Erebus 25 years on

[Wirraway]

www.stuff.co.nz

Erebus 25 years on
21 November 2004

It was the disaster that rocked a nation. Ruth Laugesen talks to three people whose lives were changed by the Erebus crash.

At 8.20am, a quarter of a century ago next Sunday, 237 passengers and 20 crew fastened their seatbelts for what was supposed to be a very special trip. Flight TE901's sightseeing joyride over Antarctica was due to take 11 hours.

The aircraft never returned.

In a small country, it seemed as if everyone knew, or had connections to, someone who had been on board the jet as it smashed into the side of Mt Erebus.

The crash was only the beginning of the anguish for those most closely bound up in this loss. The remains of 213 bodies were identified, but for the families of a further 44, the pain of loss was made more intense because the remains of their loved ones were never found.

The pain continued as New Zealanders tried to understand what had happened. On one side of what was to become a bitter national debate, air accident chief inspector Ron Chippindale ruled it was pilot error. He said the pilots were flying too low when they had not established where they were. On the other, Commission of Inquiry head Justice Peter Mahon blamed Air New Zealand for a last-minute change to the flight path that took the plane over towering Mt Erebus. It was a change of which the pilots were unaware. Mahon also levelled the charge of an attempted cover-up by the national airline.

Mahon's famous accusation, of "an orchestrated litany of lies", still reverberates down the years. Mahon was rebuked by superior courts, and prime minister Rob Muldoon refused to table the report, but many of the public came to Mahon's defence. Even now, the aviation industry remains sharply divided over the issue.

Erebus 25 years onNext Sunday, Sir Edmund Hillary, who was originally scheduled to be a commentator on that flight, will give a reading at a memorial service in Antarctica.

Here, three people discuss how their lives were changed forever by the Erebus disaster.

The widow

Anne Cassin's husband was Greg Cassin, co-pilot of the Erebus flight. After the crash, Cassin went on to gain her own commercial pilot's licence, becoming a top flight instructor whose lessons included aerobatics. Six years ago she was blinded by a stroke. Now 56 and living in Nelson, she still misses intensely the sensation of flying a plane. Her daughter Maria flies jumbo jets for Air New Zealand.

"I felt disbelief (when I heard), because I was just rung up by a staff member to say that the plane was missing. I just couldn't believe that somebody would do that. I thought it must have been a hoax.

"So I rang up the Air New Zealand office to find out if it really was true. Somebody came on the line to say 'yes, it does appear to be true'. It hadn't been heard from for several hours by then. I (held out hope) for days, because it was days before his body was found. I had this crazy notion that maybe he was in a snow cave somewhere, and still surviving. You sort of try and think up scenarios: maybe he didn't go on that flight for some reason. (It was) still very much hopeful, wishful thinking. I guess I didn't really allow myself to believe it until they rang to say they'd found the body.

"I immediately understood . . . just how many other families would be hurting as well. But you go into survival mode, and it's a sort of numb, horrible feeling. The children were four, nine and 12.

"It's quite unbelievable that it happened; when I look back I still feel quite astounded at what happened. But we just put it behind us. We just live for now, really. You can't live in the past. I've found that life, when these things happen, it makes you turn in another direction, and it's not all bad. You take on a new focus, and concentrate on that, and it gets you through.

"It's amazing how long it goes on for, 25 years later, and there's still talk about it. You realise it's never going to be behind you."

The photographer

Fred Freeman, now 74, was in the Air New Zealand boardroom the night chief executive Morrie Davis told the waiting reporters and photographers that all hope was gone for the missing flight. The Auckland Star photographer's image of the devastated chief executive that night was unforgettable.

"He was absolutely cut in half. He was dreadful. He didn't talk very long. He was gutted.

"I had got the call that night to go to the Air New Zealand building. We stayed there most of the night. The phones in the Air New Zealand office - they were going eyes out. They were getting calls from all around the world.

"Everybody realised this plane had gone with all these people on board, and it was a full plane. And the tension was . . . you could have cut the tension with a knife.

"(Davis) looked to me as though he might have had a few drinks, but that's only a personal thing. He was pretty cut up. Everybody was cut up at the time, because it looked as though there was going to be no show for anybody, and all those people on board.

