Erebus 25 years on [Archive] - Page 4

PapaHotel6

16th Jun 2016, 20:56

Cazalet 33 said

How very wrong!

Sector whiteout is well known and well understood.

Read what I said. I never said there is no such thing as sector whiteout but to surmise, as Mahon and Vette did that at 1500 feet the crew suffered this optical illusion which caused them to "see" good VMC conditions, with a false horizon, and what's more, look convincingly like the entrance to McMurdo Sound is a massive, massive leap of faith that is often written as if it were a proven fact.

Whereas we all know that if you're skimming along the base of a cloud layer at 1500', with ice below you, you're pretty much going to see a wall of white regardless of whatever tricks your occipital cortex might or might not be playing.

It's astonishing how Mahon managed to explain away Brooks asking "where's Erebus/just thinking about high ground in the area" as *not* indicating alarm, but he has no problem putting forwards the optical illusion theory as if it were solid fact.

All the above is, of course, putting aside for a moment the fact they should never have descended to that level in the situation they were in in the first place.

That video you keep referring to is good entertainment for people who have no knowledge of things aeronautical, for mainly it is NZALPA propaganda.
And it's laughably invalid from a scientific point of view.

Mahon said:

In my opinion, neither Captain Collins nor First Officer Cassin nor the Flight Engineers made any error which contributed to the disaster, and were not responsible for its occurrence.

And 3-Holer said
That is NOT saying the crew was blameless, that is saying the crew did not make any error which contributed to the disaster!
I'm not sure what your point is, or why you are trying to cloud the argument with semantics, but the meaning of the above cannot possibly be anything other that Mahon felt the crew were blameless. He was subsequently quoted as such ad infinitum while he was still alive. And this is how Mahon is quoted to this day - by the media, and also the likes of Holmes, Dunne, and Williamson who tried to get the crew formally exonerated in Parliament.

3 Holer

16th Jun 2016, 22:43

My point is, Mahon never attempted to blame any person(s), throughout the whole inquiry, for this accident. He and others were merely investigating what the causal factors may have been. He was, of course, hindered from the start by unrelenting screams of "pilot error" from the government and Air NZ, but he carried on methodically and with great professionalism. He was afforded many accolades for the way he conducted the inquiry and the findings, which have already been acknowledged here.

"Others" will continue with the pilot error theory but we know now it was the administrative failures in the structure of the airlines' Antarctic operation that contributed most to this disaster.

There have been apologies from Air NZ and the NZ government which are on public record.

Anotherday

17th Jun 2016, 01:48

Most amusing part of this is all those who find Collins blameless but would never fly his non certified non approved INS wandering letdown.

To all intents and purposes as the inquiry showed when lawyers went after MD and the US DOD, the aircraft shouldn't have been below MSA in those conditions.

IF, and it's a big if, it had been on the track they thought they were on and they descended, they still weren't actually approved to descend "VMC" in those conditions anyway. It's like some of you are saying they got away with breaking the SOPs for that flight before and the should have got away with it again. Flying outbound in the hold using the INS without updating, or Radar, and they still could have hit the western side of Mt Bird instead of Erebus while within INS tolerances.

Lawyers would have said its the manufacturers fault, MD would have shown aircraft not certified for that manoeuvre, Mahon would have hypothesised white out and any professional aviator would still be wondering what they were doing down there.

Guessing location in debatable VMC, at 1500ft, in a relatively featureless barren terrain, at 6 miles a minute, in a widebody jet.

Does anyone remember their first cross country where instructor said "don't look for features outside and try to fit them in on the chart with where you think you are"..........

framer

17th Jun 2016, 02:47

people who think that doing this;in debatable VMC, at 1500ft, in a relatively featureless barren terrain, at 6 miles a minute, in a widebody jet. is not a colossal error of judgement ( what does a Captain get paid for again? ) have either never held a passenger jet command or if they have, they shouldn't have.

prospector

17th Jun 2016, 05:06

My point is, Mahon never attempted to blame any person(s), throughout the whole inquiry, for this accident.

You mean by saying that the "crew committed no error that contributed to the disaster" or in plain English, were blameless, does not shift all the responsibility for the disaster onto other people??

PapaHotel6

17th Jun 2016, 06:12

Once again, referring to Mahon's quote:

In my opinion, neither Captain Collins nor First Officer Cassin nor the Flight Engineers made any error which contributed to the disaster, and were not responsible for its occurrence.

3 Holer says:
That is NOT saying the crew was blameless, that is saying the crew did not make any error which contributed to the disaster!

And 3 Holer also says:
My point is, Mahon never attempted to blame any person(s), throughout the whole inquiry, for this accident.

So if I understand you correctly, your interpretation of Mahon's statement that the "crew made no error" does not mean he's saying they were without blame. However, no party is actually blamed for the accident either.

3 Holer

17th Jun 2016, 08:53

people who think that doing this;
Quote:
in debatable VMC, at 1500ft, in a relatively featureless barren terrain, at 6 miles a minute, in a widebody jet.
is not a colossal error of judgement ( what does a Captain get paid for again? ) have either never held a passenger jet command or if they have, they shouldn't have.

Let's stick to the facts for a minute:

Forecast at McMurdo prior to descent. Cloud base 4000 feet and viz 40 miles.
From CVR:
1.Aircraft 6000 descending to 2000 and in VMC.
2.There are no less than 13 references made by one pilot to the other confirming that the aircraft was flying VMC.
debatable VMC, at 1500ft,..........I don't think so. :=

Oh, and finally................The hundreds of photos taken by the passengers showed the plane was flying in clear air in good weather.

prospector

17th Jun 2016, 09:26

Let's stick to the facts for a minute:

Yes, lets do that.

Weather at the McMurdo area at the time of the disaster was reported to be completely overcast at 3,500ft with other cloud layers above, and a wind of 10 knots. Mountain tops in the area were covered in cloud and although the surface visibility was good surface definition was poor and horizon definition only fair because the sun was obscured and snow surface features could not be readily identified from close up. Other aircraft in the area reported Ross Island as being completely obscured by cloud, and the crew of a helicopter which landed at Cape Bird Hut, 35 kilometres from the crash site and only an hour later, said it was overcast art 1,500ft with light snow Shortly afterwards they landed on the beach 10 kilometres from the site, in snow flurries and deteriorating conditions which made them cut short their visit.

So, here we have a helicopter crew, experienced in the area, giving up because of weather, and in the same conditions we have a DC10, 1,500ft at a minimum speed of 260kts, uncertain of there position, knowing there was a 12,000 odd foot mountain somewhere very close, even the slopes of Ross Island were above that height, and some people believe that was acceptable behaviour??

You will note no doubt, that other aircraft in the area reported Ross Island completely obscured by cloud, perhaps they were all part of a conspiracy to refute Mahon, Vette, theory of sector white out??

Oh, and finally................The hundreds of photos taken by the passengers showed the plane was flying in clear air in good weather.

And they also showed that the aircraft passed on the wrong side of Beaufort Island, and nobody noticed?? very astute navigation.

3 Holer

17th Jun 2016, 09:46

knowing there was a 12,000 odd foot mountain somewhere very close,

Straight ahead,as it turned out, compliments of the Air NZ navigation department and omitting to advise Captain Collins and his crew. Now that's a colossal error of judgement.

prospector

17th Jun 2016, 09:54

3 Holer,
Your aeronautical licence is shown as HR/MC, is that all? Have you ever flown any aircraft?? anywhere?? at anytime??

3 Holer

17th Jun 2016, 10:47

prospector, I am flattered you have taken the time to peruse my profile, I myself, have not done the same with yours.

If I said I had flown many thousands of hours in the B747-300 / B767 / B727-200
or was just a PPL with 100 hours in a C150, what difference would that make to you? Would it make my contribution to this thread any more or less credible? Would you be anymore or less rational to reasonable debate?

Thrill me with your acumen prospector.

prospector

17th Jun 2016, 11:17

HR/MC , I do believe I now know what those letters stand for.

Would it make my contribution to this thread any more or less credible?

Not more or less credible, but perhaps more understandable

megan

17th Jun 2016, 13:21

For those that hold steadfast to the not below 6,000 argument, Captain Wilson, the briefing officer, told the crews they were permitted to descend to whatever level McMurdo gave them a clearance.

Had Captain Collins been on the track he thought, on confronting the bad weather he possibly would have climbed out straight ahead, knowing from his previous plotting that he would be in the clear re terrain.

Which brings up another point. Have you ever seen an IMC approach procedure without a missed approach depicted? ANZ had one before the NDB was withdrawn. The assumption seems to be that becoming visual was guaranteed, which I guess it might be since you wouldn't be commencing the approach unless McMurdo gave an adequate weather report. But no forethought had been given to an aircraft breaking out below an 8/8ths overcast and what they might have been confronted with.

And that is whiteout. As Chippendale said,One other hazard is the effect caused by dark coloured rocks or ridges visible above the snow, which may give the impression that good contrast conditions exist, resulting in a landing attempt on terrain which is not suitable for the purpose, but which due to the whiteout effect appears to be safe since the pilot has not realised that the dark colour of the rocks is giving the illusion of contrast.

In addition, a commonly reported problem is a loss of distance judgement or perception and it becomes difficult to estimate whether a perceived hill or hummock is a distant hill or a small protrusion a few feet away.So our crew break out, see the dark buildings of the McMurdo base but SFA of anything else. How long do they bumble about before taking decisive action and get the hell out of there? And in which direction? No guidance on the approach plate. Once again a demonstration of an ill considered operation.

Some seem to have difficulty in coming to grips with what whiteout is capable of. My only experience in Antarctica was 8/8ths at 20,000 and visibility unlimited, but you could see nothing - inside a ping pong ball as someone said earlier.

To place blame, my opinion is it falls on the nav department. They failed in so many areas it is beyond belief. They had no idea where the waypoints lay, and failed in their duty to advise the crew of the change. What's the point of a crew briefing if its not of the route to be flown.

For those who castigate the man for not plotting his position, it wasn't SOP as far as I can tell, so why is it a black mark? Guys and Gals flying RNP into Queenstown I bet don't plot the waypoints. One guy says it better than I.Perhaps, though, the paradigms for determining who is in command, who is in direct control and who is responsible, are changing. The levels of complexity of modern transportation systems are such that the notion of the sole commander and his executive crew, all powerful and totally responsible for the safety of the ship, a notion developed over many millennia of maritime (and more lately of aerial) navigation, is not as relevant as it used to be. We now live in an era of transportation systems in which many minds are involved in the operation of any particular vehicle, and the safe delivery of that vehicle to any particular destination can be seen as the product of systematic co-operation by a team of decision makers. There has to be trust at all levels for such systems to function properly. The pilots of modern aircraft have to place their trust in the organisation behind hem for the system to work.Who checks the oil levels? Who does the water drains? The maintenance? Who designs the ILS approach? The crew have to accept that the people within all departments are professionals doing their tasks in a professional manner. Not to say they don't make mistakes like all of us, but they all play a role in the safe operation of our air transportation system. To expect the front seats to be the goal keepers for everybody elses mistakes is to expect far too much.

A four engine airliner crashed, following the loss of all engines, with the loss of all on board because it was suspected an engineer erred in doing the fuel drains. A jet put its wheels through the trees because of an error in the airport/approach plate.

Hempy

17th Jun 2016, 16:59

^^^ wtf? Don't drink and post!

p.s are you aware of what controlled airspace actually is below 60" south?

Chronic Snoozer

17th Jun 2016, 19:26

For those that hold steadfast to the not below 6,000 argument, Captain Wilson, the briefing officer, told the crews they were permitted to descend to whatever level McMurdo gave them a clearance.

So if they were cleared to 50' it would have been fine to do so would it?

For those who castigate the man for not plotting his position, it wasn't SOP as far as I can tell, so why is it a black mark? Guys and Gals flying RNP into Queenstown I bet don't plot the waypoints. One guy says it better than I.

How hard was it/is it to check the waypoints? Surely someone would have checked the track/distance to the next waypoint thus ringing some alarm bells.

You would have thought that someone who had little experience operating in this area, would be checking and checking again (or have his crew do it) the aircraft's position given the presence of a 13000' mountains, irrespective of the SOPs. Thats airmanship. My 2c.

Anotherday

17th Jun 2016, 20:27

It wouldn't have mattered what level the radar at McMurdo gave them clearance to descend to. All the radar was concerned about was traffic in the area and in prior briefings AirNZ had been told they would receive no support from Radar whatsoever.
The whole idea that any clearance to descend by the briefing officer or radar or the baggage handler at Auckland airport absolves the crew of their own duty of care to their pax is ridiculous.
There is a saying in aviation and any safety led industry "If there is any doubt there is no doubt" The fact that we are debating if the weather was good enough says it all.
And if it makes you feel better then sorry, 2000 ft in marginal VMC, in a widebody jet, at 5 miles a minute, over featureless terrain, including a 12448ft mountain and next to that a 5948ft peak that they also could have hit, while without radar, or any way of updating their maybe 3 miles an hour drifting INS, is still not safe.
Collins let corporate pressure influence him and a false sense that his prior experience enabled him to justify the decisions he made on the day. Any commander has the right to operate outside of the SOPs as he sees fit, if and when required for the safety of his passengers and aircraft. In this instance Collins operated well outside the SOP for no justifiable reason and the accident occurred.
"But thick here eh Bert"

prospector

17th Jun 2016, 21:00

From where does all this knowledge come from????

So our crew break out, see the dark buildings of the McMurdo base but SFA of anything else. How long do they bumble about before taking decisive action and get the hell out of there? And in which direction? No guidance on the approach plate. Once again a demonstration of an ill considered operation.

What approach plate are you referring to? There was never any approach plate because the only procedure was a cloud break procedure, there was never any intention that the flights would ever be landing at McMurdo.

The actual weather at McMurdo has been posted a number of times, the weather people advised the conditions were no good for sightseeing, so what was the point of carrying out a homegrown descent procedure to get to Scott Base anyway???

knowing from his previous plotting Could you advise where you found anywhere that any plotting was done? if any plotting had been done then surely they would have realised they were not on the track they thought they were.

For those who castigate the man for not plotting his position, it wasn't SOP as far as I can tell, so why is it a black mark?

You need to be told to keep an accurate plot of your position????, especially before descending below MSA?

PapaHotel6

18th Jun 2016, 00:39

Megan said

Who checks the oil levels? Who does the water drains? The maintenance? Who designs the ILS approach? The crew have to accept that the people within all departments are professionals doing their tasks in a professional manner. Not to say they don't make mistakes like all of us, but they all play a role in the safe operation of our air transportation system. To expect the front seats to be the goal keepers for everybody elses mistakes is to expect far too much.

I agree, and this is where I have a problem with those who try and clinch the argument with "buck stops with the Captain" statements. Of course there are aspects of the commercial aviation infrastructure that are outside the Captain's control and quite capable of bringing down the aircraft. But here's the thing. No one ever expects the high altitude Nav track to be one of those. If they had, to the extent that a single mistyped digit could crash an aircraft, do you think the crew would have been permitted to enter the INS data manually, as was the case with TE901? No, it would've been entered with reference to a chart and triple checked as it was entered.

There's good evidence that Air New Zealand's navigation section was sloppy, and that the expected level of professionalism wasn't lived up to. Vagueness surrounding destination waypoints and arse'ing around with them isn't good. But never would it be expected to cause an accident. Slight surprise prior to commencing descent perhaps (as was the case with Capt. Simpson's flight), problems with fuel management at the absolute worst. Hitting a mountain, no.

3 Holer

18th Jun 2016, 01:26

But never would it be expected to cause an accident.

After the accident, that was also the sentiment of Air New Zealand’s navigation section, the NZ government and Ron Chippendale.

How wrong they were.

Mind you, it took no less than four extensions of the Mahon inquiry, sitting through hours and hours of sometimes, unbelievable evidence and a determined Justice Peter Mahon to prove how wrong that assumption was.

prospector

18th Jun 2016, 02:11

3 Holer,

Your slavish adherence to the Mahon report, even after it has been shown to be incorrect in many important details, by many of his peers in the legal world, and definitely by many people who have a great deal of aeronautical experience, leads me to the conclusion you must have the same amount of Aviation experience as Justice Mahon.

. Your refusal to accept what is indisputable fact is beyond belief.

This from PH6 earlier post.

I was an avid proponent of Mahon until I became a private pilot myself, studied more about the differences between high and low altitude navigation, IFR flying and more about Aviation in general and I now believe that the factors leading directly to this disaster were the fault of Capt. Collins. Other factors which have been well described were all secondary.

Perhaps the video's produced by NZALPA , and the Mahon report, influenced many people until they actually have first hand knowledge of how the system works.

3 Holer

18th Jun 2016, 04:49

NZALPA's video...............influenced many people until they actually have first hand knowledge of how the system works.

Would that include shredding documents in the navigation department, coercing people to have memory lapses, tow the company line testimony whilst under oath and altering CVR content to suit the establishment? Just to name a few. Is that “how the system works” in your world prospector?

As for your reference about Mahon’s aviation experience. As with most of your arguments on this thread, you seem to think the more aviation experience a person has, the more he is qualified to speak on this subject. Wrong, wrong, wrong again. Using your logic, if that was true, they would have appointed an aviation expert to head the Erebus Inquiry. Muldoon thought Mahon would know “how the system works” and would find in Air NZ and his government’s favour. Alas, they miscalculated Justice Mahon’s integrity (staying true to his moral and ethical principles), initiative (his proactive, resourceful and persistent approach to the accident) and his inclusion (by embracing and valuing the perspectives and contributions of all during the testimonies and investigations).
Mahon never needed any aviation experience, he knew very well how the system worked.

Finally, prospector, if as you attest,” the Mahon report has been shown to be incorrect in many important details, by many of his peers in the legal world, and definitely by many people who have a great deal of aeronautical experience”.

Why did the following occur:

In 1999 the Minister of Transport, Maurice Williamson, who worked at Air New Zealand as a corporate planner at the time of the crash, tabled the Mahon report in Parliament. Williamson argued that the time for apportioning blame was over and that he was tabling it because 'of the lessons it taught'.
On 23 October 2009 Air New Zealand CEO Rob Fyfe apologised to those affected by the tragedy for Air New Zealand's failures and for its treatment of families of the victims.

The controversy of Justice Mahon’s opinions aside, his report is most notable for its groundbreaking allocation of culpability to organisational failure. (Paragraph 393. Mahon report) This kind of conclusion was somewhat revolutionary in 1981, as identified in the chapter entitled “Erebus and Beyond” in the book Beyond Aviation Human Factors.

PapaHotel6

18th Jun 2016, 06:04

Prospector said

Perhaps the video's produced by NZALPA , and the Mahon report, influenced many people until they actually have first hand knowledge of how the system works.

It certainly did in my case. There was so much about the Mahon the report that was believable to the general public with little or no aviation knowledge.

His writings about the computer track being changed, descriptions of whiteout and romanticised writings of Collins and his infallabilty made us all feel like aviation experts. And the big company trying to shaft the little guy, the government guy (Chippindale) being a ponderous, ex- military buffoon with no appreciation of how modern aircraft functioned....... enter Vette with his *brilliant* psychological insights......Collins's lovely family..... you couldn't write better stuff.

The truth however, which has been very well described in this thread - was quite a bit more complex, and nowhere near as romantic. And, as patronising as it sounds, you do actually need a fair bit of aviation knowledge - even experience - to appreciate it, and put all the factors into the correct perspective.

Fantome

18th Jun 2016, 09:21

If ever a writer is so inspired and tackles a return to IMPACT EREBUS
then it is to be hoped he gives attention to this thread from its beginning and other forums where many conflicting views are canvassed. The unimpeachable integrity of men such as the late Justice Peter Mahon and the late Captain Gordon Vette should
be reacknowledged in any thorough appraisal of the whole disaster (and the whole saga of conflicting verdicts on Erebus which make a reappraisal all
the more fascinating.)

For instance the views of posters such as 3-holer and others of like mind seem eminently balanced and knowledgeable.

framer

18th Jun 2016, 10:14

To expect the front seats to be the goal keepers for everybody elses mistakes is to expect far too much.
I disagree. To me ( on a daily basis) it seems that is the primary role.
The crew have to accept that the people within all departments are professionals doing their tasks in a professional manner.
Again I disagree. Maybe accepting that most within all departments will do their jobs in a professional manner I could agree with. The crew have to accept, and be comfortable with, the fact that some people will not do their jobs in a proffessional manner and as a result during their career the crew will see rags left in undercarriage uplocks, cowlings left unlatched, out of date data bases loaded, correct data bases loaded with waypoint errors, poorly designed stars and approaches, ATC clearances that create traffic conflicts, banned dangerous goods loaded for flight, incorrect fuel loads uplifted, important ground handling procedures not followed etc etc.
The role of the flight crew ( among other things) is to recognise these things and deal with them in an appropriate manner, this is happening all day every day all around the world and is why Airlines won't give jet commands to people who have 500 hours. Most 19 year olds could quickly learn the stick and rudder stuff, it is this fandangled airmanship thing that can't be taught at university.

megan

18th Jun 2016, 16:37

I disagree. To me ( on a daily basis) it seems that is the primary role.I want to fly with you framer, being so omnipotent and all. Then again, perhaps not, you thinking that you’re so good. ;)^^^ wtf? Don't drink and post!
p.s are you aware of what controlled airspace actually is below 60" south?Hempy, get off the sauce man. What has controlled airspace south of 60” got to do with anything. Think you mean 60°, not that it makes any difference, but when you’re in the state you’re in I understand.
So if they were cleared to 50' it would have been fine to do so would it?If you were idiot enough to ask for it, and someone was idiot enough to give you clearance, I guess fill your boots. Flights had flown previously at 1,500 and less, though you will always get the argument that it was OK, despite being against SOP, because it was in really, really good VMC.

But answer, if you can, why Captain Wilson was briefing crews that it was OK to go below 6,000.You would have thought that someone who had little experience operating in this areaAnd there’s the rub, the crews had zip, zero, narda experience in polar operations.Could you advise where you found anywhere that any plotting was done?You need a little comprehension prospector. My post was quite plain, the plotting he had done the previous night. Perhaps I was not clear enough.What approach plate are you referring to?Ok, cloudbreak. They were never able to fly the cloudbreak procedure in IMC when the NDB was available, for the simple reason they wouldn’t have the RADAR monitoring that was demanded. As the US said, being able to provide radar monitoring was “absurd”.

Had they been able to fly the IMC cloudbreak, which they couldn’t, there was absolutely no guidance given should they find themselves in whiteout conditions ie able to see the base buildings, aircraft and vehicles on the runway, but nothing else. Scramble back to the MSA, after spending whatever time it would take to realise the predicament they were in, of which they have zero experience, and what escape route to take?

By a poster on another thread.Descent below the LSALT of FL160 had to be made in VMC as you say. What advantages accrue from specifying the VMC descent to be made in the stipulated sector overhead McMurdo? Assuming the descent was made in the sector and did not go below 6,000 what weather parameters ruled operations from that point on? 7,000 foot overcast permissible? At no time were the operations immune from whiteout, the point of impact would just be 4,500 feet higher, that’s all. It matters not in the scheme of things (to my mind) where the descent is made if being made in VMC conditions. And there is no evidence that the aircraft was in anything but VMC from FL160 right up to the point of collision. The argument that the other aircraft had gin clear conditions is moot, VMC is VMC, you either are or you aren’t. The only problem being the crews had no business to be tooling around in VMC due to a complete lack of both experience and training. Had the flights continued in the manner in which they were being conducted it was just a matter of time before someone stubbed their toe. And it would not have been the crews fault, however much the apologists for management duck and weave.

