathways available leading to this tragedy and therefore it would have been avoided. Both the operator and the regulatory authority would have had procedures in place back then, as they do today, to see and avoid these pathways.


The Captain of flight TE901 clearly thought he could achieve the productivity goal without compromising the safety goal. That does not necessarily mean he put the productivity goal ahead of the safety goal - it may merely show he was mistaken in his beliefs. And if so, we need to find out why.

There was only one way the captain could have prevented this accident - by electing not to descend - but there were a multitude of things the operator could have done to ensure the pathways to the tragedy weren’t available. They didn’t do any of them, mainly because they, and the regulatory authority were totally ignorant of them at the time. None of this was explored by the official accident report but this is attributable to the fact that there was simply no requirement to do so, under the then version of ICAO Annex 13 (Accident Investigation).

Now the “pilot error” pundits will point out that the Captain’s “command responsibility” means that he failed in his command role. Fair enough. It is a great pity, though, that in order to have “succeeded” in his command role he would have been required to outwit a seriously flawed system.

prospector
10th Dec 2003, 10:03
Rongotai,
No, not putting you into either camp, and agree with what you are putting forward.

Deadhead,
Very Good, I would think that the originator of this thread has got his money's worth by now. Hard to change the views of people who were involved at the time but hopefully some of the younger blood will have a more balanced view now.

Prospector

koru_kid
10th Dec 2003, 10:25
I'd like to thank you all so much for your responses to this thread. I'm deeply humbled by the time and effort you've all obviously put into it.

I wasn't even alive at the time of Erebus, and your generosity in sharing your knowledge with me is greatly appreciated and has led me to have a far greater understanding of the accident.

If you have anything more to say, please by all means keep it coming.

Kaptin M
10th Dec 2003, 12:16
This topic has been interesting reading for me, as prospector and I have had several short "exchanges" over the subject, in the past.

Undoubtedly some pilots, at times, may believe that they are under a certain deal of pressure to "perform", and may tend to "stretch" limits eg. approach minima.
In this case, Air New Zealand sold these flights SOLELY on the basis of pax being able to see Antarctica and Mount Erebus - as promoted in their brochures.

You are correct, prospector, in stating that if Capt Collins and his crew had strictly observed Air New Zealand's directives to not descend below 16,000 except in VMC, then the accident could have been avoided - however having experienced whiteout, it is indeed entirely possible to believe that one IS visual. There appears to be a horizon, and as the surroundings are known to be flat and snow-covered, one does not expect to see any variation for as far as the eye can see.

However, the FACT is the final co-ordinates of the flight plan were altered WITHOUT the knowledge of the crew, the night before the flight by Air New Zealand ground staff, yet ALL information supplied to the crew to prepare them for what they EXPECTED to see below 16,000' was based upon the original waypoints, as prospector notes,
From the CVR a few moments before impact
"I still cant see very much at the moment-as soon as I see something that gives me a clue as to where we are I'll let you know"

As Casper noted earlier, there were break-ins to the homes of Capt Collins and the F/O, and company material was stolen.
That Air New Zealand believed themselves possibly culpable, was highlighted by the immediate shredding of as much of the paperwork relating to that flight as was possible.
That the regulatory authorities may also have been involved in trying to hide Air New Zealand's possible liabilities, was made evident during the cross examination of Ian Gemmel, an investigator at the crash site, who was purportedly seen removing documents from the aircraft/flight crews' flight bags, and his attempt to hide the same when questioned - "Did you, Mr Gemmel, remove anything from the flight deck (of the crashed aircraft)?", to which Gemmel replied, "There was no flight deck as such."

prospector
10th Dec 2003, 13:28
Kaptin M,
Wondered where you had got to. The requirements for descent to McMurdo were as in Company memorandum to Antarctic crew's,

OAA: 14/13/28 dated 8 Nov 1979. Headed MCMURDO NDB NOT AVAILABLE. It was succinct and unambiguous.