With VMC flight we can imagine the aircraft as being at the centre of a bubble or sterile area, that is, a minimum height above ground or cloud, a minimum height below cloud, and a minimum distance horizontally from cloud or ground. All of that is achieved by estimation with the Mk. 1 Mod. 0 eyeball (the V in VMC). That pre-supposes that you do not need to know where you are, since any obstacle, it is assumed, will be seen. Normal obscuration’s to our vision are caused by such phenomena as smoke, dust, mist, fog, cloud or precipitation. Both the cause and degree of obscuration is easily discernible. That is a pilots real world experience, but there are always exceptions and caveats. The exception and caveat in this case is EXCEPT IN POLAR REGIONS. Mention has been made that other flights were made on gin clear days. Maybe so, but even in such conditions you may still very well fall afoul of the tricks of light and depth perception unique to polar operations. There is good reason the US military, in their wisdom, required crewmembers to have made three familiarisation flights to the ice before embarking on the adventure themselves.There is a reason some operators do not permit VMC operations over the ice/snow when an overcast is present.
Collins let corporate pressure influence him and a false sense that his prior experience enabled him to justify the decisions he made on the day. Any commander has the right to operate outside of the SOPs as he sees fit, if and when required for the safety of his passengers and aircraft. In this instance Collins operated well outside the SOP for no justifiable reason and the accident occurred.Amen to what you say. Except, it was the norm not to follow SOP on the Antarctic flights, and he may very well have been influenced by the actions of those who went before. The “Normalisation of Deviance” part. Couple that with the lack of adequate training, the failures of the nav department, briefings that didn’t comply with the SOP, failure to provide McMurdo with a copy of the now changed flight plan putting the aircraft over the top of Erebus, to which they would have objected. Had they known it was planned over Erebus the inference given is that the aircraft would have been cleared by a route clear of the mountain. What a missed opportunity.

Had the pilots done their own flight planning, and not relied on the nav dept, things may have been different.

All those bloody cheese holes. When applying Prof. Reason’s Swiss Cheese model to this accident there are so many holes as to lead one to believe that insufficient cheese remains to sustain one mouse for one day.
The operation was such a disordered mess that an accident was inevitable. Only three questions need to be asked,

When

Where

To whom

As Chippendale said,
There was no explanation of the horizon and surface definition terms in the operators’ route qualification briefing or pre flight dispatch planning, and only a passing reference to whiteout conditions.

The operator had not ensured that all significant information was included in the route qualification briefing and presented in an unambiguous manner.

As a result of questions put to some of the pilots of earlier Antarctic flights it was obvious that misconceptions were held about the minimum altitude to which the aircraft was permitted to descend in VMC and the actual topography below the flight planned track from Cape Hallett to McMurdo.You need to be told to keep an accurate plot of your position????, especially before descending below MSA?Chippendale had a comment about that. No one was plotting topography against INS, it took 14 months to detect the cockup.The fact that a computer error of over 2° of longitude to the west could exist for 14 months indicates there was no regular valid comparison between the topography and the geographical co-ordinates by flight deck crews.Last word by a young lady.Janine Marsden-Brown, January 9th, 2005 at 6:47 am

On a very personal note, I would like to say that I do not believe it was pilot error, I believe it was one bad mistake after another leading to a catastrophe. I think the pilots did exactly what was expected of them and ANZ did pressure pilots to make it a fanastic scenic flight. ANZ tried to whole-heartedly blame the pilots from day 1 until the information about the flight data turned up.

After losing both my parents in the Erebus crash I have complete contempt for the way Air New Zealand handled the situation. Although I was only 16 at the time, I read every piece of information about the crash and every book that was written. Air New Zealand treated my 2 brothers and I with complete disrespect, it took 5 years, a team of lawyers and the NZ victims families had to form a consortium before we got any settlements. Since then several overseas people told me that ANZ settled with them a few months after the crash.

25 years later all I can say is I hope ANZ learned something from their mistakes of the Erebus crash.

Hempy

18th Jun 2016, 17:24

Hempy, get off the sauce man. What has controlled airspace south of 60” got to do with anything. Think you mean 60°, not that it makes any difference, but when you’re in the state you’re in I understand.
Quote:
So if they were cleared to 50' it would have been fine to do so would it?

Sorry, my phone doesn't give me flash 'degrees' symbols, but regardless...Flights over McMurdo, whilst in the NZ FIR, are the responsibility of the USN. Controlled Airspace ends at FL195, the rest is Class G. So your 'clearance' below A060 signifies your lack of knowledge.

p.s re: framer. Given what you've written, I wouldn't fly with you if you were the 2nd last pilot on the planet (making the massive assumption that you aren't a Walt..)

Fantome

18th Jun 2016, 18:00

MEGAN . . . I for one take hat off as you have shown a fine grasp of the myriad of conflicting and technical elements right across the board.

That last quoted post from Janine Marsden-Brown adds a necessary plaintive voice . .. .one that serves perfectly to remind us never to forget the deep personal toll that marked for so many a grief beyond comprehension.

megan

18th Jun 2016, 18:19

So your 'clearance' below A060 signifies your lack of knowledge.Really?For the purpose of flights to the Ross Dependancy civilian operators accept the USN and FAA ATC procedures utilised by military aircraft as mandatory.

Promulgation of radio navigation information at McMurdo was the responsibility of the USN who installed, calibrated and maintained in accordance with TERPS. This manual was standard for the FAA, USAF, USN, US Army and the US Coast Guard. However, because of the special nature of the operations in Antarctica the aids and ATC procedures were installed specifically for the Antarctic Support, Operation Deep Freeze aircraft. Promulgated procedures are intended for use by Operation Deep Freeze aircraft only, others may use at their own risk.Perhaps you can fill us in with the relevant USN and FAA procedures applying at McMurdo at the time. The airline was not aware of the procedures in place at the time.

Hempy

18th Jun 2016, 19:07

Could someone please remind me again as to what ICAO says the PIC is responsible for? Some people here seem to have forgotten (or never learned....)

framer

18th Jun 2016, 20:14

I want to fly with you framer, being so omnipotent and all. Then again, perhaps not, you thinking that you’re so good.
Address the point of the paragraph Megan rather than trying to deflect with childish insults. I made a good point left in undercarriage uplocks, cowlings left unlatched, out of date data bases loaded, correct data bases loaded with waypoint errors, poorly designed stars and approaches, ATC clearances that create traffic conflicts, banned dangerous goods loaded for flight, incorrect fuel loads uplifted, important ground handling procedures not followed etc etc.
The role of the flight crew ( among other things) is to recognise these things and deal with them in an appropriate manner, and your reaction is to deflect.

prospector

18th Jun 2016, 21:20

Megan,

You need a little comprehension prospector. My post was quite plain, the plotting he had done the previous night. Perhaps I was not clear enough.

I initially thought that was what you meant. Then I thought surely not, of what point is plotting your position on a school atlas prior to the flight relative to deciding to go below MSA without knowing precisely your position.

It is not as if it would have been any hardship, there was a readout right above their heads with continually updated Lat and Long. To transfer that to a chart would be a very simple matter.
The lack of any meaningful effort to establish exactly their position prior to descent below MSA means one has to agree with Bob Thomson's comments that this crew thought "they were on a Sunday drive".

for the simple reason they wouldn’t have the RADAR monitoring that was demanded. As the US said, being able to provide radar monitoring was “absurd”.

What rubbish, try to stick to established known reported fact. I quoted in a previous post, from Gordon Vette's "Impact Erebus" that the radar could be switched to surveillance mode, and it was in that mode , it was well capable of monitoring the approved descent as promulgated to this crew prior to departure.
Had they been able to fly the IMC cloudbreak, which they couldn’t, there was absolutely no guidance given should they find themselves in whiteout conditions ie able to see the base buildings, aircraft and vehicles on the runway, but nothing else. Scramble back to the MSA, after spending whatever time it would take to realise the predicament they were in, of which they have zero experience, and what escape route to take?

Once again completely wrong. The weather report they received was well below condition required for any descent, and they were even advised that the area was no good at all for any sightseeing. All this information is available in relevant publications. Would suggest you avail yourself of this information.
As the US said, being able to provide radar monitoring was “absurd”.
From where did you glean that information??

Here again is the actual weather at the relevant time, you will note that Ross Island is reported as being completely obscured by cloud, not sector whiteout, cloud. You will also note, or perhaps not, that the cloud cover at McMurdo was total at 3,500, how could any descent be commenced that was limited to 6,000ft?

Weather at the McMurdo area at the time of the disaster was reported to be completely overcast at 3,500ft with other cloud layers above, and a wind of 10 knots. Mountain tops in the area were covered in cloud and although the surface visibility was good surface definition was poor and horizon definition only fair because the sun was obscured and snow surface features could not be readily identified from close up. Other aircraft in the area reported Ross Island as being completely obscured by cloud, and the crew of a helicopter which landed at Cape Bird Hut, 35 kilometres from the crash site and only an hour later, said it was overcast art 1,500ft with light snow Shortly afterwards they landed on the beach 10 kilometres from the site, in snow flurries and deteriorating conditions which made them cut short their visit

Now please advise how you think any descent was justified,? yes it was a sightseeing flight, but the pax had been advised if weather conditions were not suitable they would go to an alternate area. The crew's ultimate job was to get the pax back home again, safe and sound, if they missed their sightseeing through weather the company could not be held accountable for that. It was always a possibility, and I would be quite certain they would rather have missed Scott Base and got home again.

PapaHotel6

18th Jun 2016, 23:03

The lack of any meaningful effort to establish exactly their position prior to descent below MSA means one has to agree with Bob Thomson's comments that this crew thought "they were on a Sunday drive".
Nor was the descent procedure discussed amongst the crew in any meaningful way, they didn't discuss terrain clearance and never mentioned Mt Bird that that they easily could have hit if they had been where they thought they were. They simply saw a cloud break and down they went.

Fantome

19th Jun 2016, 00:34

In any open forum discussing the finer points my money's on Megan every time. Not that that means diddly-squat.

if they missed their sightseeing through weather the company could not be held accountable for that. It was always a possibility, and I would be quite certain they would rather have missed Scott Base and got home again.

….. as one of his harsher critics espouses. " rather have missed Scott Base and got home again. " .. . . Yep. . . you're probably right there in your certainty that they'd want to get home again . . .. seems a reasonable proposition as opposed to having your mortal remains strewn across the bleak and lonely face of Erebus.

3 Holer

19th Jun 2016, 01:12

PapaHotel6 states:

Nor was the descent procedure discussed amongst the crew in any meaningful way, they didn't discuss terrain clearance and never mentioned Mt Bird that that they easily could have hit if they had been where they thought they were. They simply saw a cloud break and down they went.

How do you know the descent procedure wasn't discussed?

PapaHotel6

19th Jun 2016, 01:20

How do you know the descent procedure wasn't discussed?

Because of something called the CVR - that stands for "Cockpit Voice Recorder". Of course, it's possible they held said discussion in whispers, or sign language, or by passing notes to each other; but I don't think so.

3 Holer

19th Jun 2016, 01:27

So are you now assuming the descent procedure was only discussed in the 30 minutes prior to impact ?

PapaHotel6

19th Jun 2016, 01:31

So are you now assuming the descent procedure was only discussed in the 30 minutes prior to impact ?
No, I said no such thing; I said as a point of fact that no such discussion took place. And also that no reference to Mt. Bird was made before or during the descent.

Please stop wasting bandwidth.

megan

19th Jun 2016, 02:31

Bob Thomson's comments that this crew thought "they were on a Sunday drive".All the crews thought they were out for a Sunday drive. See Chippendales comment re no one checking the INS against topographical information. Took 14 months for some one to wake up.As the US said, being able to provide radar monitoring was “absurd”.
From where did you glean that information??Do keep up prospector. It was given in evidence by one of the controllers.it was well capable of monitoring the approved descent as promulgated to this crew prior to departure.Absolute nonsense. See comment from the controller, "absurd" he said. The weather report they received was well below condition required for any descentI don't know if you are being purposely thick (comprehension again?). I was not referring to Collins, I was talking of ANY FLIGHT, I wrote,They were never able to fly the cloudbreak procedure in IMC when the NDB was available, for the simple reason they wouldn’t have the RADAR monitoring that was demanded.Now please advise how you think any descent was justified,?Reread what I wrote about VMC and think about it for a moment.Descent below the LSALT of FL160 had to be made in VMC as you say. What advantages accrue from specifying the VMC descent to be made in the stipulated sector overhead McMurdo? Assuming the descent was made in the sector and did not go below 6,000 what weather parameters ruled operations from that point on? 7,000 foot overcast permissible? At no time were the operations immune from whiteout, the point of impact would just be 4,500 feet higher, that’s all. It matters not in the scheme of things (to my mind) where the descent is made if being made in VMC conditions. And there is no evidence that the aircraft was in anything but VMC from FL160 right up to the point of collision. The argument that the other aircraft had gin clear conditions is moot, VMC is VMC, you either are or you aren’t. The only problem being the crews had no business to be tooling around in VMC due to a complete lack of both experience and training. Had the flights continued in the manner in which they were being conducted it was just a matter of time before someone stubbed their toe. And it would not have been the crews fault, however much the apologists for management duck and weave.

With VMC flight we can imagine the aircraft as being at the centre of a bubble or sterile area, that is, a minimum height above ground or cloud, a minimum height below cloud, and a minimum distance horizontally from cloud or ground. All of that is achieved by estimation with the Mk. 1 Mod. 0 eyeball (the V in VMC). That pre-supposes that you do not need to know where you are, since any obstacle, it is assumed, will be seen. Normal obscuration’s to our vision are caused by such phenomena as smoke, dust, mist, fog, cloud or precipitation. Both the cause and degree of obscuration is easily discernible. That is a pilots real world experience, but there are always exceptions and caveats. The exception and caveat in this case is EXCEPT IN POLAR REGIONS. Mention has been made that other flights were made on gin clear days. Maybe so, but even in such conditions you may still very well fall afoul of the tricks of light and depth perception unique to polar operations. There is good reason the US military, in their wisdom, required crewmembers to have made three familiarisation flights to the ice before embarking on the adventure themselves. Had marginal VMC been available at McMurdo they would have been permitted to descend, and could quite possibly, given the nature of whiteout, be confronted with exactly the same problem that caught Collins. Better to be dead doing something the airline considered legal, heh? The crews knew nothing about whiteout. As has been said, tooling about in a jet at low level in what is only just legal VMC is a bad, bad, bad, VERY BAD idea. The airline just didn't know about it though.Could someone please remind me again as to what ICAO says the PIC is responsible for? Some people here seem to have forgotten (or never learned....)And some are ignorant of the causal chain that leads to accidents.

3 Holer

19th Jun 2016, 02:58

PapaHotel6 so confirming:

I said as a point of fact that no such discussion took place.

I will try and keep this simple. I asked, how did you know Nor was the descent procedure discussed amongst the crew in any meaningful way and you said from the CVR (Cockpit Voice Recorder). The CVR contains only 30 minutes of conversation, none of which contains any descent briefing/procedure.

Is that what you base your statement of "no descent procedure discussed" on ? If not, then I say again, how do you ascertain, as a point of fact, that no descent briefing was discussed?

P.S. Moderators decide who is wasting bandwith.:=

PapaHotel6

19th Jun 2016, 03:00

Megan said:

All the crews thought they were out for a Sunday drive

... which in no way exonerates this particular crew.

Can I ask - for the record - does anyone here (apart from 3-Holer) believe that the crew of this flight were completely without fault in the accident?

megan

19th Jun 2016, 03:29

which in no way exonerates this particular crewNo, but nor was it all their fault, as some wish to make claim. There is always a long list of contributors to any accident, save suicide, but nevertheless, I can understand where 3-holer is coming from, given the amateurish airline operation of the flights.

As a counterpoise, think of a highly experienced air force F-18 pilot being sent to operate off a carrier with no training in deck landings. Have the carrier heaving and rolling to its limits and what do you think the outcome might be? OK 3 wire? Like hell. On a blue water exercise most likely he'd have to punch out.

Here we have highly experienced airline pilots being asked to fly a VMC operation in the worlds most demanding environment with absolutely no training or experience and has been exceptionally poorly planned and what do you think the outcome might be? Janine Marsden-Brown can tell you.

prospector

19th Jun 2016, 04:09

Absolute nonsense. See comment from the controller, "absurd" he said.

Aha!!!! So Gordon Vette in his book "Impact Erebus" on page 49 is talking an "absurdity" when he states

He probably either did not understand their reasons or else he would have been surprised that they had the radar switched into surveillance mode, which, even though it has blind spots overhead, would allow them to monitor his initial approach and probably allow him to come below MSA on approach.
I don't know if you are being purposely thick (comprehension again?). I was not referring to Collins, I was talking of ANY FLIGHT,.QUOTE]
I was under the impression the debate was about Mahon claiming the crew were blameless, or "did not commit any error"
[QUOTE] They were never able to fly the cloudbreak procedure in IMC when the NDB was available, for the simple reason they wouldn’t have the RADAR monitoring that was demanded.

I see it all, the surveillance mode was installed just prior, and for this flight??

All the postulating in the world, and who said what when is completely irrelevant. their riding instructions were given in
OAA:14/13/28 dated 8 Nov 1979 Headed McMurdo NDB not available.

Delete all reference to 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 360 grid to 270grid from McMurdo field, within 20nm of TACAN CH29
4. Descent to be coordinated with local radar control as they may have other traffic in area.

You will no doubt note VMC FL160 to 6,000ft. no requirement for any approach plate, no requirement for any overshoot. The whole descent was to be VMC below 16,000ft.

You will perhaps, or not, note the dates given for these requirements

Here we have highly experienced airline pilots being asked to fly a VMC operation in the worlds most demanding environment with absolutely no training or experience.

This was the airlines fault? nothing to do with NZALPA insisting that their senior pilots all have a turn at this perk flight?

Fantome

19th Jun 2016, 04:46

Can I ask - for the record - does anyone here (apart from 3-Holer) believe that the crew of this flight were completely without fault in the accident?

To exonerate , meaning to absolve someone from blame for a fault or wrongdoing, may be an act of legal absolvement or an absolvement
in the light of a commonly held opinions in the minds of the laity.

So in the case of Jim Collins and the crew of TE901 who are neither in the dock nor subject to pillorying by the general public , or stoning at the hands of members of the PPRuNe fraternity for that matter, the relevance of exoneration is at best dubious. By what we can deduce of the reckoning of the unjustly maligned the late Captain Gordon Vette it seems fair to say the apportioning of blame, the question of exoneration or not, is not in any way a function of an enquiry seeking impartial and soundly based analysis and conclusions.

It is an example of the stereotypical leading question - do you think it right to exonerate the crew of this aircraft for causing this accident?

PapaHotel6

19th Jun 2016, 05:26

do you think it right to exonerate the crew of this aircraft for causing this accident?

I don't, no. But I think what you're asking is "is there anything to be gained by aportioning blame?"

Mahon said the crew made no error that contributed to this accident. That, to me, is patently false, and worth arguing against even nearly 40 years later. Over and above that I have no interest in debating whether the crew were 90% responsible or 20% responsible. But to absolve them from blame is to condone the poor airmanship they displayed and as a pilot I just can't let that lie.

framer

19th Jun 2016, 06:01

I agree with PH6.
Everyone knows the mistakes and poor behaviour of Air NZ, that is not denied by anyone in any forum/ book/ doco/ crew room anywhere. The bit that many people object to is saying that Collins should be absolved of blame completely, the cry of the late P Holmes and some politicians who never have been, and never will be encumbered with the level of responsibility that Collins held, to have the crew exonerated, simply shows that they don't understand the subject. He was not without error and to say so is not disrespectful to him or his family. I'm sure he was a good man and good men make mistakes, such is life.

megan

19th Jun 2016, 06:28

nothing to do with NZALPA insisting that their senior pilots all have a turn at this perk flight?Of course it was the airlines fault. Who was charged with the responsibility of running a safe airline, certainly not the NZALPA.

What were the bargaining chips the NZALPA held over the airline to force it to bend to their will? Sorry, your excuse is a cop out.Aha!!!! So Gordon Vette in his book "Impact Erebus" on page 49 is talking an "absurdity" when he statesHe probably either did not understand their reasons or else he would have been surprised that they had the radar switched into surveillance mode, which, even though it has blind spots overhead, would allow them to monitor his initial approach and probably allow him to come below MSA on approach.The controllers were expecting the aircraft to come down the sound, in which case the aircraft would have been picked up. No one had told the controllers that the plan they held which covered the previous 14 months had changed. I wish you'd read the report in its entirety rather than banging continuously on about the airlines supposedly "safe" VMC letdown, which it wasn't, safe that is.

prospector, I've come to the conclusion that (A) you worked, or those close to you, worked in the airlines upper echelons, or perhaps the nav dept (B) communicating with you is a complete waste of time as you have absolutely no comprehension of what is written.

The name Dale Whitthoft, age 33, won’t mean anything to anybody here. Married with two daughters aged 3 and 1 years, and a work colleague who lived 1K away from us, decided to get back to work early, as he was the project engineer working on a big project. Left the wife and kids behind so they could enjoy a holiday.

He caught American 191 (DC-10) which dropped the number one engine onto the runway during take off. A short cut had been taken during an engine change in order to cut man hours required, and hence cost. Damage was done to the airframe in the process, initiating the engine failure.

The crew were climbing out with a perfectly flyable aircraft, and being in excess (172kt) of the engine out speed (V2 153kt), slowed the aircraft to the speed mandated by SOP, whereupon the left wing stalled (159kt)because of retracted leading edge devices on that wing, brought about by damage to the hydraulics. The aircraft hit the ground with 112° of bank and 21° nose down pitch. All 273 died.

So whose fault, for those who love to apportion blame?

The aircrew? They had a perfectly flyable aircraft. Framer might like to comment here, the crew supposedly being the gate keepers for everyone elses mistakes.

The person who designed the LE slat mechanism? (note: it couldn’t happen on a Boeing so I’m told, because they are mechanically latched when open, whereas the DC-10 relied on hydraulic pressure to keep them open)

The person who designed the engine out SOP? If they hadn’t slowed the aircraft they could have just done a circuit and landed.

The guy who planned and put into place the man hour saving procedure?

The people who actually did the engine change?

PapaHotel6

19th Jun 2016, 06:39

Megan - I get what you're trying to do, but your analogy above isn't really valid and is bordering on poor taste. That AA aircraft was hardly "perfectly" flyable, and those pilots did everything they were supposed to do until the end. RIP.

prospector

19th Jun 2016, 07:02

prospector, I've come to the conclusion that (A) you worked, or those close to you, worked in the airlines upper echelons, or perhaps the nav dept (B) communicating with you is a complete waste of time as you have absolutely no comprehension of what is written.

Sorry, that would be about as accurate as the rest of the conclusions you have stated.

What can you not understand about

Delete all reference to briefing dated 23/10/79. Note that the only let down procedure available is VMC below FL160(16,000ft) to 6,000ft as follows:

Quote:

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 360 grid to 270grid from McMurdo field, within 20nm of TACAN CH29
4. Descent to be coordinated with local radar control as they may have other traffic in area.

That was the requirement for any descent below MSA, Why?? because the airline was well aware of the lack of experience of any of their crew in Antarctic operations.

Why did they not stick to one or two crews that had the experience required by other operators? could it be because NZALPA wanted their senior pilots to have a turn at this perk flight?.

The controllers were expecting the aircraft to come down the sound, in which case the aircraft would have been picked up. No one had told the controllers that the plan they held which covered the previous 14 months had changed. I wish you'd read the report in its entirety rather than banging continuously on about the airlines supposedly "safe" VMC letdown, which it wasn't, safe that is.

Surely you can remember what you posted a few posts back
The controllers were expecting the aircraft to come down the sound, in which case the aircraft would have been picked up. No one had told the controllers that the plan they held which covered the previous 14 months had changed. I wish you'd read the report in its entirety rather than banging continuously on about the airlines supposedly "safe" VMC letdown, which it wasn't, safe that is.

.

.
Once again proof positive of the lackadaisical approach to the entire operation by both the airline itself, and the CAA
If you added and by this crew, then I would have to agree. I say again, it is only Mahon's opinion that the crew were blameless that is in dispute

And do you believe that this crew "committed no error"?

3 Holer

19th Jun 2016, 07:10

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.

framer

19th Jun 2016, 07:43

3 Holer and Megan, I'm not arguing that there were not many links in the chain, I'm arguing that Collins made mistakes and asking for, or expecting exoneration is inappropriate.
I asked a while back if you guys were thought that the outcome would have been the same regardless of which Air NZ crew had been assigned to that duty, the silence was deafening. If you take the time to answer that question I'l set aside some time this evening to comment as invited. Remember, Im not suggesting Air NZ didn't cock it up, they did. I'm suggesting that Collins showed poor judgement and as such cannot be exonerated of all responsibility.

Fantome

19th Jun 2016, 08:39

Oh how tiresome.. . .. the poor old needle in the record is stuck again.. again ..again . . sanctimoniously .
(you could even be excused of thinking mindlessly - it was all so different before everything changed.)

Once more unto the breach . . . . ..

Of all the fallacious claims made over and over down all the years since the Mahon Report was tabled
is the repeated one that the pilots should have known better, should have twigged to the signs, should have displayed superior judgement so as not to have to call upon superior airmanship. It is frustratingly the most enduring and most typical of a case of being wise after an event. Mammoth online talk fests and reams of tabled reports , notes and conclusions , many of them hypothesising about how the flight should have been conducted, how the descent was a negligent and cavalier act, none of this would have taken place if they had been where they thought they were. To lose sight of this primary fact, to be led along labyrinthian channels of secondary importance, is to fail to grasp or give sufficient credence to what was in fact a simple procedural oversight, but one with disastrous unforeseen consequences.
Were the potential consequences foreseen then needless to say there'd have been hardly even a minor incident to report upon and rectify.

PLovett in post #601 on 6th May last -

Oh boy......sit back........snack at hand and drink ready and watch the fireworks.

ampan

19th Jun 2016, 09:12

Slightly off topic but there is a major misconception about the briefing, conducted three weeks before the flight. 27/09 #663: :" There was a briefing a few days prior to the flight where the crew were told that the route was well to the side of Mount Erebus."

Not true. The crew were told that the final waypoint was at McMurdo Station. There can be no dispute about this, because it was recorded on tape. They may not have known that a route to that waypoint from Cape Hallett would go over Erebus. This is because the chart they were given did not include Cape Hallett.

The night before, the captain plotted the route using an old flight plan. This is when he would have concluded that the final waypoint was well out to the west of McMurdo Station. He would also have noted that a route to McMurdo Station went over Erebus.

Conflicting information. No attempt to resolve the conflict. Flying around at 1500 feet in the vicinity of a 13000 foot mountain. One of the worst of a slew of very bad errors.

3 Holer

19th Jun 2016, 09:38

none of this would have taken place if they had been where they thought they were.
Absolutely correct Fantome.

framer it is impossible to say if "the outcome would have been the same" if another crew was flying the aircraft that day. It's a bit like saying"If Aunty had aggetts she would have been Uncle."

We can only collate the facts and evidence of an accident and draw conclusion of what caused it. Mahon, Vette, et al, did this during the Erebus Inquiry and did it very well. I see no reason why Justice Peter Mahon's finding: ".... the single dominant and effective cause of the disaster was the mistake made by those airline officials who programmed the aircraft to fly directly at Mt.Erebus and omitted to tell the aircrew" could be challenged, as it is factual and undeniably true.

PapaHotel6

19th Jun 2016, 09:48

Fantome said:

Mammoth online talk vests and reams of tabled reports , notes and conclusions , many of them hypothesising about how the flight should have been conducted, how the descent was a negligent and cavalier act, none of this would have taken place if they had been where they thought they were. To lose sight of this primary fact, to be led along labyrinthian channels of secondary importance, is to fail to grasp or give sufficient credence to what was in fact a simple procedural oversight, but one with disastrous unforeseen consequences.

Mammoth online talk vests and reams of tabled reports , notes and conclusions , many of them hypothesising about how the flight should have been conducted, how they weren't where they thought they were, none of this would have mattered if they hadn't performed the negligent and cavalier descent. To lose sight of this primary fact, to be led along labyrinthian channels of secondary importance, is to fail to grasp or give sufficient credence to what was in fact a simple procedural oversight, but one with disastrous unforeseen consequences.

3 Holer

19th Jun 2016, 10:06

if they hadn't performed the negligent and cavalier descent.

I can't find any reference to this in the Mahon Report. You are permitted a little poetic licence at times PapaHotel6, but blatant "porky pies" does nothing to enhance your credibility or research on this subject.

megan

19th Jun 2016, 10:11

I asked a while back if you guys were thought that the outcome would have been the same regardless of which Air NZ crew had been assigned to that dutyI'll be brave enough to stick up my hand framer, quite possibly yes. You can never be absolutely sure in your judgements of course, but the entire operation was such a mess that I can only repeat my previous, the only question to be asked is,

Where
When
To whom:" There was a briefing a few days prior to the flight where the crew were told that the route was well to the side of Mount Erebus."

Not true. The crew were told that the final waypoint was at McMurdo Station. There can be no dispute about this, because it was recorded on tape.Nonsense ampan. Chippendale said,An examination of this briefing revealed certain significant items were not included,

The procedure for determining the minimum flight level recognised for the Antarctic area and specifically the McMurdo control area.

The way in which the Air New Zealand route varied from the normal military route, which followed the reporting points depicted on the RNC, particularly on the leg from Cape Hallett south to McMurdo.

A comprehensive discussion of the visual phenomenon peculiar to the Antarctic ie the whiteout conditions, which might be anticipated with overcast sky and and snow covered terrain below.A complete stuff up by the airline.

I see our good friend ampan is back, perhaps we can can expect more erudite and insightful insights posts as per his previous ,Collins was thick, like you are: Couldn’t even pass School C

As to what was going on inside the head of Captain Collins, the answer is: Very little.Can't expect too much of substance heh ampan?

Fantome

19th Jun 2016, 10:27

mate. .. . . . do you bash your head against the wall because when you stop you feel a lot better?

If Aunty had aggetts . . . and I say BALLS! . . . (saw that one coming)

BTW further digression . .. . in RAAF parlance particularly during Second W W 'balls' was heard a lot.(more balls than bull-****, probably.)
Dr Clyde Fenton the flying doctor in Katharine who wrote his celebrated book called FLYING DOCTOR
about that period of his colourful life. . . . he received a telegram from the department in Melbourne
grounding his Moth and suspending his licence . . forthwith
. His priceless response was to telegraph them back with . . THEY'RE ROUND AND THEY BOUNCE. . .FENTON

prospector

19th Jun 2016, 10:40

What was the point of the descent, the weather was reported to the crew as being below that required for any chance of of sightseeing.

framer

19th Jun 2016, 10:45

3 Holer, you originally said As Mahon,Vette, et al found out, by discovering the "incompetent administrative airline procedures", only Captain God could have prevented the Erebus disaster. when pressed you say framer it is impossible to say if "the outcome would have been the same" if another crew was flying the aircraft that day. It's a bit like saying"If Aunty had aggetts she would have been Uncle."
which one do you stand by now? Captain God or Aunty Uncle?
Megan, I appreciate your reply. Unfortunately I have run out of puff tonight but look forward to rejoining the conversation tomorrow evening.

Fantome

19th Jun 2016, 12:41

there is no inconsistency here as the statements require no correlation

suggested reading for the elimination of muddled thought . . . potentially -

STRAIGHT AND CROOKED THINKING

by ROBERT H. THOULESS

READER IN EDUCATIONAL PSYCHOLOGY IN THE UNIVERSITY OF CAMBRIDGE

TABLE OF CONTENTS -
PREFACE

I. EMOTIONAL MEANINGS

II. ALL AND SOME

III. SOME DISHONEST TRICKS IN ARGUMENT

IV. SOME LOGICAL FALLACIES

IV. WORDS AND FACTS

V. THE DANGERS OF SPECULATION

VI. THE MEANINGS OF WORDS

VII. DEFINITION AND SOME OF ITS DIFFICULTIES

IX. TRICKS OF SUGGESTION

X. HABITS OF THOUGHT

XI. PREDIGESTED THINKING

XII. PITFALLS IN ANALOGY

XIII. PREJUDICE

XIV. THE VALUE OF STRAIGHT THINKING

APPENDIX
I. THIRTY-EIGHT DISHONEST TRICKS
II. A DISCUSSION ILLUSTRATING CROOKED THINKING

This revised and enlarged edition first published 1953
by Pan Books Ltd., S Head/art Place, London, S.W.I

onetrack

19th Jun 2016, 12:56

O.K. Let me try a different approach, as an impartial observer. Let's try the Geoffrey Robertson Hypothetical approach.

Let's say Capt Collins, by some miracle, was the sole survivor of the crash. It has been decided by the authorities that there is adequate cause for him to be put on trial. He is now charged with 256 counts of manslaughter.

Geoffrey Robertson is the prosecutor. He has Capt Collins in the dock and is interrogating him.

Robertson: "So, tell me Capt Collins, why you thought it was safe to descend to a very low altitude, when there was a very large mountain in the vicinity, with terrain height much greater than the altitude you were planning to descend to? - and you had no idea where that mountain was, exactly?"

Collins: "Because I was in VMC and I could see some terrain features fairly clearly - and the passengers were desirous of good, close-up, low-level views of Mt Erebus. It was company policy to give passengers a good spectacular view of Erebus and McMurdo Sound, that's what they paid to see."

Robertson: "I see. But you descended without knowing precisely where Erebus was, in relation to your aircraft, didn't you? Wouldn't you consider this action more than a little foolhardy?"

Collins: "No. I was given a flight path and I was following it. That flight path was supposed to take us past Erebus into McMurdo Sound at low level for the benefit of the passengers. How was I to know there were serious navigational errors in the flight path information given to me?"

Robertson: "But you had the opportunity, both before and during the flight, to check the accuracy of the flight plan information, and to cross-check your position with the information in the flight plan supplied, did you not?"

Collins: Yes, of course, I did some cursory checks - but checking the aircrafts position in flight, was the job of other crew members in the cockpit. I was busy flying the aircraft. I believed we were on the correct course into McMurdo Sound - Mulgrew even indentified Ross Island. I descended in VMC to gain some clarity, visually, as regards my aircrafts precise position in relation to the terrain.

Robertson: "But you descended below the minimum safe altitude, despite poor levels of visibility in that declared VMC - and you are heard saying on the CVR - 'Actually, those conditions don't look very good at all'. And Mulgrew agreed with you - 'No, they don't.' Is that correct?"

Collins: Yes .. but you'll note, I said, a little later in the cockpit conversation, 'We're 26 miles North, we'll have to climb out of this'. I was aware of the potential danger".

Robertson: Yes .. but you didn't climb in time, did you? You crashed, directly into high terrain that you knew, was close by - but which high terrain, you had no inkling of its precise whereabouts, in relation to your aircraft? In essence, you failed totally, in your duty of care towards your 256 passengers. Is that correct?"

Collins: If you prefer to put it that way ......... Yes.

The silence in the courtroom is so intense, one could literally hear a pin drop.

The Outcome: Capt Collins is cleared of all 256 counts of manslaughter, but is convicted of the lesser charge of "reckless flying". Sentencing is deferred to enable the Judge to consider mitigating factors, and correspondingly, the length of the sentence.

As a typical example of what the above scenario could have been, here's one recent one ...

Pilot found not guilty of manslaughter of young passenger (http://www.abc.net.au/news/2016-02-24/pilot-found-not-guilty-of-manslaughter-of-young-passenger/7190634)

Fantome

19th Jun 2016, 14:33

An interesting courtroom drama play script . . .(minus Robertson's perambulating propensity for theatrics). But as far as enlarging upon our understanding ,. . . ??? then again. . as relevant as my own occasional sweeping digressions .

As with any prosecutor's bag of tricks it is slanted against the plaintiff from the outset.

Captain Collins counsel if he was doing his job would have briefed Jim Collins
whatever you do not admit any errors of judgement. If an attempt is made to put words in your mouth such as you had no idea where that mountain was, exactly ? , you say truthfully that there was no reason to suspect you would at any time be closer to Erebus than 20 miles at the least.

without a long adjournment I think this could be doing my head in . ..

3-holer . .. . your #817 . .. think you might need to insert 'not' in the last line.

(of course anything and everything can be challenged. . . but in this case the facts as confirmed and never denied after Morrie Davis came clean support a position that
the finding . . . of the failure of the airline's nav department to etc etc . .is not now or ever open to any
legitimate challenge.)

------------------------------------------------------------------------------------
THE PROBITY OF THE CHIEF INSPECTOR OF ACCIDENTS.

Just in case anyone following or coming new to this debate is labouring under the misapprehension that the conduct of the initial investigation into the accident was entirely transparent and above board, here is an extract from an article by Captain Gary Parata , who found alarming departures from the accepted protocols for making the transcripts from the recovered CVR.

Captain Parata (then Chairman of NZALPA’s Accident, Incident and Safety Group and a flight recorder specialist with the IFALPA Accident Analysis and Prevention Committee) considered flaws in the procedure used for the production of the published transcript, and why – as a result of those procedural flaws – the Chief Inspector’s theory and conclusions were misleading.

The initial CVR Group assembled by Mr R Chippindale travelled to Washington and underwent specialised training, adhered strictly to that training, and produced a single, handwritten transcript. For their efforts and professionalism they were roundly praised by NTSB and FBI experts.

(But) the transcript actually published in the formal accident report was significantly different to the version produced by the CVR Group. Chippindale made 55 changes to the transcript without consultation with the CVR Group and in direct contravention of accepted protocols. Chippindale’s actions were inexplicable - ‘at best, an extraordinarily non-standard performance; at worst, a highly improper and prejudicial act.’
The complete failure of the accident-investigation system to identify and prevent unprofessional conduct like this was what Justice Mahon later described as “culpability of the organisational system” (Mahon, 1981).

3 Holer

19th Jun 2016, 20:37

Not bad onetrack but like the Matlock court scenes, all fiction and not a lot of fact. :ok:

Whiskery

19th Jun 2016, 20:56

3-holer . .. . your #817 . .. think you might need to insert 'not' in the last line.

I see no reason why Justice Peter Mahon's finding:"............." (it) could be challenged, as it is factual and undeniably true.

??:confused:

oggers

19th Jun 2016, 22:06

As with any prosecutor's bag of tricks it is slanted against the plaintiff from the outset.

I would be very surprised if that were true.

jack red

19th Jun 2016, 22:45

3 Holer were you flying with NAC in the early '70s ? pm me, we may know the same people.

megan

20th Jun 2016, 00:21

That AA aircraft was hardly "perfectly" flyable, and those pilots did everything they were supposed to do until the endThe aircraft was perfectly flyable, and the accident forced a rethink of the SOP regarding slowing to the safety speed. The pilots did as they had been trained, and what was expected of them, and can't be faulted. It was to point out (framers comment) that the crew can't be the gate keepers of every one elses mistakes/errors.

Poor taste? - well, thats in the eye of the beholder. Unfortunately, all accidents have a human element, and a lot of us forget that in our discussions. The whole point of accident discussion is to learn how to protect the human element.

I note that no one has taken up the challenge as to who was to "blame" for the AA191 accident.

prospector

20th Jun 2016, 00:33

Having trouble with your comprehension?

The thread is supposed to be about Mahon statement that the crew of Flt 901 made no error.

It has been stated many times that no one involved in this disaster is blameless, that includes NZCAA, Air New Zealand,

I note that no one has taken up the challenge as to who was to "blame" for the AA191 accident.

If you want to establish blame for that incident why not start another thread?

Fantome

20th Jun 2016, 01:11

no . . .. . this thread's title reflects a much broader canvas. Wirraway who kicked it off eloquently on 21 November 2004 was not rebutted until #11. That poster began by defending Mr Chippendale citing the depth of his experience compared with Justice Mahon , then hinting at the flawed judgement of Justice Mahon and Captain Gordon Vette. All along his tone has invariably been one of not only an absolute intolerance of viewpoints he does not share but a petty sniping tendency to sarcastic belittlement .

ampan

20th Jun 2016, 01:26

megan at #820 appears to be someone who, when faced with aunanswerable point, elects to answer a completely different one

I said:
" There was a briefing a few days prior to the flightwhere the crew were told that the route was well to the side of MountErebus." Not true. The crew were told that the final waypoint was atMcMurdo Station. There can be no dispute about this, because it was recorded ontape.

Megan’s response:
“Nonsense ampan. Chippendale said: “An examination of thisbriefing revealed certain significant items were not included. The procedure for determining the minimumflight level recognised for the Antarctic area and specifically the McMurdocontrol area. The way in which the Air New Zealand route varied from the normalmilitary route, which followed the reporting points depicted on the RNC,particularly on the leg from Cape Hallett south to McMurdo. A comprehensive discussion of the visualphenomenon peculiar to the Antarctic ie the whiteout conditions, which might beanticipated with overcast sky and snow covered terrain below.”

There is an almost complete disconnection between the pointI made and Chippendale’s quote. It’s like countering a flat-earth proponentwith a recipe for pavlova.

There’s no issue about this. The audio was recorded. Therecording was played at the hearing. The waypoint was at McMurdo Station, whichis exactly where you would expect it to be. Further, Mahon’s report acceptedthat fact, because he had no choice.

Fantome

20th Jun 2016, 01:44

Mr Chippendale forfeited his credibility and his right to the assumption of probity from the time he took it upon himself to doctor the expertly complied transcript of the CVR as described at #826.

prospector

20th Jun 2016, 03:38

This extract from John King publication has also never been challenged

Because the findings of the Royal Commission id Inquiry on the cause of the disaster were limited in scope, being legally an opinion and not a statement of fact, they could not be appealed in legal terms, unlike the Office of Air Accidents investigation report, which remains the sole official account- and has never been officially challenged.

then hinting at the flawed judgement of Justice Mahon and Captain Gordon Vette.

So all the people at McMurdo, and the other aircraft crews who reported that Ross Island was completely covered in cloud were mistaken in their observations?

The statement by Megan that the radar could not monitor the approved descent procedure has also proven to be incorrect or is he is accusing Vette of an "absurdity".

Can anyone advise the date that Captain Wilson was supposed to have advised the crew that any altitude the McMurdo Radar allowed them to descend to was actually made?

piratepete

20th Jun 2016, 03:50

I clearly remember walking past the Air NZ passenger lounge that fateful day to my 737-200 we were to fly to Apia with Polynesian Airlines.We "jostled" with TE901 parked next to us to try to get pushed first which we did.They taxied right behind us.Hearing the basic news the next day was a horrible shock.
I cant understand all of this silly arguing and discussion now going on.The DC10 crashed because the Captain decided to embark on a VISUAL descent into unfamiliar terrain without actually being in visual conditions and not knowing his actual position.It is just not acceptable to descend to 1500 feet in an area with a 16000 foot MSA in such conditions.Yes we have likely all done it at least once in our careers but the lesson from TE901 must never be forgotten.RIP.

Fantome

20th Jun 2016, 04:52

I cant understand all of this silly arguing and discussion now going on.The DC10 crashed because the Captain decided to embark on a VISUAL descent into unfamiliar terrain

now that's a great shame you have this simplistic view Pete . . .. your emotional connection you acknowledge . .. that's not hard to get and to empathise .. especially considering your undoubted detailed knowledge and depth of experience in certain related fields . . . . but it would seem nevertheless that you side with that narrow school of armchair critics who simply say he should have stayed high for various undoubtably with hindsight valid reasons . . end of story.
Well sorry .. . but this discussion has been going on for years and any ad hoc opinion now as to the whys and the wherefores just does not any longer cut the mustard .. . Cap'n.

BTW . . a post from R & N HIGH WINDS AT SCHIPOL last year. If the question you posed there
Pete was ironic then I get it . . otherwise .. . ?

31st Jul 2015
piratepete

COMPLETE HONESTY
Hand on heart, with total honesty, and after 20,000 plus hours, 14000 hours as PIC on heavy jets, 4000 plus hours as a simulator/line/base/ground instructor, TRE TRI etc bits-of-paper in my Navbag, almost 40 years as an AIRLINE PILOT, .......I HAVE NEVER EVER MADE A SINGLE MISTAKE, NEVER EVER!......

megan

20th Jun 2016, 06:41

Can anyone advise the date that Captain Wilson was supposed to have advised the crew that any altitude the McMurdo Radar allowed them to descend to was actually made?Captain Wilson confirmed that during his briefings given in 1978 and 1979 crews were told that they could descend to any height authorised by the USN Air Traffic Controller.
The statement by Megan that the radar could not monitor the approved descent procedure has also proven to be incorrect or is he is accusing Vette of an "absurdity".Vette said,Their optimism rose as the radio from McMurdo came on with its offer: ‘Within a range of 40 miles of McMurdo we have radar that will, if you desire, let you down to 1500 feet on radar vectors.

‘Roger, New Zealand nine zero one. That is acceptable,’ replied Cassin.
Collins expressed his relief. ‘Crikey, that’s what we Want to hear.’

He eased back slightly on the three power levers, thinking maybe the briefing was wrong and they could pick up the aircraft above 6000 feet, and beyond 40 miles.

They were now passing over a thinning belt of stratus through which the fragmented pack ice showed. But only a short way ahead, a big break of some 40 by 20 miles, broken only by a few fluffy clouds, was showing up.
The safe course was to descend into this space in an orbit which would bring them around and back onto the navigation track again.

From where they were the base of the major cloud areas appeared to be about 10,000 feet. Once they got below this, they could be in the clear with miles of visibility to continue the run up McMurdo Sound until intercepted by radar.

If conditions proved unsatisfactory once they descended into the clear opening, then there would be no problem climbing back to 18,000 feet, and flying on to McMurdo waypoint, before doubling back to do a run over the Dry Valley on the Victoria Coast mainland — which they could still see was in sunshine.

The aircraft, locked on to 18,000 feet, was still {lying in crystal sunshine. Elusive glimpses of pack ice showed through the scattered cloud below, and the tantalising knowledge that the land was close at hand kept the crew on visual tenterhooks, scanning keenly for the white glow of sun on snow, and the darker patterns of rock. It was some consolation for the crew that the radar was operating, and that the Americans were happy for them to fly over the ice airfield at 1500 feet.

There was a nagging doubt at the back of Jim Collins’ mind, possibly associated with the briefing, that the approach radar would be unable to pick them up above 6000 feet. On previous flights the approach had been largely clear of cloud and, as a sure aid, the feed in had been attained by using McMurdo’s NDB (Non-Directional Beacon) to bring them into the orbit of the precision approach radar, at 6000 feet.The controller was expecting them to come down the sound, as all the other aircraft had, and in accordance with the flight plan they had held for the last 14 months.

The agreement between the airline and CAA in August 1977 for an authorised letdown to 6,000 feet in the designated area south of Ross Island was regarded by the Americans, when they found out about it, after the disaster, as quite impractical. In the view of Chief Warrant Officer Priest, who was chief traffic controller and Mac Centre Supervisor during the 1979/80 season, this 6,000 feet sector was “absurd” because of the inability of radar control in that sector.

So they guy in charge of McMurdo said it was an absurdity, but your saying he was wrong?" There was a briefing a few days prior to the flight where the crew were told that the route was well to the side of Mount Erebus." Not true. The crew were told that the final waypoint was at McMurdo Station. There can be no dispute about this, because it was recorded on tape.Chippendale,An examination of this briefing revealed certain significant items were not included, The way in which the Air New Zealand route varied from the normal military route, which followed the reporting points depicted on the RNC, particularly on the leg from Cape Hallett south to McMurdo.