Delete all reference in briefing dated 23/10/79. Note that the only let-down procedure available is VMC below FL160 (16,000ft) to 6,000ft as follows:
1...Vis 20 km plus
2...No snow shower in area.
3...Avoid Mt Erebus area by operating in an arc from 120 Grid through 360G to 270G from McMurdo Field, within 20nm of TACAN CH29.
4...Descent to be coordinated with local radar control as they may have other traffic in the area.

These requirements were to avoid the problems of whiteout, remember that neither the Captain nor the First Officer had ever been to the ice prior to this flight.

It has thus far been an interesting thread with some very good input, nobody is interested in any "conspiracy theory", that is not the intent and certainly if it descends to the usual "89er" thread type hyperbole I for one will be very dissappointed.

For your edification, the person you refer to as an "investigator" was in fact the Chief Pilot of Air New Zealand at the time, a very highly qualified person who carried out the first Antarctic flight as Captain.


Prospector

4Greens
10th Dec 2003, 14:37
Any chance of a response to my query on checking Lats and Longs on the chart?

prospector
10th Dec 2003, 14:49
4Greens,
There would appear to be no record at any time that the Lat/Long were checked. One would have thought that as soon as there was any doubt of position this would have been done. It perhaps show's the complete trust the crew had in the integrity of the briefing and the flight plan. One would perhaps have thought that such a check would have been opportune prior to commencing a descent outside the parameters laid down. All this is only my opinion of course and perhaps I will get flamed.

Prospector

Far Canard
10th Dec 2003, 16:28
I have stated previously that the crew should not be blamed. Having read the posts here I am still convinced this is the case.

The question of descending outside company laid down criteria needs to be answered. The crew knew their flight path was clear of terrain and this led them to make an error in judgment and carry out the non-procedural descent. If the Captain knew his track was straight toward the mountain then there would have been no problem regarding the descent.

A 747-400 flew a non-precision approach into Auckland during an ILS outage and came very close to the Manukau Shopping Centre as the crew descended too fast too soon.

The question is this:

Is it safe to turn off the ILS at an airport when the weather is bad? Some would say yes as there are strict operating procedures laid down that will avoid an accident. I would say that it would be better to leave the ILS on and wait for a sunny day. The same goes for the DC10 accident. If you brief the pilot for a particular flight path, don’t go and change it or you are pushing your luck.

Some people ask me why the Americans have a much safer aviation system than the rest of the world. I believe it is due to the fact that they cater for the lowest common denominator with regard to operational issues. Sure you can lay down procedures but they will not always be followed. New Zealand is still a long way behind and we tend to believe that procedures will be followed and it is totally safe to:

1 Alter the briefed flight path on an Antarctic flight.
2 Turn off the ILS when the weather is bad.

The Americans would take a different view and know that these things are courting disaster. Did you know it is an FAA policy to have ILS approaches at all airports served by turboprop scheduled services. In New Zealand we rely on people and procedures to keep us safe so we can use NDB / DME and VOR / DME approaches at most places. That’s why we had to clean up the Dash 8 wreckage east of Palmerston North. Of course we just need to blame the crew and we are fine!

Menen
10th Dec 2003, 20:32
I have found the discussions rivetting. I just wish that the depth and clarity of these discussions could be applied to many of the single pilot accidents that have occurred in the past.
Unfortunately when a light aircraft goes in, maybe the pilot and a passenger are dead, and no significant property damage occurs, the accident is soon forgotten just like an accident on the road.

A case in point was the RFDS King Air accident at Mount Gambier. A highly experienced pilot flies wings level into the ground at night three miles on the extended centre line of the runway. There was mist and ground fog and the possibility that he may have followed an erroneous T-VASIS fly-down signal. ATSB hint that the pilot stuffed up. The Coroner showed scant interest and accepted the ATSB report without question.

Whiteout and erroneous VASIS rays of light - they are all visual illusions.