So ampan, what is your interpretation of what Chippendale said? He's not correct? The audio did say "to McMurdo", but all the maps, photos and sample flight plan indicated down the sound. In any event, the mention of McMurdo would mean very little for the simple fact the waypoint down in the bottom of the sound, where Collins thought he was going, was also called McMurdo on the flight plans. Right royal cock up heh?

PapaHotel6

20th Jun 2016, 06:42

Facts
- The high altitude NAV track was changed the night before the flight. The crew were not advised.
- Collins descended VFR below approved MSA. He did not verify his position using the INS readout and a chart prior to commencing descent.
- The area to which he was heading once descended was completely covered in cloud.
- He had failed to establish VHF comms with McMurdo.
- He failed to capture the TACAN
- He re-armed the INS several times during the descent. The INS is not approved for terrain avoidance nor a VFR NAVAID.
- The flight engineer inquired as to high ground during the descent, which didn't elicit any response from the two pilots. No reference to Mt. Bird was made during the descent. The Flight engineer also said "I don't like this" shortly before the decision was made to climb out.
- When still faced with poor visibility at 2000', Collins elected to descend further to 1500'.

Not Facts
- Collins was justified in believing the track ran down Mc Murdo sound.
- They did, or did not have VMC conditions during the descent.
- They were deceived by an optical illusion at 1500' causing them to see a flat horizon and what looked for all the world to be perfect VMC conditions.
- Air New Zealand masterminded a massive cover up.

Mitigating factors
- The crew had no experience in polar flying
- The crew had almost no training in polar flying
- Briefings and SOPs surrounding the flights were vague
- The crew probably felt some commercial pressure

3 Holer

20th Jun 2016, 07:53

IRREFUTABLE FACT:

Mahon observed that ‘the occurrence of any accident was normally due to the existence of a variety of factors’. He asserted that in this case there were 10 factors; the disaster would not have occurred had any one of them not been present. But he then went on to describe a single cause of the disaster:

In my opinion therefore, the single dominant and effective cause of the disaster was the mistake made by those airline officials who programmed the aircraft to fly directly at Mt Erebus and omitted to tell the aircrew. That mistake is directly attributable, not so much to the persons who made it, but to the incompetent administrative airline procedures which made the mistake possible.

He disagreed with Chippindale’s ‘probable cause’ that the pilot was at fault, and cleared the crew of any responsibility for the accident. The blame lay squarely with Air New Zealand.

framer

20th Jun 2016, 07:54

Thanks for being brave enough to answer the question Megan.
The fact that you think that no matter which Air NZ crew were assigned to that duty the outcome would " quite possibly" have been the same suggests to me that you and I are so far apart in our thinking and experience that we will never see eye to eye and that there is probably no gain from continuing to debate the subject.
I believe that very few Air NZ Captains of the time would have felt comfortable descending to 1500ft, clean, at 260kts, with no VHF reception, no UHF reception, and the weather that was reported at the time. You on the other hand believe that "quite possibly" all of the Air NZ Captains would have chosen to do this. To me, your position is preposterous. I'm glad you answered the question though as now it is clear to me just how differently we view the situation.
I'll now browse the report on the accident you invited me to comment on, and answer it as best I can.
Cheers.

3 Holer

20th Jun 2016, 08:19

framer says:
and the weather that was reported at the time.

Forecast at McMurdo prior to descent. Cloud base 4000 feet and viz 40 miles.
From CVR:
1.Aircraft 6000 descending to 2000 and in VMC.
2.There are no less than 13 references made by one pilot to the other confirming that the aircraft was flying VMC.

I knew a few Captains in my outfit that would prefer to do ILS approaches in CAVOK conditions rather than a visual approach. Fair enough, whatever you are comfortable with. No problem descending to 1500 feet with those conditions forecast from my point of view, but yourself and those "very few Air NZ Captains of the time" that wouldn't, no problems. We should all know our limitations and respect them.

prospector

20th Jun 2016, 08:29

Why I ask that question

Captain Wilson confirmed that during his briefings given in 1978 and 1979 crews were told that they could descend to any height authorised by the USN Air Traffic Controller.

Delete all reference to briefing dated 23/10/79. Note that the only let down procedure available is VMC below FL160(16,000ft) to 6,000ft as follows:

Surely the written orders after the verbal briefing has precedence??

As has been posted many times, the crew knew of this requirement, a copy was found in the cockpit wreckage.

Nobody has yet explained why it was that trained, experienced Met observers, and crews of other aircraft operating in the same area, reported that Ross Island was completely obscured by cloud, and that the weather for sightseeing was completely unsuitable, well below the minimums required for the approved descent, so why was it even attempted? commercial pressure has been forwarded, but since when has commercial pressure overruled good sense?

And after all this well known, indisputable fact, can anyone say this crew made no errors?

I know many people who have never sat in the sharp end of an aeroplane digest Mahon report as gospel, but it has many holes in his reasoning, one that stands out is the use of the WX radar in mapping mode. Other pilots doing this flight have stated that Ross Island showed up very well. Mahon comes up with some theory of dry ice giving no returns. But as is shown in the photo's of the land that the crew failed to identify correctly, the ice was surrounded on the seaward side by many large patches of bare rock. . These would certainly have shown up if the radar had of been used in mapping mode.

that the approach radar would be unable to pick them up above 6000 feet. On previous flights the approach had been largely clear of cloud and, as a sure aid, the feed in had been attained by using McMurdo’s NDB (Non-Directional Beacon) to bring them into the orbit of the precision approach radar, at 6000 feet.

The Approach radar at 6,000ft. The radar could be switched to surveillance mode and that would have picked them up within a few minutes if they had of maintained MSA for a few more miles, even on the track over Mt Erebus.

6,000ft minimum descent was a strict CAA rule when approving these flights. I very much doubt anyone could say an invitation to descend to 1,500ft by an Air Traffic Controller could in anyway overrule this CAA requirement.

Capt Mayne Hawkins who stated "I was in no doubt at the briefing that the lower limit was 6,000ft. The weather on my flight was perfect, with clear skies and 100 miles of visibility. Ice tower asked me for a low run, but I kept to 6,000ft.
If there'd been the slightest doubt in my mind I would have been down there with the best of them. I was a ground attack pilot for five years flying Vampires, Venoms and Meteors in Cyprus, the Middle East and Singapore, so I knew what I was doing.

Fantome

20th Jun 2016, 08:39

I believe that very few Air NZ Captains of the time would have felt comfortable descending to 1500ft, clean, at 260kts, with no VHF reception, no UHF reception, and the weather that was reported at the time. You on the other hand believe that "quite possibly" all of the Air NZ Captains would have chosen to do this.

I'm thinking Framer remains intent on attempting to dissect conjecture. Ad nauseam. Is this a case of giving unrealistic attention to hypotheticals?
We all know why they were not where they thought they were. There can be no doubt whatever that Justice Mahon and Captain Gordon Vette spent many many hours and days and nights agonising is not too strong a word, over a reconstruction of events based on hard evidence. Nobody had a better handle on the facts. Yet thirty-seven years later the revisionists and the knockers are thick at the door. Mahon, Vette, Chippendale, Davis all are now deceased. And yet in some ways it seems the ashes still are warm. Perhaps a little R.I.P. would not be out of place. And for all those souls lost that fateful day no expression of empathy for their families will ever begin to touch the surface.

prospector

20th Jun 2016, 09:01

We all know why they were not where they thought they were.

But surely before you begin a descent below MSA, knowing there is a bloody big mountain very close that nobody had sighted, where they thought they were is not good enough? Surely being certain, when the means for positively ascertaining your exact position was so easy to obtain? would have been a very good idea, and by not using any other method than the track you thought you were on only is foolhardy in the extreme? quite apart from not being "proper" below MSA.

Surely that is all the debate is about, that this crew should shoulder some of the responsibily for the disaster? If as Mahon says they made no error, then surely that puts all the error on other people. They also made mistakes, but those mistakes could have been corrected if astute airmanship had of been exhibited by the crew.

COMPLETE HONESTY
Hand on heart, with total honesty, and after 20,000 plus hours, 14000 hours as PIC on heavy jets, 4000 plus hours as a simulator/line/base/ground instructor, TRE TRI etc bits-of-paper in my Navbag, almost 40 years as an AIRLINE PILOT, .......I HAVE NEVER EVER MADE A SINGLE MISTAKE, NEVER EVER!......

Impressive pedigree, but would you not have reprimanded any body who commenced a descent below MSA, as this crew did, just because they thought they knew where they were??
Fantome, that was a very big edit, just as well I copied that pedigree first.
.

ampan

20th Jun 2016, 09:27

megan's #839 continues with another irrelevant reference to something Chippendale says, but continues on to misquote the evidence. It is said that the audio contained a reference "to McMurdo", the suggestion being that that phrase could include a location 20 miles to the west of McMurdo Station. Let's look at the precise wording. If Megan can be bothered, it's in Exhibit 12: " A standard route definition will be used employing the From-Via-To Format. Enter NZAA 79S/167E this being the approximate co-ordinates of McMurdo Station."

They then went into the simulator, which was programed by F/O Cassin using an old flight plan. After the simulator was used to practise the change to grid navigation, it was then repositioned to overhead the final waypoint to practise a cloud-break procedure. So where did it end up? Overhead McMurdo Station, or 20 miles west. Answer: Overhead McMurdo Station.

There is absolutely no doubt that every pilot who attended the briefing believed that the final waypoint was at McMurdo Station, hence Captain Simpson's surprise when he found that it wasn't.

What about all the evidence from other pilots saying that they didn't think the route went over Erebus and thought it would be to their left? There is nothing inconsistent in that. Note that the only map they had was a photocopy of the inset to NZMS135, which didn't include Cape Hallett - so they could not picture a line from Cape Hallett to McMurdo Station. They all believed the waypoint was at McMurdo Station, but thought that a route to that point would take them down the Sound with Erebus to the left.

megan

20th Jun 2016, 23:59

ampan, all you need do is look at the flight plan that was included with the briefing. It calls the point down in the bottom of the sound, 27 miles away from the real McMurdo, McMurdo. So the audio mentioning only reinforces the flight plan positioning of "McMurdo", particularly in light of the fact that the maps indicate tracking to the false "McMurdo" position as well.

One wonders why there was no leg on the flight plan from the false McMurdo to the real McMurdo in the event they needed to make an IMC descent in the earlier flights. Could it be because the nav dept had absolutely no idea where the false McMurdo was placed?6,000ft minimum descent was a strict CAA rule when approving these flights. I very much doubt anyone could say an invitation to descend to 1,500ft by an Air Traffic Controller could in anyway overrule this CAA requirement.So you need to answer why Captain Wilson in his briefings told crews they could go below 6,000. I have no idea of the reason, and I doubt you do either.

ampan

21st Jun 2016, 00:25

I'm not interested in the altitude issue and the various alleged rules. Let's just say that the captain was subject to the general rules of good airmanship.

The track issue is different. The first correct statement by megan is that the nav section did not know that the final waypoint was 20 miles west of McMurdo Station. Absolutely correct. They though the waypoint was at the NDB at McMurdo Station. Captain Simpson noted the 20 mile difference and told Captain Johnson that the waypoint might be better positioned at the TACAN, which was a couple of miles away from the NDB. The nav section obliged, thinking they were only moving the waypoint from the NDB to the TACAN.

The track diagram you refer to was not in the briefing papers handed out at Captain Collins briefing. It somehow found its way into the briefing papers given to Captain McWilliams a couple of years before, and showed the military route to the Byrd reporting point followed by a left turn towards the runway at Williams Field. But the military route was designed for a landing, The Air NZ route was not. It's a complete red herring of no relevance.

Fantome

21st Jun 2016, 01:38

can you show us a red herring with relevance ?

ampan

21st Jun 2016, 02:12

I don't think a red herring can ever be relevant, by definition (unless the captain had a dinner of rotten fish the night before, which might explain his performance.)

3 Holer

21st Jun 2016, 02:22

ampanyour last post have raised some prudent points.

I'm not interested in the altitude issue and the various alleged rules – some of the previous operating crews appear to have accepted that culture.
The nav section obliged, thinking they were only moving the waypoint from the NDB to the TACAN. – but they never bothered to check the new track was straight at Mt Erebus.
somehow found its way into the briefing papers given to Captain McWilliams a couple of years before. – how does that happen in a professional airline?
The Air NZ route was not. It's a complete red herring of no relevance. – I would respectfully suggest that there was a lot of relevance especially to the 257 victims of this terrible tradgedy.

So it remains, undisputed,Mahon’s profound statement .........................” the incompetent administrative airline procedures which made the mistake possible”

ampan

21st Jun 2016, 02:59

The nav section always believed the track went over Erebus.

prospector

21st Jun 2016, 03:07

So it remains, undisputed,Mahon’s profound statement .........................”

What a funny post, it has been disputed ever since he made it.

framer

21st Jun 2016, 07:33

Megan: I have had a quick read of the American DC-10 report that you referred to, and since you asked for my take on it I'll give it although I don't see it as being particularly relevant to this thread.
I think there were three causal factors at an Industry level, two at an organisational level, and one at an operational level. None of the causal factors I identified during my amateur assessment involved the flight crew.
My assessment of the causal factors wouldn't be any more valid than the next airline captains but, my opinion on the responsibilities of command is probably as valid as the next guys and this is what I have been offering.
You chaps make quite a show about " those who like to lay blame" and the " knockers" and the " revisionists" etc but you miss the gist of what most here are saying. It is not that Collins is the one to blame, it is that he is not free of responsibility.
The judgement and decision making of the crew who lost the engine on departure isn't in question whereas the judgement and decision making of Collins is.
Anyway, have a good day and don't forget how much responsibility is on your shoulders next time you operate, it helps with making decisions considerate of risk.

ampan

21st Jun 2016, 07:46

Don't include me in the 'measured and reasonable' group. I lay the blame on the captain. Were it not for his appalling series of errors, the co-ordinateswould not have mattered.

PapaHotel6

21st Jun 2016, 07:46

A couple of own-goals from 3-Holer from this page alone. IRREFUTABLE FACT:

Mahon observed

So it remains, undisputed,Mahon’s profound statement
They were amusing at first, but like any oft-repeated jokes, have started to run dry. Please think before you post.

You chaps make quite a show about " those who like to lay blame" and the " knockers" and the " revisionists" etc but you miss the gist of what most here are saying. It is not that Collins is the one to blame, it is that he is not free of responsibility.

Very succinctly put Framer.

3 Holer

21st Jun 2016, 08:44

It's sad you find humour in all this PapaHotel6 but it is consistent with your posts.

PapaHotel6

21st Jun 2016, 09:38

I lay the blame on the captain. Were it not for his appalling series of errors, the co-ordinateswould not have mattered
I agree with you ampan, but the counter argument is that without the appalling failure of the navigation section, the errors Collins made would not have mattered.

To which I reply this.

The navigation department does work of crucial operational importance. But it takes a big leap of imagination to connect a professional failure in the promulgation of the high altitude NAV track to collision with terrain at 1500'. But VFR rules, and MSA rules are basic rules of airmanship and flight, and it takes no imagination whatsoever to understand how violation of those would lead to tragedy.

Hence the biggest professional failure was that of Collins.

Cazalet33

21st Jun 2016, 09:49

They all believed the waypoint was at McMurdo Station, but thought that a route to that point would take them down the Sound with Erebus to the left.

That's the nub of the thing, right there.

It is what was in the heads of the crew which led to disaster.

That mental model had been set up by the airline and to a lesser extent by the CAD. That is why the prime responsibility rests with the airline management and its overseer.

The fact that the crew members were hopelessly inexperienced in the task at hand and their training was woefully inadequate compounds the culpability.

prospector

21st Jun 2016, 10:00

The fact that the crew members were hopelessly inexperienced in the task at hand and their training was woefully inadequate compounds the culpability.

How then did all the previous flights manage to get down there and back home again??

PapaHotel6

21st Jun 2016, 10:13

How then did all the previous flights manage to get down there and back home again??

By exhibiting good airmanship in spite of crap airline management.

Fantome

21st Jun 2016, 11:27

Cazalet33 -

They all believed the waypoint was at McMurdo Station, but thought that a route to that point would take them down the Sound with Erebus to the left.

That's the nub of the thing, right there.

It is what was in the heads of the crew which led to disaster.

That mental model had been set up by the airline and to a lesser extent by the CAD. That is why the prime responsibility rests with the airline management and its overseer.

The fact that the crew members were hopelessly inexperienced in the task at hand and their training was woefully inadequate compounds the culpability.

Perfect summation. The will to engage in ceaseless debate is mystifying . ..
. . unless it is human nature to fasten the teeth lock them there fixedly no matter what. Many are the cases of accidents plumbed at great depth about which in the end a whiff of natural justice prevails. For when the accused are unable to say one word in their own defence a point is reached when it as well to emulate the wisdom of Solomon and draw a veil upon irreconcilable dispute.

megan

21st Jun 2016, 13:46

unless it is human nature to fasten the teeth lock them there fixedly no matter whatYou've nailed it Fantome. On another thread about Erebus, some poster (I won't divulge who, but you may be able to guess from his postings here) was berating another poster about their lack of knowledge, particularly with respect to Polar operations, and hoped that the person wasn't a pilot, or if was, hopefully retired. Those of us in the know fell about laughing, because the individual getting the heat, at the time, sat in seat 0A of a jet flying in and out of Antarctic airfields.By exhibiting good airmanship in spite of crap airline managementNo they weren't, because most were busting SOP. What saved them was the good weather they encountered.

Cazalet33

21st Jun 2016, 19:07

most were busting SOP. What saved them was the good weather they encountered.

You bastard! You utter utter bastard!!

You done bust the code and you done so publically. Bastard!

Can I say so without being given "time away"?

PapaHotel6

21st Jun 2016, 20:20

No they weren't, because most were busting SOP. What saved them was the good weather they encountered.
Yes, fair point - although Collins's descent was in a league all of its own.

prospector

21st Jun 2016, 20:46

Captain Roger Dalziell's flight, which because of unfavourable weather took the alternative sightseeing route over the South Magnetic Pole.

So it was possible, because of weather, to use judgement to alter the plan.

Re the radar,
The captain of a USAF C141 Starlifter following 49 minutes behind the Air New Zealand flight said no terrain was visible and he made a long gradual descent over the water, navigating entirely by the inertial navigation system and maintaining 16,000ft until being picked up by McMurdo radar about 38 miles out.He immediately entered cloud on starting his final descent, passing between layers with good visibility but no sight of the ground until the aircraft broke out of cloud at about 5,000ft and landed normally at McMurdo

framer

21st Jun 2016, 21:41

So it was possible, because of weather, to use judgement to alter the plan.

It appears that way. I might try it on my next flight.

Cazalet33

21st Jun 2016, 21:48

So it was possible, because of weather, to use judgement to alter the plan.

It is always possible to use judgement to alter the plan.

That's why we earn more pay in the left seat (on plankwing flights) than in the righthand seat.

In this case, the mindset (on all seats) was set by the airline, not by some maverick.

jack red

21st Jun 2016, 22:27

3 holer check ur PMs
while I'm here I think mahon did get it right he was just the victim of a determined government and a stacked appeals court. if the case against collins had any substance he would have been pursued in a civil court. i don't think the litigants would have had much success.

hat,coat...........door

prospector

21st Jun 2016, 23:07

With the weather report they received from the met people at McMurdo, and being advised that the area was no good for sightseeing

It is always possible to use judgement to alter the plan.

then obviously the wrong judgement was used.

That's why we earn more pay in the left seat (on plankwing flights) than in the righthand seat.

Exactly, and if a wrong decision is made, such as in this case, why is it that the nav section who laid out the plan, all above MSA using the most up to date nav system, but nothing planned below MSA, that was left to the judgement of the crew according to the .weather conditions met at the destination, got so much flak from Mahon? .

Cazalet33

21st Jun 2016, 23:20

obviously the wrong judgement was used.

Very obviously.

why is it that the nav section who laid out the plan, all above MSA using the most up to date nav system, but nothing planned below MSA, that was left to the judgement of the crew according to the .weather conditions met at the destination, got so much flak from Mahon?

Equally obviously.

prospector

21st Jun 2016, 23:28

Equally obviously.

Obviously, but why, it was not the cause. It was only a part of the disaster.

Did they do any of the planning below MSA??

megan

22nd Jun 2016, 00:35

I'll pose a question if I may. Just suppose an aircraft inbound was given the weather as 8/8ths 17,000, 20k vis, surface poor, horizon poor. Meets the airline criteria for a VMC let down in the prescribed area, so what problems, if any, may be encountered during,

1. the letdown
2. sight seeing at 6,000

prospector

22nd Jun 2016, 00:43

If it was being radar monitored for terrain and traffic clearance, as was one of the requirements for descent below MSA, and if it had not been reported by met observers that Ross Island was completely obscured by cloud, and the descent was in the area prescribed by the company to keep it clear of Mt Erebus, I would have thought no problem.

Fantome,

Perfect summation. The will to engage in ceaseless debate is mystifying

Not mystifying, just trying to establish that Mahon was not correct in his use of selected pieces of evidence to suit his opinion and disregarding anything that went against that opinion.

Ollie Onion

22nd Jun 2016, 02:53

Surely to say as Mahon did that they crew made 'no' errors is to cheapen the profession. That statement is basically saying that as professional pilots we will just fly the thing to the crash site should the setup be bad enough! The clues were all there for this crew, yes their training was crap, the change of routing was not expected and the whiteout was something they had no experience. But the inability to contact McMurdo, the lack of TACAN, the marginal conditions that meant they couldn't sight the high terrain and the unfavourable met reports from other aircraft should have all given pause for though before descending so low. The organisation put them in a bad spot, their mistake was not using the clues on the day to trap some of those errors. We're the crew wholly responsible..... NO, do they hold any responsibility...... YES.

ampan

22nd Jun 2016, 03:29

Please stop trotting out this nonsense about the captain being ignorant of sector whiteout. The CVR shows that he knew of the problem. I would venture to suggest that he knew about from the mid-1950s, flying sorties out of Wigram in a Harvard. One of the first things his instructor would have warned him about when flying close to Mount Hutt in a low overcast was the visual issue.
So when he made his unannounced descent below MSA through that hole in the cloud, claiming to be VMC, he knew full well that he was not.Why did he do that? Because he was actually relying on the AINS, and he also knew full well the AINS was not to be used for a descent of that nature. This was why he was pleased to be offered a radar-assisted descent (which never came,but he went ahead regardless.)
When he levelled out at 2000 feet, there was no “false horizon”. That was something dreamt up by Vette, unsupported by any of the experts. There was no horizon, so he should have been out straight away.Instead, down to 1500 – ”we’ll probably see further anyway”. He then went on for two full minutes inside a ping-pong ball, before deciding to bale out. The F/O said it was clear to the right if he wanted to do a 180. Answer ”No negative”, and he pulls out the heading select knob and initiates a LEFT turn. Left, towards where he’ssupposed to think the high ground to be. Why did he do that?
No-one will ever know, but my theory is that the pennies stared to drop. Told at the briefing that the waypoint was at McMurdo Station.The night before, he discovered that the waypoint was 20 miles west, but he didn’t check it. Also discovered that a track to McMurdo Station went over Erebus. What if the waypoint is at McMurdo Station, like I was told at the breifing? That would explain the communication problems. It would also mean that Mt Bird is to my right, so the only way out is left.

PapaHotel6

22nd Jun 2016, 04:00

So when he made his unannounced descent below MSA through that hole in the cloud, claiming to be VMC, he knew full well that he was not.Why did he do that? Because he was actually relying on the AINS, and he also knew full well the AINS was not to be used for a descent of that nature.
Well, we don't know for certain whether he was VMC or not; but what we do know is that at the very least he was using the INS as some sort of "backup" - and he should not have been.

When he levelled out at 2000 feet, there was no “false horizon”. That was something dreamt up by Vette, unsupported by any of the experts. There was no horizon, so he should have been out straight away.Instead, down to 1500 – ”we’ll probably see further anyway”. He then went on for two full minutes inside a ping-pong ball, before deciding to bale out.
I also agree, but again, this is just summation not fact. But I think it's more likely than Vette's "false horizon" hypothesis - which is so often purported to be fact rather than just one (biased and unqualified) person's theory.

megan

22nd Jun 2016, 04:05

If it was being radar monitored for terrain and traffic clearance, as was one of the requirements for descent below MSAPlease stop the nonsense about being radar monitored. The controllers had no idea of the descent procedure the airline had dreamt up, nor in what location it was to be carried out. And to top it off, had they known, the were incapable of doing so.

And radar monitoring was not required for the introduced VMC descent. And it wouldn't have been available if it was because of the above. Another great, great element in the airlines planning.

PapaHotel6

22nd Jun 2016, 04:12

Please stop the nonsense about being radar monitored. The controllers had no idea of the descent procedure the airline had dreamt up, nor in what location it was to be carried out. And to top it off, had they known, the were incapable of doing so.
???? The controllers clearly offered him a radar let down right before he elected to go down VMC!

grummanavenger

22nd Jun 2016, 04:36

[All the crews thought they were out for a Sunday drive. See Chippendales comment re no one checking the INS against topographical information. Took 14 months for some one to wake up.]
The above incorrect, the First Officer behind the Captain's seat in the aircraft commanded by Dalziell maintained a track plot using the overhead lat/long data and transferred this to a topo so near real time actual position available.

prospector

22nd Jun 2016, 05:16

Re the radar,

Quote:

The captain of a USAF C141 Starlifter following 49 minutes behind the Air New Zealand flight said no terrain was visible and he made a long gradual descent over the water, navigating entirely by the inertial navigation system and maintaining 16,000ft until being picked up by McMurdo radar about 38 miles out.He immediately entered cloud on starting his final descent, passing between layers with good visibility but no sight of the ground until the aircraft broke out of cloud at about 5,000ft and landed normally at McMurdo

Megan, you say,
And radar monitoring was not required for the introduced VMC descent. And it wouldn't have been available if it was because of the above. Another great, great element in the airlines planning.

Requirements for descent
4. Descent to be coordinated with local radar control as they may have other traffic in the area.

How could they coordinate anything if they had not identified the aircraft doing the descending??

I have taken quotes from "Impact Erebus" that confirm the radar was available. They have been printed in this thread a number of times, or was Gordon Vette also mistaken about the availability of radar for the descent?

framer

22nd Jun 2016, 06:21

The above incorrect, the First Officer behind the Captain's seat in the aircraft commanded by Dalziell maintained a track plot using the overhead lat/long data and transferred this to a topo so near real time actual position available.

So Dalziell kept his flight safe aye..... who would have thought? According to Megan and 3 Holer only Captain God could have prevented this flight ending up this way.
Is Dalziell actually God? I might have to change my Sunday routine.

3 Holer

22nd Jun 2016, 07:37

I thought you already had changed your Sunday routine framer. I recall reading post #814 where you state:
I'm arguing that Collins made mistakes and asking for, or expecting exoneration is inappropriate.

How do you know Captain Collins is asking for or expecting exoneration? Do you have a line to my Captain God or is this just another one, in your long, line of assumptions!

grummanavenger

22nd Jun 2016, 07:57

A prior comment, [Drift on those old IRS must have been in the order of 3-6 nm an hour.]

Not so, drift on the Radio/inertial on the DC 10 closer to 1.7 nm/hr but an uncomfortable circle of uncertainty remained after the flight south.
CRM only in its infancy in those days, but in today's era, the flight deck map reading supporting the crew's understanding of their position would be described as " confirmation bias."
On other matters, I confirm there was not any company briefing to the operating crews and not any private or casual discussions.

megan

22nd Jun 2016, 12:21

The controllers clearly offered him a radar let down right before he elected to go down VMCHave you looked at a map and seen where the airline letdown procedure was in relation to the radar. The problem was likely that the aircraft would be too close and too high. Coming down the sound they would have been miles away.The person in charge of McMurdo said that radar would not have been available, nor capable, for surveillance in the sector the airline designated for descent. Are you suggesting he didn't know what the capabilities of his radar was? Or are you suggesting they were somewhat economical with the truth ie lied?

The same radar was also used for the PAR approach, so it may have been that the azimuth portion was centred on traffic coming down the sound to the Bryd waypoint to feed traffic into the PAR. In the PAR mode the azimuth only swept plus/minus 15°. I've asked experts on the radar what it's capabilities were, as it was widely used by the RAAF in the past. No reply as yet.transferred this to a topoMust have taken his own topo, as Collins was never issued with one, I don't think the other flights were either (not checked categorically).

framer

22nd Jun 2016, 12:35

3 Holer.
You've interpreted my post incorrectly. Fantome might be able to help as he seems to be expert with language.
A comment from you on Delziell's crew plotting from the INS would be appropriate.

PapaHotel6

22nd Jun 2016, 20:22

The same radar was also used for the PAR approach, so it may have been that the azimuth portion was centred on traffic coming down the sound to the Bryd waypoint to feed traffic into the PAR. In the PAR mode the azimuth only swept plus/minus 15°. I've asked experts on the radar what it's capabilities were, as it was widely used by the RAAF in the past. No reply as yet.

It really, really, doesn't matter. The point is, Captain Collins was offered a radar descent, said "Crikey, that's what we want"...... and then proceeded to descend "VMC" without one. End of story. He never went down the road of ascertaining whether a radar descent would even be possible.

3 Holer.
You've interpreted my post incorrectly. Fantome might be able to help as he seems to be expert with language.
A comment from you on Delziell's crew plotting from the INS would be appropriate.
3-Holer will simply say "Mahon, guided by the erudite wisdom of Vette, is uncontested...crew made no error... but he never said they were blameless....not that they were in any way to blame either.......", but I'm going to go in to bat for Collins here. Yes, with the benefit of hindsight, continual plotting from the INS onto a topo would have added a layer of safety and probably would have saved the aircraft. But to do so was not a regulation or SOP; no crew member offered to do it, so the fact that Collins did not do so doesn't make him negligent - it just makes Dalziell, to his credit, extra vigilant.

The chain of errors Collins made has been well described. I don't think that the absence of continual plotting on a topo is one of them.

ampan

22nd Jun 2016, 20:37

As regards topographic maps, here's NZMS135:

https://www.google.co.nz/search?q=nzms135&biw=1360&bih=641&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjh_suhvbzNAhXRNpQKHaS8CBUQ_AUIBigB&dpr=1#imgrc=HqG3o_TSlhbKxM%3A

At they briefing, they were given a photocopy of the inset.

At despatch on the morning of the flight, they were given the whole chart.

Captain Collins atlas, which he probably studied the night before, was the same was the whole chart but obviously reduced in size to fit inside the atlas.

3 Holer

22nd Jun 2016, 22:05

You guys are incredible:

3 Holer.
You've interpreted my post incorrectly. So you now need Fantome to help you with the english language. If you can't explain yourself framer, what chance have others got of trying to decipher your posts? Look up the meaning of the word exonerate in a dictionary, it does not apply to Collins.

but I'm going to go in to bat for Collins here. I am sure he'll be really thrilled about that PapaHotel6. On the evidence, I believe Collins was descending VMC and unless you were in the cockpit, you can not argue otherwise.

the aircraft should have requested, and been cleared for, a “visual approach.” Instead, the clearance was for a “descent maintaining VMC,” which means “visual meteorological conditions,” that is, clear of clouds and with good visibility. Since the requirements for maintaining VMC are similar to those for a visual approach this anomaly was not a factor in the accident.

PapaHotel6

22nd Jun 2016, 22:21

On the evidence, I believe Collins was descending VMC
Yes, we know.

unless you were in the cockpit, you can not argue otherwise
Why?? Because we weren't there, and he said he was VMC, we have to discount all evidence to the contrary (like the clouds everywhere, the fact he kept arming the INS, never mentioned Mt. Bird which should have been nearby) and just give him the benefit of the doubt?? Sorry, but no.

But you are right in that we will never know with certainty. That is why even if Collins saw the horizon and was clear of cloud the whole way down, the case against him based on the facts (that I listed earlier) still stands

jack red

22nd Jun 2016, 22:31

the case against him based on the facts There was never a case against him. Re-read the Mahon report and this time, try to comprehend the findings. Please.

PapaHotel6

22nd Jun 2016, 22:42

There was never a case against him.
Can we please stop trying to make arguments based on semantics? It's tiresome, wastes time and everyone can see right through it. Okay, there was never a case against him in a court of law - because he was dead - but there is definitely an argument to be made that he is culpable.

Re-read the Mahon report and this time, try to comprehend the findings. Please.
Thanks, but I've read it sufficient times to know I understand and disagree with the findings. What specific findings are you suggesting I don't comprehend?

ampan

22nd Jun 2016, 23:37

From page 69 of Mahon's report:

"We asked Mr Shannon whether the overcast extended forward would form an illusory horizon in the distance at a point where it me the snow-covered rising ground. Mr Shannon said he though not. He said that in such conditions the almost invariable effect is that the underside of the overcast turns white so that there would be no horizon at."

And Mr Shannon was right, but Mahon omitted any further reference to Mr Shannon's views, because they didn't suit. This is a video of an aircraft landing in Antartica, in clear air, in a sector white-out. There is no visible horizon until the aircraft is almost on the ground, and even then it's barely discernable.

http://www.pprune.org/rotorheads/19112-flying-snow-8.html#post6996814

framer

23rd Jun 2016, 02:16

So you now need Fantome to help you with the english language. If you can't explain yourself framer, what chance have others got of trying to decipher your posts? Look up the meaning of the word exonerate in a dictionary, it does not apply to Collins.

3 Holer, everyone else appears to have interpreted my post as I intended, which is that Collins made mistakes, and requests for the crew to be exonerated ( by P Holmes , politicians, yourself etc etc) are inappropriate. I have never suggested that Collins would want to be exonerated .
You should probably concede that you were wrong to suggest that no Captain other than Captain God could have prevented the crash. Just look at it like losing a battle but the war goes on. Every time you are pressed on something you don't have an answer for you play the man not the ball. It's quite revealing really.
Cheerio

3 Holer

23rd Jun 2016, 02:22

ampan
Mahon omitted any further reference to Mr Shannon's views, because they didn't suit.
If you had continued reading para.169 on page 70, you will find your statement incorrect.
.“Mr Shannon was not very interested in the cross – talk which was taking place behind the pilots. He said he drew the conclusion that neither the pilot nor the co-pilot entertained the slightest apprehension at any stage, and he drew the further conclusion that each of them was perfectly satisfied as to the course and position of the aircraft.”
Would that be because the crew thought they were flying over the flat, safe waters of McMurdo Sound? Absolutely it would.
PapahHotel6
I understand and disagree with the findings.
So did Air NZ and the Muldoon government and in a democracy, this is a basic human right known as freedom of speech. However, you have other people in the community that understand and AGREE with those findings. Are they not entitled to the same right of freedom of speech?
Nothing is going to change. This debate (I use that term loosely) will possibly go on for another forty years and no amount of postulation will convince either party they are wrong.

3 Holer

23rd Jun 2016, 02:39

framer please look up the definition for the word exonerate.
Dancing on people's graves is not a war it's puerile. Re-read some of your posts and maybe you will reconsider your "war and battle" scenario.

Whilst you have the dictionary open, have a look at the meaning of the word "metaphorical" and see if you can see how my reference to Captain God may fit into the context of my post. If you still think I am playing the man, then I think Fantome is going to have his work cut out.;)

prospector

23rd Jun 2016, 02:49

I, and many others, are more in agreement with the OFFICIAL report, rather than an opinion

Because the findings of the Royal Commission of Inquiry on the cause of the disaster were limited in scope, being legally an opinion and not a statement of fact, they could not be appealed in legal terms, unlike the Office of Air Accidents investigation report, which remains the sole official account- and has never been officially challenged.

ampan

23rd Jun 2016, 03:00

3 holer: Perhaps I should have said "Mahan omitted any further reference to Mr Shannon's views [about the absence of a false horizon], because it didn't suit." (although I would have though that was implicit.)

What the captain saw in front of him was as shown in the above video: no horizon, inside a ping-pong ball. He should have been out straight away. But he had his nav track, so he locked the aircraft back onto it, and Mahon approved, noting that the AINS was never wrong. That was one of the dumbest of his many stupid findings, given what occurred.

PapaHotel6

23rd Jun 2016, 03:14

I understand and disagree with the findings.
So did Air NZ and the Muldoon government and in a democracy, this is a basic human right known as freedom of speech. However, you have other people in the community that understand and AGREE with those findings. Are they not entitled to the same right of freedom of speech?
Absolutely. Did I ever imply otherwise?? I was simply replying to jack red who accused me of "not comprehending' Mahon's findings.

Nothing is going to change. This debate (I use that term loosely) will possibly go on for another forty years and no amount of postulation will convince either party they are wrong.

It could well go on for another forty years. However people can change their minds. For twenty five years I myself had the same revered view of Mahon and his opinions that you seem to. I now see them as incompetent at best, manipulative and slightly evil at worst.

What the captain saw in front of him was as shown in the above video: no horizon, inside a ping-pong ball. He should have been out straight away. But he had his nav track, so he locked the aircraft back onto it, and Mahon approved, noting that the AINS was never wrong. That was one of the dumbest of his many stupid findings, given what occurred.
Agreed. The way he said "anecdotally pilots had found the AINS to be extremely accurate, therefore Collins was justified in his complete faith in it" almost defies belief. And it never dawns on him that it's not just the AINS as a piece of equipment we're talking about - but the whole system including training, system redundancy, the process of data loading etc. etc.

3 Holer

23rd Jun 2016, 03:45

You are correct prospector when you say the OFFICIAL report (Chippendale) has never been challenged (in a court of law). However, because of the “captain’s decision to make a VMC descent below the specified minimum safety height while north of McMurdo.” conclusion by Chippendale and subsequent controversy, resulted in the Royal Commission of Inquiry, and its much different assessment of the true cause.

Have you got the energy to start a new thread to debate the OFFICIAL report? Count me in!:ok:

ampan

23rd Jun 2016, 03:51

In the event that that anyone doubts that the AINS was not to be used as Captain Collins used it, note the following:

"Like any good pilot, Collins would certainly have made up his mind that unless visual conditions were good, there was no way he would take the aircraft below Minimum Safe Altitude of 16000 feet. MSA constitutes a platform for pilots. Once below it they leave behind the self-sufficiency of the inertial navigation system and commit themselves once more to guidance from aids on mother earth, and to visual flying - 'eyeballing' it in pilot jargon."

That's from p119 of Impact Erebus by Gordon Vette. (He then goes no to suggest that the captain did not know about sector white-out, conveniently ignoring the CVR, Collins years in the RNZAF at Wigram, and the visit he and Lucas made to Operation Deep Freeze a few weeks before the flight.)

framer

23rd Jun 2016, 07:03

We're going around and around in circles again just like we did a few years ago, no middle ground has been reached yet again so I'm going to bow out. Maybe in 2021 the thread will work its way to the top again as it tends to do and we will do it all again. I imagine that these conversations have value because they will be able to be accessed by people wanting to know more about the event and how people in our time viewed it.
Until then, if you are still in command of an airliner as I suspect many of us are, take heed of the lessons , remember that those paid to support your flight are human and make mistakes just like you do, and that the rules are there to protect you from their mistakes and yours. Unless there is a good reason, stick to them for your passengers sake.
Thanks for the conversation.

Pakehaboy

23rd Jun 2016, 07:49

Quote framer....Until then, if you are still in command of an airliner as I suspect many of us are, take heed of the lessons ,

Well mate,reading this debate on a daily basis ,like many ,has been an enlightening experience indeed.The willingness of the major debaters to explore every word,sentence and quote has also been enlightening.I just hope,like you have stated,I've learned something and it will serve me in a time and day.

prospector

23rd Jun 2016, 08:11

Thanks for that Pakehaboy and framer, I have been out of the drivers seat for a few years now, and been following this thread for a number of years.

To see somebody getting involved and seeing and appreciating the many different views, and hopefully giving some thought to all that has been written makes all the angst worth while.

Must admit I have had to convince myself to "not blow my cool" a few times.

3 Holer

24th Jun 2016, 09:30

no middle ground has been reached yet again and it will continue framer until some new evidence surfaces from either the pro Mahon camp or the pro Chippendale camp.

I see this impasse resulting from the following:

At the time of this accident, Human Factors and Crew Resource Management training was in it's infancy.

Air New Zealand, Chippendale and the NZ Government went very hard at playing the "pilot error" card. This resulted in the inevitable and anticipated reaction from ALPANZ. The public were alerted to document shredding, subjected to allusive/vague interviews by Morrie Davis and Robert Muldoon and the final humiliation to both, the revelation of a route change, by the navigation department, taking the aircraft directly over Erebus without informing the crew.

Kiwis, like Aussies, don't like being deceived especially by governments. Public backlash was swift and savage against Air NZ and Muldoon's government.
Enter Muldoon's olive branch. An independent royal Commission of Inquiry, Justice Peter Mahon residing. The government did not like the Mahon findings. Enter the UK Privy Council court of Appeal. Public saw it for what it was and again, public backlash.

There was never a definitive conclusion to this tragedy. Mahon supporters believe he got it right, Air NZ/ Government thought they got it right.
Who will come up with any new evidence to disprove the Mahon/Chippendale arguments? I don't know, but I do know until this happens, we shall all be back here again 4 to 5 years debating the same old,same old.

PapaHotel6

24th Jun 2016, 10:20

There was never a definitive conclusion to this tragedy. Mahon supporters believe he got it right, Air NZ/ Government thought they got it right.
Who will come up with any new evidence to disprove the Mahon/Chippendale arguments? I don't know, but I do know until this happens, we shall all be back here again 4 to 5 years debating the same old,same old.

Indeed, although as I have said I myself have changed "sides". I prefer to think this represents progression, rather than simply preferring one valid argument over another.

Without getting into the relative merits of what they said yet again, this was always going to be too big for Chippindale, and setting up the Royal Commission of Enquiry as a one-man band was just plain dumb. Leaving a legacy of......... us debating it nearly 40 years later.

ampan

24th Jun 2016, 20:04

Despite the location, there was probably more evidence about this accident than any other. They even managed to recover the units that the waypoints were manually punched into. They were analysed in the US and they were able to determine that the waypoints entered were those on the flight plan.

The task was not too great for a High Court judge. He had a year, with nothing else to do. Go and read some other High Court judgments. Many of them are much more complicated. The problem was that Mahon misinterpreted some evidence, ignored other relevant evidence, and was deliberately misled by the union, particularly as regards the critical evidence of Captain Simpson. He then decided to finish his report with the "orchestrated litany of lies", which was extremely foolish and consistent with someone suffering from a neurological condition. Note that he died two years later of a head tumour.

3 Holer

25th Jun 2016, 01:32

I was the other way PapaHotel6. I was a very junior F/O at the time and thought it had to be pilot error. I had no training in HF/CRM and thought I knew it all. Then reports of cover ups, documents being shredded, documents being removed from pilot's homes and I started to think "something doesn't smell right in downtown Auckland". Mahon got to the bottom of it and more.

The rest is history and until some new evidence surfaces, I will stick with the Mahon report. Have a Merry Christmas.:ok:

PapaHotel6

25th Jun 2016, 01:55

I was the other way PapaHotel6. I was a very junior F/O at the time and thought it had to be pilot error. I had no training in HF/CRM and thought I knew it all.
Interesting. My own growth in aviation sent me other way. I was a Mahon disciple and CRM "expert" before I even had my PPL.......

Then reports of cover ups, documents being shredded, documents being removed from pilot's homes and I started to think "something doesn't smell right in downtown Auckland". Mahon got to the bottom of it and more.

But this wasn't what led you to change your mind I presume?? Okay, you were convinced Air NZ behaved dreadfully, which probably left an awful taste (as it did me at the time) but that in itself doesn't make pilot error more or less probable on the day, correct?

Have a Merry Christmas.
Midwinter Christmas? ;)

megan

25th Jun 2016, 02:26

the "orchestrated litany of lies", which was extremely foolish and consistent with someone suffering from a neurological conditionNay, he made an astute observation, but a politically incorrect one. You can only withstand a certain amount of BS, and to say so doesn't infer anything neurological. In saying it, he likely knew the outcome.

PapaHotel6

25th Jun 2016, 02:53

Nay, he made an astute observation, but a politically incorrect one. You can only withstand a certain amount of BS, and to say so doesn't infer anything neurological. In saying it, he likely knew the outcome.
The highest Court in the land examined his reasons for making precisely that "Orchestrated Litany of Lies" comment, and completely and unreservedly discredited them. How can you possibly use the word "astute" in relation to that observation??

megan

25th Jun 2016, 03:33

PH6, just a laymans opinion of the airlines stance in the case. We are all entitled to one, opinion that is, or is that now against the law in this PC world?

3 Holer

25th Jun 2016, 03:40

PapaHotel6, if you're still having trouble with comprehension, I believe Fantome still has a couple of vacancies in his english class.;)

PapaHotel6

25th Jun 2016, 04:05

Yep, ya got me. Mahon's brilliant report was just too gold-darn hard for me to wrap my tiny brain around.

ampan

25th Jun 2016, 04:29

Two examples of what a dope Mahon was: (1) Of the most significant lines in the CVR transcript was "Very hard to tell the difference between the cloud and the ice." That line was never referred to in the report, or even the subsequent book.

(2) Faced with indisputable evidence that the waypoint conveyed at the briefing was at McMurdo Station, Mahon had this to say: "The pictorial representations showing the observers that the flight path was down McMurdo Sound and these displays would, not unnaturally, take precedence over the spoken words indicating a direct track from Cape Hallett to McMurdo Station and indicating the NDB co-ordinations as the destination waypoint." (p60)

There are so many mistakes in that one single paragraph that I'm only going to identify the worst, which is that pilots would silently sit through a briefing, receive contradictory information, and then make there own decision about which would "take precedence." Ian Gemmell was right: Mahon was an idiot.

megan

25th Jun 2016, 04:35

Mahon's problem was he went beyond his remit. It does not make his observations incorrect re the airline conduct during his commission, he just wasn't supposed to say what he said.

See - The Judicial Committee of the Privy Council Decisions

The Honourable Thomas Peter Thomas Mahon v Air New Zealand Limited and Others (New Zealand) [1983] UKPC 29 (20 October 1983) (http://www.bailii.org/uk/cases/UKPC/1983/1983_29.html)

Faced with indisputable evidence that the waypoint conveyed at the briefing was at McMurdo Station, Mahon had this to say: "The pictorial representations showing the observers that the flight path was down McMurdo Sound and these displays would, not unnaturally, take precedence over the spoken words indicating a direct track from Cape Hallett to McMurdo Station and indicating the NDB co-ordinations as the destination waypoint.
Wish you'd stick to the facts ampan. Chippendale said,
Although 2 of the pilots were shown a printout of the erroneous computer flight plan in advance of the actual flight they were not shown on a topographical map that the intended tack passed almost directly over the highest point in the area, Mt Erebus (12450 feet). Charts were carried in the aircraft on the day of the flight but these were very small scale (the largest scale was 1:3,000,000 with 1:1,000,000 insert of Ross Island) and not available to the crew until the final pre-flight dispatch planning on the morning of the departure. The 3 “maps” of the area between Cape Hallett and McMurdo which were used in the route qualification briefing all showed a track located clear of high ground and passing to the true west of the mountains as did one of he maps issued on the day of the flight. In fact the flight planned route passed to the east over very high ground instead of over the sea level ice shelf as portrayed on the briefing “maps”. One track and distance diagram issued at the route qualification briefing showed that the track from Cape Hallett was direct to the McMurdo TACAN but this did not show the location of any topographical feature.

3 Holer

25th Jun 2016, 05:01

I wouldn't be putting to much credence in what Ian Gemmell "said"...........