Spotlight
10th Dec 2003, 20:59
Menen

The only comparison I can see is that in both accidents the pilots homes were broken into.

Casper
11th Dec 2003, 05:29
4 Greens & Prospector

I'm unaware of the ANZ policy at the time re checking of lat & long. However, I suspect that, if any pilot was advised of ANY doubt in regard to any waypoint, then that pilot would indeed check the lat & long of every waypoint on the flt plan.

In this case, I believe that Capt Collins was not advised of any discrepancy, despite the flt planning dept being aware of what they perceived to be a minor one. Also, why would any route so near to Mt Erebus be included in the plan? Can anyone explain?

I agree with a previous post that stated the opinion that a large amount of paperwork was shredded because ANZ perceived that they could be held responsible for some contribution to the disaster.

Please also correct me if I'm incorrect but was not the reason for the Privy Council's finding based on points of law and not of fact?

I had also heard a claim that the NZ Appeals Court had on its bench some persons with vested interests in ANZ. It may have simply been a wild claim at the time - I don't know.

4Greens
11th Dec 2003, 05:36
Thanks Prospector et al for the gen on Lats and Longs. It was a requirement in most airlines for all waypoints to be cross checked using the chart. In other words they would have noticed the route discrepancy much earlier if they had been doing this.

Kaptin M
11th Dec 2003, 06:19
4Greens, is it possible that this requirement (to check Lats and Longs) was initiated BECAUSE of the Erebus crash?

My experience with this type of navigation was on B74 classics (one of the Captains with whom I flew, being Derek Ellis, mentioned earlier), and the system from recollection involved one crew member reading the co-ordinates from the Flight Plan whilst a second crew member input them.
After all (or in the earlier system - a max of 9) were entered, all crew members then checked Tracks and Distances against the Flight Plan!
So even IF Capt Collins' crew had performed these checks, the tracks and distances would have shown NO discrepancies!

Even with today's extremely accurate onboard navigation systems, there are OFTEN differences between Flight Plan tracks and distances, and those shown on Jepp charts. It is also quite probable that the final tracks and distances on TE901's flight plan were not represented on any navigation charts, as this was supposed to be the visual (sightseeing) part of the flight.

Remember, it was not ALL co-ordinates that were changed - WITHOUT the knowledge of the crew - but only the last few, which, in all likelihood the crew (and Air New Zealand Flight Planning staff) probably did NOT expect to use, as at this stage of the flight, they would have expected to have been visual - which Capt Collins undoubtedly THOUGHT they were, but with a little less than optimum visibility.
20nm visibilty is not great, and in whiteout conditions it is quite conceivable that one could believe they had met that requirement.
It is my understanding that Air New Zealand did NOT proceed with these flights, when weather conditions in Antarctica would have prevented the low level sightseeing.

prospector
11th Dec 2003, 06:41
Casper,
The specifics of this accident are far to complex to enter into on this forum. The errors of ommission and commission are many and varied. I would like to recommend that you read all that is written about the subject in "New Zealand Tragedies-Aviation, Accidents and Disasters" by John King. It has the benefit of hindsight and all the conflicting points of view are well presented. It is also the source of a wealth of information on many other aeronautical facts and would be an asset in anybodies library. I would like to quote again from this book, many people would not agree, but I do.

" The one exception was Captain Roger Dalziell's flight which, because of unfavourable McMurdo weather, took the alternative route over the South Magnetic Pole, diverting even before reaching the specified decision point of Cape Hallett. It's unpopularity with the passengers, however, was a likely factor in making Captain Collins more determined to press onto McMurdo when conditions were marginal and, according to company instructions, well below minuma for the area"

Re the findings of the Privy Council. No, point of fact and in particular Exhibit 164, which Mr Mahon laid inordinate faith in to prove his theories.

Re the appeal Court, some people tried to make an issue of the fact that there was some family relationships between ANZ staff and Court members. You must, like the rest of us draw your own conclusions as to the relevance of this.