The NZ government has apologised twice for the Erebus disaster and appointed Mahon in 1985 as Commissioner of Inquiry into the 1984 Queen Street riot. He wrote an award winning book about the disaster and that book won the New Zealand Book Awards prize for non fiction in 1985.

How are we going Captain Gemmell? Are we a bit wreckless with the truth in your assessment of Justice Peter Mahon? :=

ampan likes his poetic licence when it comes to facts megan.

ampan

25th Jun 2016, 05:03

The point is that Mahon believed that the information presented at the briefing was contradictory. If so, what would have happened? At least one of the pilots would have questioned the briefing officer, particularly Captain Simpson, a qualified navigator. No pilot would sit there in silence and take their pick, yet according to Mahon, that's what happened. Nothing said by Chippendale changes any of that.

megan

25th Jun 2016, 05:48

The evidence given by Captain Wilson and by Captain Johnson as to the verbal content of the RCU briefing was not accepted by the majority of the pilots who attended the briefings. Indeed, there was one pilot who said that upon listening to the evidence given before the Commission in relation to the briefing he had attended, he was led to wonder whether he had been at the same briefing.

More airline obfuscation of reality? Orchestrated litany of lies?

ampan

25th Jun 2016, 05:57

PapaHotel6

25th Jun 2016, 06:41

The part of the evidence that was not accepted was the part that said the pilots were told the track went over Erebus.

As regards the waypoint, being a separate and distinct issue (being a point lost on the idiot Royal Commissioner), none of the pilots said that thought the waypoint to be 20 miles west of McMurdo Station, out in the middle of nowhere.

I agree. But it doesn't matter. Even if Charles Lindbergh and Chuck Yeager had sworn to Collins on that fateful morning that the track would take him right down McMurdo Sound, ** he still wouldn't have been justified in descending how and when he did**

3 Holer

25th Jun 2016, 07:53

Photos developed from the passengers’ cameras found in the wreckage showed that the weather over Antarctica had been clear moments before the crash, launching Vette on a search to find out why none of the men on the flight deck saw or tried to avoid the mountain as the plane approached it descending through 2,500 feet.

Vette discovered that in certain conditions, the powerful effect of “whiteout” eliminated visual borders, and that pilots might not see obstacles as big as mountains directly in front of them.

Vette’s alternative explanation was considered credible, and was incorporated into the commission’s final report, which was officially accepted by the government in 1999.

megan

25th Jun 2016, 09:11

The part of the evidence that was not accepted was the part that said the pilots were told the track went over Erebus.

none of the pilots said that thought the waypoint to be 20 miles west of McMurdo Station, out in the middle of nowhereSo if the track didn't go over Erebus, where did it go?

Where did the pilots think the waypoint was, if not out in the middle of nowhere and didn't pass over Erebus? Collins knew where the waypoint out in the middle of nowhere was, and called McMurdo.

PapaHotel6

25th Jun 2016, 10:23

Photos developed from the passengers’ cameras found in the wreckage showed that the weather over Antarctica had been clear moments before the crash,
Okay. Firstly, "Antarctica" is quite a big place. Secondly, the photos showed there was clear weather to the side of the aircraft at various points of the descent but crucially the area to where the aircraft was headed - Ross island - was completely covered in cloud. This is undisputed. This is also why there were no photographs taken to the south - it was just a wall of cloud in that direction. Mahon pontificated on this as if it was some big mystery.

launching Vette on a search to find out why none of the men on the flight deck saw or tried to avoid the mountain as the plane approached it descending through 2,500 feet.
They didn't see it because they had ice below, cloud above. It isn't rocket science. I've encountered the same thing flying towards Ruapehu, and it didn't take any dastardly clever optical illusion.

Vette discovered that in certain conditions, the powerful effect of “whiteout” eliminated visual borders, and that pilots might not see obstacles as big as mountains directly in front of them.
Vette "discovered" nothing. He came up with a hypothesis that sought to legitimise why the pilots didn't climb away immediately at 2000'/1500'. It's a theory only.

Vette’s alternative explanation was considered credible, and was incorporated into the commission’s final report, which was officially accepted by the government in 1999.
Vette proposed that mindset combined with an optical illusion meant they "saw" acceptable VFR conditions at 1500' right up until impact. I believe this to be fanciful in the extreme. In any case, they were not VMC at 2000' (or why did they descend further to 1500').

The Mahon report was "tabled in Parliament" - whatever that means - by an MP who thought he was doing a good thing. If you believe that that episode adds credibility to anything.... you probably don't belong here.

megan

25th Jun 2016, 13:31

none of the pilots said that thought the waypoint to be 20 miles west of McMurdo StationTrue, but they didn't say it went direct to the base either. Please use FACTS ampan, not what you imagine while having a wet dream. ;) Chippendale said,Two of the 3 pilots of the operating crew of flight TE 901 were subjected to the specially devised audio-visual, written and simulator route qualification briefing for the route to and from Antarctica (First Officer Lucas had not received the Antarctic route briefing).

An examination of this briefing revealed certain significant items were not included:

The way in which the Air New Zealand route varied from the normal military route, which followed the reporting points depicted on the Radio Navigation Chart (RNC), particularly on the leg from Cape Hallett south to McMurdo.
Topographical maps for use on the flight. With the exception of a Photostat copy of a small insert enlargement of a map of Ross Island (1:1,000,000), these were not issued to the crew until the day of the flight, and were of a relatively small scale i.e. 1:5,000,000 and 1:3,000,000.

Although topographical charts for the area were available on the day of the flight the only “charts” of the area below the flight planned track from Cape Hallett to McMurdo available at the initial briefing were:

The passenger information map (an overprint on a 1:16,000.000 chart)

The RNC chart and

A slide depicting a schematic diagram taken from the rear of a passenger brochure

All of which showed a track proceeding o the true west of Mt Erebus down the McMurdo Sound. While these “charts” were not intended to be used for navigation the track shown was not that to be followed by TE 901. Several members of earlier crews were of the opinion that the inbound track to McMurdo was intended to be on an alignment which was over the sea level ice to a point adjacent to McMurdo but to the west of that base. (The dialogue which accompanied the audio visual briefing referred to the RNC chart when discussing the appropriate flight levels for the flight.)

The strip map of the route from Christchurch to McMurdo issued on the day of the flight also had two tracks printed on it both depicting a passage to the west of Ross Island. A track and distance diagram issued at the route qualification briefing correctly depicted the intended flight plan track from Cape Hallett to the McMurdo TACAN, but this showed no relationship to geographical location or terrain.

The audio visual presentation of the route qualification briefing showed two slides purporting to be of the track between Cape Hallett and the McMurdo TACAN. The first which only showed Cape Adare, 73 miles northwest of the Cape Hallett waypoint, accompanies the statement “We are almost 77° south proceeding from Cape Hallett towards Ross Island at Flight Level 330. Mt Erebus, almost 13000 feet, ahead. McMurdo Station and Scott Base lie 20 miles beyond the mountain in the direction of grid north”. A second slide accompanies the statement “Now approaching Erebus at 16000 feet the minimum sector altitude. In VMC a descent to this minimum altitude up to 50 miles before McMurdo will be found advantageous for viewing”. This slide gave no indication of the relationship of the track to Mt Erebus, as it shows a view of Mt Erebus taken from behind the co-pilot’s seat with the aircraft heading north.

The computer flight plan used at the briefing had been in error for 14 months in that it showed the destination point for McMurdo as two degrees ten minutes of longitude to the west of the intended turning point. This error was not corrected in the computer until the day before the flight. Although it was intended that it be drawn to the attention of the previous crew, immediately prior to their departure this was not done, nor was it mentioned during the preflight dispatch planning for the crew of the accident flight. The crew was shown a copy of the erroneous flight plan with the incorrect co-ordinates at the route qualification briefing but the flight plan issued on the day of the flight was correct.And in another brilliant piece of airline planning.Mention was made in both the audio-visual presentation and the written brief of “A whiteout emergency landing area for ski-equipped aircraft” located grid northwest of and adjacent to Williams Field with a landing procedure and talk down being available from the PAR (Precision Approach Radar) Controller, Williams Field.

The United States Navy advised “The emergency whiteout landing area does not have PAR available. This area along with the skiway, is for ski equipped aircraft only. Wheel equipped aircraft would use this area only if a crash landing/wheels up landing was required.Being for ski equipped aircraft one wonders why it gained a mention at all, unless for a gear up arrival.

ampan

25th Jun 2016, 21:21

For megan’s benefit, I’ll try to explain this waypoint issuein the simplest possible terms.

A waypoint is, obviously, a point, identified by co-ordinates. Knowing its location does not identify the track to that waypoint. That’s equally obvious. To know the track to that waypoint, you have to know the location of the previous waypoint, being Cape Hallett in this case.The waypoint and the track to it are separate and distinct issues.

Look at the inset to NZMS135, which is all they had at the briefing. It does not include Cape Hallett. You will see that McMurdo Station sits on the end of a peninsula jutting out towards the middle of the Sound. It’s very easy to picture a track running down the middle of the sound to McMurdoStation.
Some of the material used at the briefing suggested a track with Erebus to the left rather than dead ahead, but remember that the track and the waypoint are separate and distinct issues. Mahon did not appreciate that.Having heard evidence that the briefed track went to the west of Erebus, he concluded, wrongly, that the briefed waypoint was to the west of Erebus. To do that, he had to ignore the indisputable evidence from the audio track with his ridiculous nonsense about one part of the briefing “taking precedence” over another.

A good indication of Mahon's forensic skills is that he never considered the obvious solution to this apparent conflict in the evidence, because he never considered the waypoint and the track as separate issues. Once you do that, it’s easy. They all though the waypoint was at McMurdo Station but thought that the track to it was down the sound to the west of Erebus.

That was Captain Collins mindset when he left the briefing.It changed the night before, when he plotted the track on his atlas, which had a copy of the whole of NZMS135, which showed Cape Hallett. He would have noted that a track from there to McMurdo Station crossed Erebus, but he also would have noted that the final waypoint was 20 miles west and that a track to that point would take the aircraft well to the west of the high ground - hence his locking the aircraft back onto the nav track at 2000 feet when he couldn't see anything (when he supposed to be VMC).

3 Holer

26th Jun 2016, 01:30

ampan, for your benefit I'll explain the waypoint issue to you.

The nav section obliged, thinking they were only moving the waypoint from the NDB to the TACAN.
The airline’s navigation section believed it was making a minor adjustment to the flight’s longstanding destination point, but a typing error some 14 months earlier meant it had actually shifted this point some 27 nautical miles to the east. Instead of the IFR route taking Flight TE901 over flat sea ice, as Collins and Cassin had been briefed, it would take them directly over Mt Erebus, a 3794-metre-high active volcano.

Just a small sample of the confusion that existed about this elusive waypoint. Did anyone in the navigation dept. really know where it was?

Does it seem strange to you ampan that ALL the preceding flights to the Antarctic returned to Auckland safely? Despite evidence pointing to flight below MSA, low flying for a great view etc,. on some of these flights.

However, Jim Collin's flight did not. Why ? Mahon and Vette found out through
persistent, thorough investigation and the statements of many witnesses.

Excerpt from Mahon report:
393. In my opinion therefore, the single dominant and effective cause of the disaster was the mistake made by those airline officials who programmed the aircraft to fly directly at Mount Erebus and omitted to tell the aircrew.

megan

26th Jun 2016, 02:34

ampan, this is my only reply to your previous post. Absolute and utter nonsense. Read my last post and COMPREHEND what Chippendale had to say.

ampan

26th Jun 2016, 03:23

I assume the significant part of what Chippendale said is the bit in bold:

"Several members of earlier crews were of the opinion that the inbound track to McMurdo was intended to be on alignment which was over the sea level ice to a point adjacent to McMurdo but to the west of that base."

If you look at p176 of Macfarlane's book, all will become clear. It shows the four relevant waypoints. For the early flights, the waypoint was at the ice runway at Williams Field which, obviously, was "over the sea ice". The hangers, associated buildings and the TACAN (ie, "that base") was 11 minutes of longitude to the east.

The pilots Chippendale spoke to were not referring to a point more than 20 miles west by the Dailey Islands, out in the middle of nowhere. They were referring to the ice runway at Williams Field.

It seems a little strange to cherry-pick comments made by Chippendale but then, I assume, to condemn his findings as to the cause. I have every word of evidence presented to the Commission by the other pilots who gave evidence, cross-examination included. If you don't believe that the comments made to Chippendale were about the early Williams Field waypoint, I'll go through every pilot's evidence.

3 Holer

26th Jun 2016, 03:36

.......the comments made to Chippendale were about the early Williams Field waypoint, I'll go through every pilot's evidence.

Irrelevant. Hearsay and argumentative.
to condemn his findings as to the cause.

His findings were condemned by the Mahon Inquiry. End of story. All we are doing here is still going around in circles
with history. Remember, the Chippendale report was the catalyst for the Mahon Inquiry. There is no point in trying to mix'n'match
snippets of evidence from both in an effort to divert the primary cause of the accident.
I'll say again:
",,,,,,,,,,,,the disaster was the mistake made by those airline officials who programmed the aircraft to fly directly at Mount Erebus and omitted to tell the aircrew."

prospector

26th Jun 2016, 04:01

Will everybody try and get one thing correct,his name is spelt Chippindale.

I'll say again:
",,,,,,,,,,,,the disaster was the mistake made by those airline officials who programmed the aircraft to fly directly at Mount Erebus and omitted to tell the aircrew."

You may well believe that, but many think it is a stupid statement.

ampan

26th Jun 2016, 04:12

Apologies to Mr Chippindale.

As for Mr 3 Holer, clearly not irrelevant but admittedly argumentative. As for hearsay, that is a word that I know the meaning of and you don't - so I suggest that you stop using it.

megan

26th Jun 2016, 05:09

Apologies to Mr Chippindale.Likewise, a gentleman who no doubt was performing under great pressure, the like of which we will never know.You may well believe that, but many think it is a stupid statement.Far from stupid. Anybody who thinks it stupid, are themselves stupid. Chippindale himself said,"He had not been able to find out definitely what caused the plane to crash"

"he had great difficulty in finding the 'ultimate cause' for the crash"

"It has been hard to establish a definite cause"

"Therefore, I have said in the report what I think is the probable cause - the last thing that made the accident inevitable, though there were other factors or causes leading up to the accident"Seems to me the good man was fully abreast of the causal chain, and the swiss cheese theory that was yet to be invented.

What is stupid is folks clinging to positions that experts have said were not tenable, radar monitoring of the airlines cloud break procedure being one.

3 Holer

26th Jun 2016, 05:30

Me too, apologies to Mr Chippindale.

Stupid is as stupid does prospector.

Meteorological information confirmed that conditions at the time were conducive to the existence of surface whiteout in a VMC environment (clear of cloud with good visibility). However, what is evident from the report is Mr Chippindale’s lack of understanding of the impact of that phenomenon in the presence of the entire crew’s mindset regarding their position.

If the "entire crew's mindset regarding their position" was over the flat sea bed of McMurdo Sound, why would "officials who programmed the aircraft to fly directly at Mount Erebus and omitted to tell the aircrew" be a stupid statement?

ampan

26th Jun 2016, 06:48

From the officials perspective, the aircraft had always been programmed to fly directly over Mount Erebus, so there was nothing new to tell the aircrew.

At the briefing, the waypoint conveyed to the crew was at McMurdo Station. With that knowledge and the whole of NZMS135 (provided on the morning of the flight), it was clear that the route was over Mount Erebus. But Collins had a flight plan showing a different waypoint - so he had conflicting information. What was he then obliged to do as pilot in command? Resolve the conflict. Did he? Clearly not, and he realised his mistake just before he died, when he initiated a left turn, towards the area, according to Mahon, where he thought the high ground to be.

There was nothing inherently strange about a nav track going over Mount Erebus. It was the most distinctive geographical feature. The NDB was behind it, and it was common practice to locate waypoints at beacons. The was no obligation to follow the nav track, and most didn't, because they had blue skies. If the volcano was erupting, a good idea might be to avoid it. If there was cloud cover, stay above MSA on the nav track until overhead the NDB and then use the briefed cloud-break procedure.

The notion that the aircraft was doomed from take-off, which many people actually believe, is nuts.

prospector

26th Jun 2016, 06:53

"officials who programmed the aircraft to fly directly at Mount Erebus and omitted to tell the aircrew" be a stupid statement?

Round and round and round we go.

No, the "officials" never programmed anything below MSA, it was the decision to descend below MSA against the laid down descent procedure that caused the crash, and advice from on the ground re the weather conditions at McMurdo, that were well below that required for the authorised descent procedure, advice that Ross Island was completely covered in cloud, there was a recorded conversation between Collins and Met people on the ground that passed all this information to him, but the person that passed the info was never called to give evidence, why?: because it would stuff up Mahon and Vette trying to find a reason to absolve the crew from "making any error"perhaps?
It is a fact that the AINS was not cleared as a Nav aid below MSA, and what were they doing relying on that when they had to go down to 1,500ft? if it was VMC at 2,000ft why did they have to go down to 1,500ft?.

Why was not the Lat and Long, that was being updated continuously, on this magical navigational system not used to positively give a fix before the descent was commenced?

It would appear that the radar, in mapping mode, that previous crew said showed up Ross Island very well was not used,WHY.?

If it was VMC with a min vis of 20km, why did Mulgrew say 4 minutes before impact, he would advise people where they were when he knew himself?

3 Holer

26th Jun 2016, 07:33

Some good questions prospector, but I'm afraid they will remain unanswered because the crew did not survive the accident. We, of course, can continue to presume, assume, guess, presuppose and feign the answers, through smoke & mirrors, but it will do no good.

Until someone discovers a new piece of evidence in the maze of testimony in the Mahon/Chippindale reports we will continue the merry-go-round.

PapaHotel6

26th Jun 2016, 09:31

Some good questions prospector, but I'm afraid they will remain unanswered because the crew did not survive the accident. We, of course, can continue to presume, assume, guess, presuppose and feign the answers, through smoke & mirrors, but it will do no good.

I'm presuming you don't, however, include Vette's false horizon theory in what is presumed, assumed, feigned etc?

megan

26th Jun 2016, 12:19

At the briefing, the waypoint conveyed to the crew was at McMurdo Station. With that knowledge and the whole of NZMS135 (provided on the morning of the flight), it was clear that the route was over Mount Erebus.Absolute rubbish ampan.There was nothing inherently strange about a nav track going over Mount Erebus.Give me a break, a track going over the top of an active volcano with the minimal of clearance. Only an absolute nut case would plan such a flight path. Which was Chippindales opinion as well, though not couched in such language.

ampan

26th Jun 2016, 16:15

Where the aircraft went was determined by the captain, not by the AINS, so if any captain shared your concerns, then don't go there, or punch in an offset, moving the track west. The AINS was not like a ground aid. it's purpose was to get from one side of the Pacific to the other, and it did a great job of that. It was not to be used for landings or other descents below MSA, because it could be wrong. Apart from the usual drift, it required human inputs at various stages, leaving room for mistakes, and that's exactly what happened. Captain Collins knew all of this. When he got the bad weather report, there was no talk of going down anyway using the AINS - he was going to go elsewhere. Then he got the offer of the radar-assist - a ground aid, independent of the AINS - and he gratefully accepts the offer and announces it to the passengers. The minutes pass and they are unable to make contact with the radar operator on VHF, so the obvious response was to go elsewhere, but instead, we get this unannounced inexplicable figure of eight descent while pretending to be VMC. I don't see any point in 3 Holer trotting out quotes from Mahon, because Mahon was an idiot.

PapaHotel6

26th Jun 2016, 19:09

Ampan's post above is almost completely composed of facts, not summation, or opinion, and it describes precisely why the prime cause of this accident was pilot error. Collins also made other errors which ampman doesn't mention - such as descending from 2000' to 1500'.

The only assumption ampan makes above is that they were "pretending to be VMC". Lets look at that for a moment.

There was a hell of a lot of cloud around. Ross island to the south was a wall of cloud from high altitude - we know this from the reports, and also because Erebus wasn't seen at any time during the descent. We also know Collins rearmed the INS several times during the descent. Never did he mention Mt. Bird (which should have been very close to where he thought he was) - either because he had zero awareness of the surrounding topography; or because he did not expect to see it - which can only be because there was cloud around. I don't think I've *ever* been in conditions like this where I could somehow have descended from 16,000' to 1,500' and been VMC the whole way.

Is it possible Collins had true VMC conditions at all times during the descent? Yes. Is it likely? I don't think so. I think all the evidence is against it - including the fact the words "VMC" were repeatedly mentioned.

ampan

27th Jun 2016, 01:41

Here's a good example of Mahon's sheer pig-headedness: He was not thrown in the deep end re aviation. The taxpayer paid for an aviation expert to assist Mahon: Sir Rochford Hughes. Sir Rochford identified the descent without a radar fix as a clear-cut error requiring that the crew receive some, but not most, of the blame. Mahon completely ignored what Sir Rochford had to say and never even referred to the subject - which is what people tend to do with something to which they have no answer.

megan

27th Jun 2016, 05:59

Mahon was an idiotI don't agree, there were elements he didn't understand, certainly. The first class idiots, who stood head and shoulders above any others, resided in the airline executive.

3 Holer

27th Jun 2016, 07:18

Hempy

27th Jun 2016, 10:23

PapaHotel6 and ampan. You two should hook up together as a comedy act, your last couple of posts could beat anything Dean Martin and Jerry Lewis ever put together. Those posts were really funny in a pathetic sort of way.

When you both stop being silly, I'll re-enter the debate.

That sounds like the too cool for school version of 'taking my bat and ball and going home'.

The difference between your side of the argument and the general consensus, 3 Holer, is that whilst the consensus admits that other parties were just as responsible for placing some holes in the Swiss cheese that led to that accident as the crew were; you argue that the crew were responsible for no holes at all!

What have you learned from that accident? To always crosscheck your indicated position against a chart when descending below the height of a mountain nearby that you should be able to see but you can't? Or that if you find yourself in a position where you are required to descend below the height of a mountain that is nearby that you can't see, you should follow the approved procedures and stay at a safe altitude until your position is fixed by a ground based navigation aid located on the 'safe side' of the nearby mountain, that you can't see..?

PapaHotel6

27th Jun 2016, 19:55

the consensus admits that other parties were just as responsible for placing some holes in the Swiss cheese that led to that accident

I hate the Swiss Cheese model of accident causation. It's rattled off as though it explains everything, as if it's some cunning piece of insight when in actual fact it's pretty trite. It also doesn't differentiate between relative degrees of causation, or the relevance of the individual 'slices. Wikipedia says " it has been subject to criticism that it is used over broadly". And how.

The AINS was a "slice of cheese" with a hole in it - the "hole" being the vagueness and confusion surrounding the destination waypoint. But this was a slice of cheese that should never have been in the deck in the first place. Collins placed it in there by not independently verifying his position prior to descent then subsequently using the AINS during the descent in a way it was never intended.

megan

28th Jun 2016, 00:43

I hate the Swiss Cheese model of accident causation. It's rattled off as though it explains everything, as if it's some cunning piece of insight when in actual fact it's pretty trite. It also doesn't differentiate between relative degrees of causation, or the relevance of the individual 'slicesThe swiss cheese model is a very good one, and not at all trite. You are quite correct though in that it doesn't differentiate between the relative elements, because removing any one of the elements might presumably remove an opening for the accident occurrence.

Imagine if the nav dept had gone to the trouble of plotting the waypoint on a map. Collins is castigated for not plotting his position, but we have a gentleman sitting in an office, with presumably all the time in the world, and he does nothing to check the data that he is entering/typing. What might have been the outcome if he had entered the correct co-ordinates?

What might have been the outcome if the "Ops Flash" at the top of the flight plan had the message "McMurdo co-ordinates changed"? Would the crew have said to themselves, "I wonder where the new McMurdo is?", and then gone to the trouble of plotting the position?

Then again, when the 27 mile discrepancy was reported, no one had the intellectual curiosity of resolving the issue. Not helped by the fact that the airline was run on the basis of phone calls, and not documentation. It would seem that there might not have been a safety reporting system in place, and if there was, it certainly was not used to report the discrepancy.

For what purpose does the nav dept exist, if not to provide information crews can supposedly rely upon? Had the flight planning been left to the crew, they would have got out the RNC chart, followed the relevant tracks to Byrd, thence the real McMurdo, for the company proscribed cloud break procedure. The real question is, why didn't the airline follow the route that had been surveyed by experts, and published for industry use? And why the stupid cloud break procedure, which had half (grid north east sector) of the designated area at 16,000 positioned in the radar cone of silence (the reason the controllers called the procedure "absurd"), when an NDB approach was available (prior to it be taken down)? Hells bells, had the airline actually talked to the Americans (which they never did), the radar might have been organised to actually monitor a descent inbound from Byrd to McMurdo, to whatever altitude the airline/authorities desired to set as a limit - 6,000?.

But I forgot, the airline invented aviation.

PapaHotel6

28th Jun 2016, 01:05

The swiss cheese model is a very good one, and not at all trite. You are quite correct though in that it doesn't differentiate between the relative elements, because removing any one of the elements might presumably remove an opening for the accident occurrence.
A debate on the relevance of the "Swiss Cheese" model is probably outside the scope of this thread. Let's just say I disagree, and it predisposes to "hindsight bias" - which involves placing undue significance on factors that prior to the event should not have been relevant (like the high altitude NAV track being different to what the crew expected).

What might have been the outcome if the "Ops Flash" at the top of the flight plan had the message "McMurdo co-ordinates changed"? Would the crew have said to themselves, "I wonder where the new McMurdo is?", and then gone to the trouble of plotting the position?
Maybe. Maybe not. But provided they stayed above MSA, the worst case scenario should have been what happened on Capt. Simpson's flight.

But I forgot, the airline invented aviation.
They certainly didn't set up a bullet proof infrastructure, that's for sure. But in this whole episode - if any parties can be accused of making up the rules of aviation to suit them; it would be Collins and Mahon.

3 Holer

28th Jun 2016, 04:02

You disappoint me Hempy. You appear to be siding with the anti Mahon camp who, all through this debate (and the last 40 years), have been trying to insidiously introduce the pilot error card to camouflage and convince the “consensus” to reconsider Mahon’s findings.
There is not one post of mine where I have stated the crew ......were responsible for no holes at all!
The debate has always, in my opinion, been about the Chippindale v Mahon reports. Chippindale (Air NZ &Muldoon government) went too hard on the pilot error theory. Mahon was seen as being too lenient on the pilots in his summary of probable cause. However, to Mahon’s credit, he took the time to collate evidence and present it in an impartial way.
I contend and will continue to believe that, until there is any new evidence, Mahon got it 100% correct. The Air New Zealand flight department and administration section was toxic and Mahon got to the bottom of it. Para. 393 cannot be disputed and has never been proven wrong. This was (and still is) the catalyst for division between the two camps.
The MSA/low flying is rubbish and was shown to be a “smokescreen”
Myths & Facts. Erebus disaster:
The 16,000-foot safety ceiling was soon shown to be a smokescreen. Air New Zealand had claimed flights were not allowed lower than that till south of Ross Island, and that they were not allowed lower than 6000 feet at any stage. But a succession of pilots at the royal commission said they had flown as low as 1500 feet in the area with the full knowledge of the airline. They were, after all, sightseeing flights and there was not much to be seen from 6000 feet or 16,000 feet. Mr Chippindale initially upheld the height restriction claims, but in an interview in 1989, on the 10th anniversary of the disaster, he acknowledged that Air New Zealand had only made the claim to try to avoid insurance liabilities. He accepted that previous flights had also gone down low and that the airline had condoned it.
The AINS tracking argument is just another one.
All parties, please think about this:
In its 1983 decision, the Privy Council expressed the wish that everyone caught up in the Erebus conflagration would move on from it. "The time has now come for all parties to let bygones be bygones so far as the aftermath of the Mt Erebus disaster is concerned. The time for bitter feelings is over."

megan

28th Jun 2016, 05:38

if any parties can be accused of making up the rules of aviation to suit them; it would be Collins and MahonBeg once again to differ. It was the airline that made up the rules to suit themselves. Their cloud break procedure would not have passed TERPS, which governed McMurdo operations, or any other regulatory authority given to designing such procedures. Absolutely nothing about the operation could, by any stretch of the imagination, be called "professional".

Why Collins may have done what he did would require the insights of a behavioural psychologist, which unfortunately we lack. But given the airlines modus operandi, I have an understanding of why he may have done what he did - back up and see my post re VMC. As for Mahon, any misunderstanding that he may have had would arise with any judge presiding over a technical case, whether it be financial, engineering, etc. I say "would" because different people will read into, and take away their own interpretation, judges after all are human, and subject to all the frailties thereof. The trouble with communication, whether it be oral or written, is the belief that it has taken place. Mahons finding for example, I can understand from where he was coming, others don't agree, ampans trenchant criticism being a case in point. Neither of us will change the others mind.

The following was written in 1995 by David Beaty,
When the Human Factor in Aircraft Accidents first appeared in 1969, it was recognised in the Press worldwide as ‘The first major attempt to pin down the human failings that caused planes to crash.

However such human factor causes were resisted by aircraft manufacturers, airlines and the pilots themselves till the major disaster of Tenerife in 1977 when two 747s collided and 583 people perished. That caused elements of the aviation industry to begin to make tentative moves towards understanding the problem. By 1991, human factors were being researched and taught in psychology departments and airlines in Europe and America. Indeed the study and practice of aviation human factors was beginning to blossom into an industry.

Even so, there had been and still is understandable resistance to that study in that we all tend to deny making mistakes in a society that blames and demands heavy
penalties from those of us who do make them, especially ones with huge financial implications such as those resulting in an aircraft accident.

Denial is a defence mechanism that is used by our society and frequently by ourselves as individuals to ensure its and our survival. It is dangerous to go against the grain of public opinion and the opinion of our masters. We might lose our jobs. We would certainly lower the esteem in which we are held. Even Darwin hesitated for years before publishing The Origin ofthe Species because of public opinion at that time, and kept a low profile on whether our similarity to the bodily characteristics of animals might in some way and to some degree be matched by a similarity to the ways animals think and feel and react.

The age-old witch hunt to identify a scapegoat — usually the pilot — has begun to give way to the concept of the collective mistake. The practice of Cockpit Resource Management (CRM) has been tvvinned with Line Oriented Flight Training (LOFT), though even as late as 1992, only four airlines in America had integrated CRM/LOFT programmes.

Then human factor education courses have been started in some enlightened airlines. There is a human factor examination requirement in the pilot licence. joint training of flight deck and cabin crews has started, to which one or two enterprising airlines have added despatchers, ATC and maintenance staff In other words, the concept of all being in this together and all being responsible for the outcome has at last caught on. Hopefully management personnel will also be incorporated. ICAO has initiated a sustained campaign to increase awareness of the pervasiveness of human error in aviation amongst the middle and senior managers of the international aviation community particularly in some regions where there is an even lower understanding of human factors than elsewhere in the world.

What is still to be accepted is the commonality of the causes of mistakes that lead to accidents in all areas of human behaviour. Forgetting to switch the lights off
before leaving a car may result in a flat battery. Forgetting a switch on an aircraft may cost dozens of lives. Airliners continue to collide both into each other and into
the ground for similarly universal human factor reasons. There have been at least twelve Controlled Flight Into Terrain (CFIT) accidents with horrific loss of life since the beginning of 1992.

There is need to look at mistakes in a much wider context instead of in constrained and separated specialised enclaves with little communication between them. Too many separate individuals and organisations appear to be pursuing the same rabbit from different directions without realising it. Individual expertise in the different environments of air, sea, road, rail and ground are of course essential, but a connection between them and a cross-fertilisation of information on the pivot of a corporate understanding of human factors needs to be established and maintained if we are to progress deeper into the many different areas of human understanding. One such, which so far has been avoided, is how far personality is a factor in the making of mistakes — but this minefield eventually will have to be addressed.

On the positive side, the aviation industry has now begun to realise the fundamental importance of human factor understanding. Boeing has just published Accident Prevention Strategies which advances the collective mistake theory. It reasseses 232 major accidents over the ten years to 1991 and identifies 37 individual links which could contribute to an accident.

Because of its intensive supervision and testing, its vast network of information exchange, its introspection and present excellent safety record, other industries such as the medical and nuclear are coming to aviation to learn about human factors.

What is needed is the establishment and maintenance of awareness in people of the potential of human factors for both triumph and disaster. Unless there is receptiveness, all instruction will fail to penetrate deaf ears.It seems from this thread that the last sentence is still applicable.

Amen to your final quote 3Holer.

PapaHotel6

28th Jun 2016, 06:35

So - just so we're absolutely clear. Megan and 3-Holer - you believe Collins was blameless in this accident? That no one, without the benefit of hindsight, could reasonably expect him to have behaved differently?

ampan

28th Jun 2016, 06:59

Some of you people don’t seem to appreciate how dirty this fight was, particularly by the union. Here is but one example, involving the critical evidence of Captain Simpson. But first, the background re the final waypoint.
The Various Waypoints:
Williams Field - IceRunway – 77’53” South; 166’ 48” East
TACAN – Hangers, Radar Operator on VHS – 77’ 52.7” South; 166’ 58” East
NDB – McMurdo Station, Radio Operator on HF – 77’ 51” South; 166’ 41” East
Dailey Islands – 27 nautical miles west of McMurdo Station –77’ 53” South; 164’ 48” East

[Date]
[Final Waypoint]
15 Feb 1977
Williams Field

22 Feb 1977
Williams Field

3 Oct 1977
NDB

1 Nov 1977
NDB

8 Nov 1977
NDB

15 Nov 1977
NDB

7 Nov 1978
Dailey Islands

14 Nov 1978
Dailey Islands

21 Nov 1978
Dailey Islands

28 Nov 1978
Dailey Islands

7 Nov 1979
Dailey Islands

14 Nov 1979
Dailey Islands

21 Nov 1979
Dailey Islands

28 Nov 1979
TACAN

On 14 November 1979 Captain Simpson attended a briefing,along with Captain Collins. One of the briefing officers, Captain John Wilson(retired), brought along four flight plans from a flight he had been on a week before. They were the flight plan for the route to McMurdo, the plan for the alternate route to the South Magnetic Pole, and the “as flown” versions of both. Of the two flight plans showing a route to McMurdo, the final waypoint was at the Dailey Islands, at 164’ East.
On 18 March 1980 Captain Simpson was interviewed byChippindale, and said this: “[Captain Wilson] had some old Flight Plans from previous years flights which he handedout for us to just look at – he didn’t have enough to give away.”
The phrase “previous years” excluded the flight plans brought to the briefing by Captain Wilson. So were there any other flight plans floating around? There was definitely one, that being the flight plan used to program the simulator, an identical version of which was later found in the wreckage. In that flight plan, from 1977, the final waypoint was the NDB at McMurdo Station.
If you’re the union lawyer, which flight plan do you want Captain Simpson to be looking at during the briefing when he forms his opinions as to the position of the final waypoint? You want him to be looking at one of Captain Wilson’s flight plans, with the waypoint 27 miles west of McMurdo Station – and you certainly don’t want the phrase “previous years”, because that included 1977.
Captain Simpson’s statement was taped, transcribed and sent to him for any corrections to be made. He then sent a photocopy to the union lawyers.They prepared a typewritten statement. When it came to the phrase “previous years flights”, they changed the wording to “a flight of the previous year”. Megan and 3 Holer might have some difficulty getting the point here, so I’ll spell it out: In the previous year, 1978, the waypoint was at the Dailey Islands, so 1978 was fine as far as the union was concerned – but 1977 was not. So this apparently minor change had the effect of locking Captain Simpson in to a position supported the union’s case.
I assume that lawyers have various rules as to how they aresupposed to treat people they call as witnesses and if that sort of behaviour is permitted by those rules then that so-called profession is even more rotten than most people think. (By the way, there are more examples of similar behaviour.)

3 Holer

28th Jun 2016, 08:16

On 14 November 1979 Captain Simpson attended a briefing,along with Captain Collins. One of the briefing officers, Captain John Wilson(retired), brought along four flight plans from a flight he had been on a week before. They were the flight plan for the route to McMurdo, the plan for the alternate route to the South Magnetic Pole, and the “as flown” versions of both. Of the two flight plans showing a route to McMurdo, the final waypoint was at the Dailey Islands, at 164’ East.
On 18 March 1980 Captain Simpson was interviewed by Chippindale, and said this: “[Captain Wilson] had some old Flight Plans from previous years flights which he handedout for us to just look at – he didn’t have enough to give away.”

The above is circumstantial hearsay and can't be verified as Captain Collins is no longer with us.

ampan

28th Jun 2016, 11:11

The absence of Captain Collins is not relevant The issue is what Captain Simpson said, before the union lawyers got their hooks into him. The whole of his original statement is at pages 354 to 362 of MacFarlane's book. The "previous years flight" phrase is at page 354. The subsequent statement prepared by the bent union lawyers is at pages 663 to 669 of MacFarlane's book, and the slight-of-hand re "previous years flight" is to be found at paragraph 5 on page 664. But it actually gets worse. One would think that the union would think that they had Simpson right where thy wanted him, committed to a 1978 flight plan with the Dailey Islands waypoint. But there was no evidence of that there was ever such a flight plan at the briefing, so that might cause an issue to erupt, which would turn the attention back to the original statement and the phrase "previous years flight". So in the final version, zinged to the captain just before he was to give his evidence, the wording was changed again: "During the briefing Captain Wilson produced flight plans from a previous flight to the Antartic for our perusal." The effect was to bring Captain Wilson's four 1979 flight plans back into the mix, but it could also include 1977, so in the unlikely event of Captain Simpson picking up on the various changes to the wording, he could be placated.
Captain Simpson knew nothing of the various flight plans and he probably began to believe that he must have been looking at a flight plan with the Dailey Islands waypoint. But when he came to be cross-examined on that point, he was politely taken to pieces by one of the Queens Counsel. If, however, he was looking at the 1977 flight plan with the NDB waypoint, every single piece of Captain Simpson's statements and evidence makes sense. Of all the witnesses who gave evidence, Captain Simpson received the worst treatment and ended up getting it in the neck from both sides. The process that led to that was begun by NZALPA.

megan

28th Jun 2016, 13:49

Some of you people don’t seem to appreciate how dirty this fight was, particularly by the unionGiven the criminal behaviour of the airline I don't know why you give the union a kicking. Airline visited the F/Os house and removed documentation which never again saw the light of day, destruction of all original documents on file so only copies were available, break and enter into the Captains house, pages in the Captains notebook which were noted by a police officer on the ice subsequently turned up with all pages missing, the Captains and F/Os nav bags which were noted in the store at McMurdo by police disappeared never to be seen again.

Cry me a river ampan, the dirt came from the airline, not the union.

PapaHotel6

28th Jun 2016, 20:13

Given the criminal behaviour of the airline I don't know why you give the union a kicking.

Cry me a river ampan,

WHAT????!! What credibility you had with me Megan, you've just lost. If the union lawyers manipulated a witness's statement, that is utterly abhorrent. Unethical behaviour should be viewed as such and condemned regardless of whether it supports the "side" you're on.

ampan

28th Jun 2016, 22:09

I think the union won the dirty stakes, though I'm obviously biased. Look what the did to Captain Dalziel:

Captain Dalziel’c inititial written recollections of his nterview with Chippendale, dated 15 December 1979, before the union lawyers got involved:

“Q – Was I made aware of the terrain existing on track between C. Hallett and McMurdo?”
“A – Yes, without any doubt I was made fully aware particularly location of Erebus.”

Here’s what the union lawyers made of that:

“I do not remember getting any definite idea from the briefing as to the relationship of the route south of Cape Hallett to the topography. I knew that Mt Erebus was quite close to our track and though we would fly south down the Victoria Land coast. I remember that the audio visual presentation contained a slide with the commentary “Mt Erebus ahead” and the slide indicated to me that the aircraft would pass to the right or west of the mountain depicted in the slide. Nothing was said at6 the briefing which indicated to me that the nav track went directly over Ross Island and Mt Erebus.”

Captain Dalziel was then cross-examined by one of Air NZ’s lawyers:

“ Looking at [the initial written recollections] were you made aware of the terrain existing on the track between Cape Hallett andMcMurdo? “

“I was aware there was an area of mountainous terrain.”

“Is the answer to my question ‘yes’? “

“I think it was, wasn’t it?”

“You were made aware of the terrain existing on the track between Cape Hallett and McMurdo in the course of the briefing?”

“Yes”

Captain Dalziel, obviously, should not have read out the statement prepared for him by the union lawyers, because it wasn’t the truth, which the union lawyers knew full well. But if the document was stuck in front of him outside the hearing room just before he was to give his evidence (which is what they did to Captain Simpson) then Captain Dalziel’s behaviour is understandable.

3 Holer

28th Jun 2016, 22:20

Would be nice if we could get back to debating the issues here rather than a He said/She said tirade of boring commentary. There was plenty of evidence of "witness tampering" from both sides in this saga and no one (Mahon included) gave a rats***. Stick to the facts or just agree to disagree.

Sorry to hear you have been removed from PapaHotel6's Christmas Card list for this year megan. You'll get over it - trust me.;)

Pakehaboy

28th Jun 2016, 22:28

3-holer quote..."Sorry to hear you have been removed from PapaHotel6's Christmas Card list for this year megan. You'll get over it - trust me."

Mate,as serious as this debate is,and as interesting ,for those of us watching it unravel,I actually got a good laugh out of that little gem!

megan

29th Jun 2016, 01:57

Unethical behaviour should be viewed as such and condemned regardlessFully concur PH6, but you have to fight fire with fire. The airline from the get go was out throw Collins under the bus and absolve itself from any role in the accident. But it leaves me wondering to which side the orchestrated litany of lies was directed at, airline, union, both? Any idea?

PapaHotel6

29th Jun 2016, 03:02

Fully concur PH6

Cheers.

but you have to fight fire with fire.

No, I disagree. Perverting the course of justice is always morally bankrupt.

As is, of course, an airline shredding documents pertaining to the Antarctic operation. To this day I find it astonishing that this wasn't breaking any law!

But it leaves me wondering to which side the orchestrated litany of lies was directed at, airline, union, both? Any idea?

It was unequivocally directed at the airline witnesses including the senior pilots. It was a foolish comment to make, and it was this that the Court of Appeal and the Privy Council had the most issue with. There simply weren't sufficient grounds to allege that a co-ordinated cover-up had taken place.

ampan

29th Jun 2016, 22:37

I've always wondered who the conductor of the orchestra was supposed to be. Rob Muldoon?

Apart from the union and its lawyers, the various authors who wrote books in support were nearly as slimey. Mahon’s book was pathetic. Paul Holme’s efforts did his case more harm than good. All Vette demonstrated was how highly he regarded himself. StuartMacFarlane’s mad ravings (described as “Editorial Comment”) should have been enough to persuade two doctors to sign the necessary committal papers – but in his more lucid moments, MacFarlane demonstrated that he too was capable of a dirty trick or two. At page 351 he gave the reader the following quote from First Officer Gabriel (who attended the same briefing as Captain Collins), to show that the waypoint conveyed at the briefing was not at McMurdo Station but was many miles out to the west:

“In relation to the McMurdo waypoint for your own flight down there, did you have any briefing as to where that was geographically priorto the flight?”

“Roughly I had a look at the topographical map we were given at the briefing - the inset to NZMS135. I just roughly established where we were going. I thought it would be near enough to … 50 miles to the [west] of McMurdoStation.”

“Did you do that by roughly plotting the co-ordinates on that topographical map?”

“Really just be establishing in my own mind where the position was. I can’t say I actually recorded the co-ordinate from the flightplan … but looking at the map and from what I could remember of the co-ordinates and looking at the topographical map I thought in a rough sort of way we were going to about that position there, so it wasn’t specifically plotted.”

The quote ends there. Page 1712 of the transcript shows the very next question – and answer:

“Are you speaking now of what you did and thought at the time of the briefing on 9 November?”

“No, It was after the briefing.”

3 Holer

29th Jun 2016, 22:38

It was a foolish comment to make, and it was this that the Court of Appeal and the Privy Council had the most issue with. Rubbish.
It was a legal loophole that allegedly didn't allow testimony by certain witnesses during the Mahon Inquiry that the Privy Council had issue with. I notice that none of those professed legal experts ever considered what Collins and his crew may have testified to. Posthumously, they were treated very badly. However, the public saw the Appeals Court/Privy Council finding for what it was and there was a big backlash.

There simply weren't sufficient grounds to allege that a co-ordinated cover-up had taken place. Media speculation. I don't recall anywhere in Mahon's report referencing a co-ordinated cover up. Mahon and Vette stuck to the facts, it was only the Muldoon/Davis camp that were trying to divert the issues away from the truth.

As is, of course, an airline shredding documents pertaining to the Antarctic operation. To this day I find it astonishing that this wasn't breaking any law!
Shredding documents is not against the law. Tons of old Company documents are shredded daily. You cannot rely on media speculation as fact Papa Hotel 6. Was there ever any proof that the shredded documents were anything to do with the Antarctic operation? Mahon and Vette had more important work to do without bothering with a couple of shredded documents.

PapaHotel6

29th Jun 2016, 23:26

Mahon’s book was pathetic.Yet entirely believable to a layman with little or no aviation knowledge. The company changed the computerised "flight path" to be on a collision course with a mountain. Which the pilot would have seen, were it not for the whiteout phenomenon. Therefore the pilot was not to blame. It's common sense.

But common sense also tells us that the sun travels around the earth every day. Common sense can be wrong.

Paul Holmes’s efforts did his case more harm than goodThey truly did. I nearly laughed out loud when I read that it was okay for Collins to be using the INS at low level because he was using "every safety mechanism at his disposal". What people like Holmes desperately need to realise is that they are perpetuating the pain of the Collins family, not alleviating it.

3 Holer

30th Jun 2016, 02:14

ampan
Apart from the union and its lawyers, the various authors who wrote books in support were nearly as slimey. Mahon’s book was pathetic. Paul Holme’s efforts did his case more harm than good. All Vette demonstrated was how highly he regarded himself. StuartMacFarlane’s mad ravings (described as “Editorial Comment”) should have been enough to persuade two doctors to sign the necessary committal papers – but in his more lucid moments, MacFarlane demonstrated that he too was capable of a dirty trick or two.

The above selection of books you have read, appear to have given you a great deal of stress. Not sure if it was a result of the authors or their content.

May I recommend the book, "Managing the Risks of Organisational Accidents" (1997) by James Reason. The author is neither a journalist, part time commentator or a High Court Judge.
I guarantee after reading this book, you will re-enter this debate with a more positive outlook on people. You may like to invite PapaHotel6 to join you - sort of a book club thing?

john_tullamarine

30th Jun 2016, 04:00

pompous Australian tosser

I don't know if Brian still posts these days.

While respecting your right to an opinion, I really need to leap to Brian's defence. He is quite a reasonable chap and I can't recall any post (or, indeed, social situation) comment which would warrant such an inimical observation ... just a balancing thought, if I may.

prospector

30th Jun 2016, 05:19

megan,

I've asked experts on the radar what it's capabilities were, as it was widely used by the RAAF in the past. No reply as yet.

Any reply yet???

jack red

30th Jun 2016, 06:47

megan & 3 holer, I've just added you both to my Xmas Card list for 2016 hope you don't mind!

3 Holer

30th Jun 2016, 07:53

Allow me to return the gesture by also recommending a book "Biggles..............