Prospector

SeekingAnswers
5th Dec 2004, 21:04
I would like to say straight off that I am not a pilot and that I do have a vested interest. I am on the side of the crew.
Your posts were put up a long time ago and you may never read this but I had to point something out.

Prospector said that he did wish to get into the whole "conspiracy" theory as it was not relevant. However if there was a conspiracy that destroyed evidence, and intimidated witnesses, is it not possible that if there had been no conspiracy there would have been more evidence on the side of the pilots - to show perhaps that flying at such a low level had been discussed verbally in their briefing for instance...I'm not saying that that is the case, by the way, but just pointing out that notes from a briefing were one of the main things that seemed to keep disappearing.

I'm sorry but you can't separate the two. And just because a conspiracy can't always be proved, doesn't mean that it hasn't happened. That's kinda the whole idea of the people behind it...

If anyone does know of things that happened in this way, they are more than welcome to private message them to me. I am afraid that one day all that information will die away with the people who knew...perhaps one day the history books will read more accurately...

Oh and also, I do feel it might be better not to quote Chippendale's transcripts if you want anyone to take you as seriously unbiased, best to use the official washington transcript.

Desert Dingo
5th Dec 2004, 23:49
Previous discussion about all of this can also be found on the thread:

http://www.pprune.org/forums/showthread.php?s=&threadid=152934

HSWL
6th Dec 2004, 10:43
A common thread in accident reports which attract media publicity is that the pilot in command is usually described as an excellent pilot. (He may be dead due a cock-up but he remains an "excellent" pilot). It doesn't mean a thing. Excellent pilots make mistakes like the rest of us average pilots.

SeekingAnswers
6th Dec 2004, 17:38
SO I assume that you knew these pilots personally then, and can say that they weren't excellent pilots. You can't make a comment like that without backing it up.

Not just pilots make cock ups, so do airlines, sometimes big ones.

Sunfish
6th Dec 2004, 21:01
What a magnificent thread. I'm going to add my two cents worth, the company is as guilty as hell.

Before you all jump down my throat, this has absolutely nothing to do with the technical matters.

Someone said it in the beginning. There were procedures in place, minimum descent altitudes etc, to keep everyone safe. These procedures were not followed in the interests of giving the passengers a better view.

The fact that the procedures were not followed was known to the company. It appears they knew but did nothing about it.

The crew of the aircraft wanted to give the passengers the best view, and did not follow procedures.

In effect the company and the crew had tacitly agreed not to enforce the procedures. This cost the crew and passengers their lives.


Esso Australia did the same thing to me thirty years ago and they tried to do it again to the plant operators after the Longford gas plant explosion. They put reams of safety procedures in place - but you have no way of following them and keeping your job. You either have to resign or tacitly agree not to do things by the book and just hope that nothing bad happens. If something does happen - well you weren't following procedures were you? Blame the victims.

Of course this does beg the question of wether following procedures would have kept them safe. I don't know the answer to that. Does anyone know?

rottenlungs
8th Dec 2004, 08:00
Hi Continental-520


"Wasn't Gordon Vette the ANZ Capt. that bailed out that C188 that got lost in the pacific ocean from his B767?


520."

Vette was definitely involved in the rescue of Jay Prochnow, can`t remember the exact a/c Prochnow was in but Vette was in a DC-10 for that. An amazing demonstration of the art of astro-navigation. I`m not sure if that is the incident you are thinking of but it sounds similar

Cheers

Rottenlungs

Vampire 91
8th Dec 2004, 08:46
Continental 520 & Rottenlungs

Not only did Gordon Vette display great airmanship in effecting the safe arrival of the C188 but he also demonstrated a high level of CRM. I would be interested to know if ANZ were training crews in CRM at that time.

Regarding the incident in question the story featured in a copy Reader's Digest (which I still have somewhere) and I recall that it eventually turned up as a TV movie.

To the rest of you who have contributed to this thread I must also add my thanks for the high standard of meaningful discussion.

Vampire 91