Oh, it wasn't a gesture PapaHotel6. Anyway, I finished the Bigglesworth collection in grade 3 ...........along with all the Enid Blyton Famous Five and Secret Seven books.;)

megan

30th Jun 2016, 13:15

prospector, I know from your many, many posts on the cloudbreak procedure you have a great interest. In his book Vette spells out the procedure in some detail, and it takes no great leap of imagination to see the problems inherent. Should you be seeking information might I suggest you ask a specific question, or questions, to which an answer might be provided.

prospector

30th Jun 2016, 21:42

megan,

Yes I do have a great interest in the cloudbreak procedure.

I would have thought, given the wording, and I will print it again to save interested parties having to dredge back through the many pages, states nothing about home made descents, it states THE ONLY, let down procedure available. It was issued after the briefings.

Delete all reference to briefing dated 23/10/79.

1. Vis 20km plus.
2. No snow showers 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.

This was a mandatory company requirement.

.Which one of these requirements was complied with?

.

3 Holer

30th Jun 2016, 22:35

We know that #3 wasn't , compliments of the Air New Zealand navigation department.
The descent was co-ordinated with local radar, as confirmed by the CVR.
Requirements 1 and 2 could only be verified with the crew.

So, in answer to your question prospector, only one out of three. Although forecast indicated no snow showers and visibility > 20kms.
What's your point?

prospector

30th Jun 2016, 23:28

The descent was co-ordinated with local radar, as confirmed by the CVR.

Was it??? the radar operator only had VHF comms, at no time was VHF contact established with McMurdo, at no time was a DME lockon achieved.

Please quote any contact with McMurdo radar on the CVR?

What's your point?

My point being, the company order which states "the only let down procedure available". I would have thought that was not ambiguous in any way, to the best of my knowledge "only" has only one meaning.

Nowhere does it state that if you feel like it, and the weather is below our requirements, and the local wx people advise no good for sightseeing, then you can dream up your own descent procedure, using a Nav Aid not cleared for ops below MSA, never having sighted a 12,000ft odd mountain that you know is very close, and crash into that mountain, then, according to Mahon's interpretation of the facts you "have committed no error".

megan

1st Jul 2016, 00:36

states nothing about home made descents, it states THE ONLY, let down procedure availableWell, there is your problem right there. The ONLY procedure permitted had never been used. So how did all those flights get to be zooming about as low as 1,000 AGL? They didn't, God forbid, use a home grown procedure? Normalisation of Deviance is the term you're looking for.

prospector

1st Jul 2016, 00:54

Look at the date of that directive, it was issued well after all the other flights and just prior to the flight under discussion. This crew knew about it, what the other flights had done is not relevant. And even if it was does that mean that this crew could deliberately ignore their written instructions re let down procedure?

The other flights all made it home again, if this flight had of made it home again then would "Normalisation of Deviance" been applicable?

megan

1st Jul 2016, 04:59

what the other flights had done is not relevantIt damn well is relevant. All the flights were required to operate, and make their descent in either IMC or VMC, in accordance with,Flight in the McMurdo area below flight level 160 will be restricted to an arc corresponding to a bearing of 120° Grid through 360° G to 270G from the NDB within 20 nm in order to keep well clear of Erebus.andThe original requirement for radar monitoring of any VMC letdown was deleted by the letter of amendment detailing the conditions for VMC letdowns which were to apply following the withdrawal of the NDB letdown procedure. The revised version only called for the descent to be co-ordinated with local radar control.this crew could deliberately ignore their written instructions re let down procedure?Of course not. But everybody else ignored the instructions, and that is where the "Normalisation of Deviance" comes in. You obviously are unaware of the theory and what it's about. I suggest a little reading.

Briefly, Professor Diane Vaughan developed the “Normalisation of Deviance” theory in order to explain the Shuttle Challenger accident. As a result of her analysis of the Challenger accident, she was asked to testify before the Columbia Accident Investigation Board in 2003, then became part of the Board's research staff, working with the Board to analyze and write the chapters of the Report identifying the social causes of the Columbia accident. She states, "I find that in common, routine nonconformity, mistake, misconduct, and disaster are systematically produced by the interconnection between environment, organizations, cognition, and choice. These patterns amplify what is known about social structure and have implications for theory, research, and policy". One of Vaughan's theories regarding misconduct within large organizations is the normalization of deviance. "Social normalization of deviance means that people within the organization become so much accustomed to a deviant behavior that they don't consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety". People grow more accustomed to the deviant behavior the more it occurs. To people outside of the organization, the activities seem deviant; however, people within the organization do not recognize the deviance because it is seen as a normal occurrence. In hindsight, people within the organization realize that their seemingly normal behavior was deviant.

It explains the inner workings of the airline at the time to a T, as it did the two Shuttle accidents.at no time was a DME lockon achievedIt did, but only very briefly.

prospector

1st Jul 2016, 06:24

this crew could deliberately ignore their written instructions re let down procedure?
Of course not. But everybody else ignored the instructions,

Sorry, cannot answer that, even with theory.

3 Holer

1st Jul 2016, 06:25

Please quote any contact with McMurdo radar on the CVR?

No contact with McMurdo radar does NOT mean there was no co-ordination for descent from local radar control.

At 12.32 p.m. the crew reported they were 43 miles from McMurdo Station and asked for approval to descend further in visual meteorological conditions (VMC). Mac Centre approved this and asked to be kept advised of their altitude. At 12.35 (NZST) the crew reported they were at 13,000 ft and advised they were descending to 10,000 ft (3050 m) VMC. Mac Centre asked whether they required a radar controlled let down through the cloud at this level and this was accepted. But at 12.42 (NZST) the crew advised that they were flying VMC and would now proceed visually to McMurdo Station. Mac Centre requested that the aircraft maintain VMC and keep them advised of their altitude.

There was obvious communication between Mac Centre and local radar control for the approval for the radar controlled let down. There was no traffic advised, hence the clearance to descend maintaining VMC and keep them advised of their altitude. That would be co-ordinating descent with local radar, would it not prospector?

prospector

1st Jul 2016, 07:23

We have been down this road before, and your statement is to be polite wrong.

.
There was obvious communication between Mac Centre and local radar control for the approval for the radar controlled let down

He was offered a radar monitored let down, he was never identified by the radar, what radar operator would authorise a let down if he did not know where the aircraft was???

He elected a VMC descent, and that was approved. It was approved because by so doing he was taking on his own responsibility for terrain and traffic separation.

hence the clearance to descend maintaining VMC and keep them advised of their altitude

There was no clearance issued, it was an approval and it was approved as stated above, VMC by definition is to maintain own terrain clearance and traffic separation.

megan, It did, but only very briefly. How was this established?

Hempy

1st Jul 2016, 07:56

Beattie v. United States, 690 F. Supp. 1068 (D.D.C. 1988) :: Justia (http://law.justia.com/cases/federal/district-courts/FSupp/690/1068/2359221/)

Conclusion

Upon consideration of all the evidence,[82] the Court finds as a fact that the disaster at Mt. Erebus on November 28, 1979, was caused by a combination of (1) the careless attitude of the New Zealand airline in switching flight plans for Flight 901 as and when it did, without a thorough briefing of the flight crew regarding the switch and its implications, and (2) the careless performance of the crew which did not avail itself of several available fail-safe systems, any one of which would have enabled it to discover in ample time that it was not on a proper course and would have permitted it to alter that course without significant difficulty. The air traffic controllers at McMurdo Station had no reason to suspect that these errors in the most fundamental principles of planning and airmanship had occurred, and that they had profoundly altered what would otherwise have been a safe and uneventful flight. Absent such knowledge, they had no basis for suspecting that Flight 901 was in mortal peril, or for taking extraordinary measures that even the flight crew never requested them to take.

3 Holer

1st Jul 2016, 07:58

prospector, re -read the 4th requirement please (politely).

4. Descent to be coordinated with local radar control as they may have other traffic in the area.

The radar descent was not for terrain avoidance, it was for traffic separation.

901 was advised "no traffic for descent" but to descend in VMC and keep centre advised of altitude. I assume in case traffic became a factor.

The crew complied with the 4th requirement to the letter.

3 Holer

1st Jul 2016, 08:05

The air traffic controllers at McMurdo Station had no reason to suspect that these errors in the most fundamental principles of planning and airmanship had occurred, and that they had profoundly altered what would otherwise have been a safe and uneventful flight. Absent such knowledge, they had no basis for suspecting that Flight 901 was in mortal peril, or for taking extraordinary measures that even the flight crew never requested them to take.

Absolutely Hempy. That is why Mahon and Vette were applauded for being 10 years ahead of their time re: Human Factors. Thanks to their exhaustive investigation, they discovered a toxic safety culture in the Air NZ flight department and administration of the Antarctic sightseeing flights. Collin's and his crew never had a chance.

megan

1st Jul 2016, 14:26

Sorry, cannot answer that, even with theory.Unable to answer what exactly? The fact that other crews did not comply with SOPs? If that is the case, you're being just a little too cute, and you take the position of the gal in your video.It did, but only very briefly.
How was this established?Have no idea how it was established, other than Chippindale said so.

Hempy

1st Jul 2016, 14:41

From the same ruling..

It was entirely reasonable of the air traffic controllers to expect that that was the option Flight 901 would exercise. The air traffic controllers could not possibly assume that the crew, which was proceeding visually, did not have the high terrain in the area, specifically Mt. Erebus, in sight. Alternatively, the controllers could not be expected to assume that the crew would choose to descend below the known elevation of the terrain if it could not see where the flight was going.[56] According to the expert witnesses, a pilot should first fix his position, particularly if he is in uncontrolled airspace, and then, and only then, after he has determined that it is safe, make his descent.[57] This rule holds true whether or not radar assistance is anticipated. The evidence at trial also showed that, for Flight 901 to descend below 16,000 feet while lost would have been contrary to the most basic tenets of good airmanship and stated company policy.

3 Holer

1st Jul 2016, 14:54

......for Flight 901 to descend below 16,000 feet while lost
Why assumed lost? What evidence is there to support such a statement?
According to the expert witnesses, What witnesses?
Speculation and argumentative.

3 Holer

1st Jul 2016, 15:19

Let's take a deep breath and get back on track here. I am not sure we are still debating the Mahon v Chippindale reports on the Erebus disaster.

Hempy, you are quoting text from a court case 9 years after the event. Hindsight is a magnificent thing. Mahon and Vette were ten years ahead of their time in the contribution to Human Factors and the latent error model in their findings of this accident. Is the chronological sequence so accurate to be coincidental? You decide.

prospector, you have drifted a little left of centre (IMHO) with your pizza lady scenario.
Maybe you can explain the relevance, please (politely).

megan

1st Jul 2016, 16:14

Hempy, the report was a good find. I found it interesting that it pointed out that the McMurdo controllers would only be available if they had Deep Freeze aircraft operating. So it was entirely feasible that the sight seeing flights would have no one to talk to. Puts their cloud break procedure in the trash can, and once again points out the lack of planning by the airline.

Hempy

1st Jul 2016, 16:39

Why assumed lost? What evidence is there to support such a statement?

http://www.southpolestation.com/trivia/history/erebuscrashsite1.jpg

prospector

1st Jul 2016, 20:49

Unable to answer what exactly? The fact that other crews did not comply with SOPs? If that is the case, you're being just a little too cute, and you take the position of the gal in your video.

Can we use your Professor Diane Vaughan developed the “Normalisation of Deviance” theory in a different scenario.

I see and hear of many cars going through red traffic lights. I decide to do the same, however I collide with another car going through a green light.

Would Professor Diane Vaughan theory be a credible defence??

Hempy,
Irrefutable evidence

ampan

1st Jul 2016, 20:50

PapaHotel6

1st Jul 2016, 21:57

Someone who doesn't know where they are is "lost" but so to is someone who thinks they know where they are but are wrong. I would venture to suggest that the latter person is the more lost, which describes Captain Collins situation from Cape Hallett into jaws of Lewis Bay on Ross Island. At that point he moved into the former situation, in that he didn't know where he was.
Well, I'm not sure. It's surely unreasonable to condemn someone who has no idea they are lost.

But the question we have in front of us is "was Capt. Collins justified in believing in his original position, to the extent of doing a VMC (putting aside VMC issues for a moment) descent down to 1500'?". The answer is surely no - for all the many reasons already discussed.

I see and hear of many cars going through red traffic lights. I decide to do the same, however I collide with another car going through a green light.

Would Professor Diane Vaughan theory be a credible defence??
According to Megan, yes.

Megan said :

I found it interesting that it pointed out that the McMurdo controllers would only be available if they had Deep Freeze aircraft operating. So it was entirely feasible that the sight seeing flights would have no one to talk to. Puts their cloud break procedure in the trash can, and once again points out the lack of planning by the airline.

Let's say, for arguments sake, that you're right. Let's agree for a moment that Air NZ's cloud break procedure was actually completely unusable and invalid. It doesn't matter - because the flight never got to that point! It's not as if Collins positioned himself for the procedure, briefed his crew, then said "what they hey! There's no-one at home at Mc Murdo!! Those dorks! What are we going to do do now? Have to try and go down VMC through this hole, I guess......". He was offered a radar guided descent. He abandoned that idea, simultaneously it would seem with failure to establish VHF comms and seeing a hole in the cloud. And down he went. Without even cross checking his position off the INS.

As an aside, have a look at this video at around the 7:00 mark. A flight crew in a mountainous area above cloud paying a lot of attention to MSA.

http://www.youtube.com/watch?v=2gnSWCfPF3k

3 Holer

2nd Jul 2016, 03:53

Hempy & prospector

In the early hours of 28 November a navigational coordinate in the flight plan presented at the briefing was changed. The airline’s navigation section believed it was making a minor adjustment to the flight’s longstanding destination point, but a typing error some 14 months earlier meant it had actually shifted this point some 27 nautical miles to the east. Instead of the IFR route taking Flight TE901 over flat sea ice, as Collins and Cassin had been briefed, it would take them directly over Mt Erebus, a 3794-metre-high active volcano. The flight crew were not alerted to the change. On the morning of 28 November they received the adjusted 'correct' flight plan and entered these coordinates into the on board computer.

Trying to introduce false, implied (circumstantial) evidence the crew were lost with an old photo, is mischievous and shows a lack of common decency to the families of the victims. Shameful and very unprofessional.

ampan

2nd Jul 2016, 05:07

The feelings of the families are not relevant. I thought that would have been obvious. It's like referring to Hitler and the Nazis when losing an argument.

The phrase "a navigational co-ordinate in the flight plan presented at the briefing was changed" is debatable, at the very best. We have the audio-tape, clearly stating that the waypoint was at McMurdo Station. We have the flight plan that F/O Cassin used to program the simulator, which also had the waypoint at McMurdo Station. We have the accepted fact that none of the attendees queried the position of the waypoint. And we have them all practising an out-and-back cloud-break procedure from overhead McMurdo Station, not a straight line descent from 27 miles to the west.

Everyone left that briefing under the assumption that the waypoint was at McMurdo Station. It was only Captain Collins private preparatio0ns the night before that led him to believe otherwise.

Hempy

2nd Jul 2016, 06:08

3 Holer,

lost
adjective UK /lɒst/

Not knowing where you are and how to get to a place.

The CVR has several references to the fact that they were uncertain of their exact position. It's also quite obvious that they didn't know how to get where they were going. They crashed into a mountain. How much more 'lost' do you think someone needs to be before you claim they actually were, in fact, lost?

p.s you asked for the evidence....As prospector says, it's irrefutable. If Collins and the rest of his crew knew where they were, they wouldn't have flown into a mountain now, would they?

ampan

2nd Jul 2016, 06:21

This reminds me of Mahon's silly word games about the crew being certain of their position. The more I read that Honourable gentleman's writings, the more convinced I am as to what a stupid blinkered old twit he really was.

Ollie Onion

2nd Jul 2016, 06:48

Of course they were lost, doesn't matter if they knew it or not! The plane flew into a mountain that they didn't know they were going to hit, how more lost can you be?

3 Holer

2nd Jul 2016, 06:51

If Collins and the rest of his crew knew where they were, they wouldn't have flown into a mountain now, would they?
RUBBISH

That is as ridiculous as saying:

I'll blindfold you and if you run straight ahead you will end up in the swimming pool. After the blindfold is placed on the unsuspecting "victim", the swimming pool is replaced with a brick wall.

megan

2nd Jul 2016, 07:46

I see and hear of many cars going through red traffic lights. I decide to do the same, however I collide with another car going through a green light.

Would Professor Diane Vaughan theory be a credible defence??
According to Megan, yes.That was not what I intimated. Neither of you apparently have an understanding of the theory, which encompasses the social aspect of expectations placed on an individual by organisations. Should prospector be driving a B double truck, or such, the pressures placed on him by his employer for an on time delivery may induce the drivers of that company to use the intimidating bulk of their vehicle to run red lights. Not only does it save time stopping at the light, but also working up through the gears accelerating back up to speed. It becomes an instituted practice within the company, until they collect that car coming through on the green.Everyone left that briefing under the assumption that the waypoint was at McMurdo Station. It was only Captain Collins private preparatio0ns the night before that led him to believe otherwise.That is absolute nonsense. You have a thing about the briefing, and everything you've posted in relation to that has been misrepresented. Sorry for the lengthy following, but draw your own conclusions from the evidence, compared to ampans erroneous statements.Two of the three pilots had received the specially devised audio visual, written and simulator route qualification briefing. F/O Lucas had not.

An examination of this briefing revealed certain significant items were not included;

c. The way in which the airline route varied from the normal military route, which followed the reporting points depicted on the RNC, particularly on the leg from Cape Hallett south to McMurdo.

d. Topographical maps for the flight. With the exception of a photostat copy of a small inset enlargement of a map of Ross Island (1:1,000,000), these were not issued to the crew until the day of the flight, and were of a relatively small scale (1:3,000,000 and 1:5,000,000) Although topographical charts for the area were available on the day of the flight the only “charts” of the area below the flight planned track from Cape Hallett to McMurdo available at the initial briefing were:

The passenger information map
(an overprint on a 1:16,000.000 chart)
The RNC chart and
A slide depicting a schematic diagram taken from the rear of a passenger brochure

All of which showed a track proceeding o the true west of Mt Erebus down the McMurdo Sound. While these “charts” were not intended to be used for navigation the track shown was not that to be followed by TE 901. Several members of earlier crews were of the opinion that the inbound track to McMurdo was intended to be on an alignment which was over the sea level ice to a point adjacent to McMurdo but to the west of that base. (The dialogue which accompanied the audio visual briefing referred to the RNC chart when discussing the appropriate flight levels for the flight.)

The strip map of the route from Christchurch to McMurdo issued on the day of the flight also had two tracks printed on it both depicting a passage to the west of Ross Island. A track and distance diagram issued at the route qualification briefing correctly depicted the intended flight plan track from Cape Hallett to the McMurdo TACAN, but this showed no relationship to geographical location or terrain.

The audio visual presentation of the route qualification briefing showed two slides purporting to be of the track between Cape Hallett and the McMurdo TACAN. The first which only showed Cape Adare, 73 miles northwest of the Cape Hallett waypoint, accompanies the statement “We are almost 77° south proceeding from Cape Hallett towards Ross Island at Flight Level 330. Mt Erebus, almost 13000 feet, ahead. McMurdo Station and Scott Base lie 20 miles beyond the mountain in the direction of grid north”. A second slide accompanies the statement “Now approaching Erebus at 16000 feet the minimum sector altitude. In VMC a descent to this minimum altitude up to 50 miles before McMurdo will be found advantageous for viewing”. This slide gave no indication of the relationship of the track to Mt Erebus, as it shows a view of Mt Erebus taken from behind the co-pilot’s seat with the aircraft heading north.

The computer flight plan used at the briefing had been in error for 14 months in that it showed the destination point for McMurdo as two degrees ten minutes of longitude to the west of the intended turning point. This error was not corrected in the computer until the day before the flight. Although it was intended that it be drawn to the attention of the previous crew, immediately prior to their departure this was not done, nor was it mentioned during the preflight dispatch planning for the crew of the accident flight. The crew was shown a copy of the erroneous flight plan with the incorrect co-ordinates at the route qualification briefing but the flight plan issued on the day of the flight was correct.andAs the chief inspector went on to say in a succeeding paragraph, there were provided at these briefings two charts and a slide depicting a schematic diagram which each showed a track proceeding down McMurdo Sound. This was in conflict with a reference in the recorded text of the briefing to the actual latitude and longitude co-ordinates of McMurdo Station as being the destination point of the flight, and in view of the fact that the briefing described a track direct to McMurdo, then these three diagrams were of course, in conflict with the theoretical Cape Hallettto McMurdo track to which the briefing referred.

ln addition to these inadequacies revealed in the report of the chief inspector, there were two other features of the antarctic briefings which were unsatisfactory. In the first place there was no photograph showing pilots a general view of McMurdo Sound and Ross Island as the aircraft approached from the north. This is of particular significance in view ofthe fact that the McMurdo area bears little relationship to what might be expected to be observed from a topographical map of the area. The other
deficiency was that the briefing did not include a topographical map of the area upon which the flight planned track from Cape Hallett to McMurdo had been imposed. Such a map would have indicated to pilots the precise course to which the nav track oi the aircraft would take them.

There were two mistakes in the slides which were shown. One slide purported to show Cape Hallett whereas in fact it was a slide of Cape Adare located 73 miles north·west of the Cape Hallett waypoint. The second slide showed a view of Mt. Erebus and was accompanied by the statement that the aircraft was "Now approaching Erebus at 16,000 feet the minimum sector altitude". However, the photograph of the mountain had been taken from the true south of Mt. Erebus and not from the true north, and the result was that a view of this photograph showed Mt. Erebus over to the left of the direction in which the aircraft was heading. This error accordingly coincided with the McMurdo Sound approach depicted by the three diagrams to which I have previously referred. As to the simulator exercise, this did not give the pilot any view of the terrain to be observed on the flight. It was programmed as if the flight was being made at night time. This is because the airline‘s DC10 flight simulator is only programmed to the night lighting of an aerodrome, and in the case of antarctic briefings the position of the runways at Williams Field were shown in the distance as two intercepting lines of lights. The simulator instruction adequately covered the compass and navigation conversion procedures already referred to. The evidence given by Captain Wilson and by Captain Johnson as to the verbal content of the RCU briefing was not accepted by the majority of the pilots who attended the briefings. Indeed, there was one pilot who said that upon listening to the evidence given before the Commission in relation to the briefing which he had attended, he was led to wonder whether he had been at the same briefing.

The RCU briefing for antarctic flights was primarily inadequate, in my opinion, in that--

(a) The co—ordination of the United States Navy air traffic control system with the proposed overfly was not properly explained.

(b) The pictorial representations showed the observers that the flight path was down McMurdo Sound and these displays would, not unnaturally, take precedence over the spoken words indicating a direct track from Cape Hallett to McMurdo Station and indicating the NDB coordinates as the destination waypoint.

(c] The dangers of flying over uniformly white terrain under an overcast sky were not directly referred to.

(d) The prepared text of the briefing and the constant reference to minimum safe altitudes of 16,000 feet and 6,000 feet were verbally contradicted by Captain Wilson in the 1978 and 1979 flights by indicating to the crews that they were authorised to descend to any altitude approved by the United States Navy Air Traffic Controller, and it is significant to point out that at the time when the chief inspector signed and published his report, he had not been told by Captain Wilson, or by anyone else, that this specific authority was orally given to flight crews during the course of the audio—visual presentation to which I have referred. Captain Wilson admitted this.

[e) Captain Wilson, the supervisor of the RCU briefing procedures, had not flown to McMurdo Sound. He had applied to go on such a flight, so as to improve his knowledge of antarctic conditions, but his application had been declined by Flight Operations Division.

(f] Most important of all, crews were not shown a topographical map with the nav track plotted thereon.