"You can imagine how touchy it was, because nobody (from Air New Zealand) wanted to say anything. Nobody had any real true facts or figures, or anything, excepting that they had to accept the fact the plane had gone down. It had crashed, and that was it.

"And they couldn't get to it to get any survivors.

"I was shooting with the available light in the room, which wasn't much. So I had the camera on the table so I could hold it steady. He put his hands up to his face as much to say 'bugger off, get out of the place, I've had enough, I've got to find out what's going on'.

"There was just the hush. And then it all closed off and they said, 'righto that's it'. He was cut to pieces. Personally, myself, I felt for the guy at the time. He was going through agony."

The searcher

Hugh Logan, now 51, was working at New Zealand's Scott Base when the DC10 went down. Twenty hours later, he was among the first three to arrive at the crash site. Logan went on to take part in the grim task of recovery of human remains. For two weeks, up to 60 people toiled, gathering what they could from the ice. Logan is now director-general of the Department of Conservation.

"As we came around the corner (in the helicopter) it was just a black smear . . . up the side of the hill. From a distance it looked quite small. But as you got closer to it, you think, no, this is much bigger.

"First of all we had to determine whether anyone had in fact survived. It was very clear to us, more than abundantly clear, that there were absolutely no survivors of that plane, and no one had in fact survived the initial impact at all.

"I'd been involved in alpine search and rescue in Mt Cook in the 1970s, so I'd had to deal with injured and dead people in mountain situations, but not on that scale. The main thing all of us felt was the complete devastation that was there.

"People had different ways and methods of coping with it. I think that many people simply made sure they depersonalised things to the extent they could. Some people distanced themselves from it and some people stepped away from it; they actually were involved and said, 'hang on I'm not sure I like this that much'. And they didn't continue on.

"But you dealt with it as a job to be done. It's how I dealt with it.

"For people back in New Zealand, particularly family and people associated with the crash, for them it was much worse because they couldn't readily identify with what they were having to deal with. Whereas for those at the crash site, it was real."

Erebus Remembered: Flight TE901, a commemorative exhibition at National Archives, Wellington, is on display until May 30 next year.

=========================================

Sun "New Zealand Herald"

What the PM knew about Erebus
21.11.2004
By LEAH HAINES

Prime Minister Robert Muldoon\'s backroom advisers worked to debunk the embarrassingly critical Erebus crash report even before it was released.

The revelations to the Herald on Sunday come on the eve of the 25th anniversary of the Antarctic crash that claimed 257 lives when an Air New Zealand DC10 flew into the slopes of Mt Erebus, on November 28, 1979.

The one-man commission, the late Justice Peter Mahon, was slammed by Muldoon who refused to table his 1981 report which accused Air New Zealand witnesses of participating in an "orchestrated litany of lies" on the witness stand.

An accident report had blamed pilot error - far less damaging to the Government than systems failure at the state-owned airline.

Justice Mahon found a navigation computer had been incorrectly changed so the plane was programmed to fly into the mountain, and that Air New Zealand witnesses had lied to cover up other mistakes that pointed blame at the carrier.

Muldoon responded with venom - the findings were potentially fatal to the Government-owned carrier - while Air New Zealand prepared an appeal against the lying accusations in court.

Nearly 23 years later, Muldoon\'s key advisers reveal officials were getting advice that would counter the report, months before it was released.

The prime ministerial advisory group had been leaked indications of where the Mahon inquiry was going, and hired aviation experts and even met Air New Zealand in a bid to explore their concerns.

"The Prime Minister\'s department in those days tended to work a bit in advance of events," said Muldoon\'s press secretary of the time, Brian Lockstone.

"It was at that point that it was recognised that perhaps there was going to be a report that might have been strong on emotion and perhaps some fixed ideas that might actually miss the greater point."

Pressure and conflicting opinions came from all sides, including multi-national companies who built the plane, he said.

The advisory group received a draft of the report reviewed by two pilots with polar and whiteout flying experience, working independently of each other.

"They came up with some very interesting conclusions that basically said that poor old Peter Mahon had got it wrong," he said.

Former head of the department Gerald Hensley said the advisers felt there were problems with Mahon\'s logic and told Muldoon who said they should have a closer look.

The consulted pilots argued that only one person flew the aircraft "and that\'s the pilot," he said.

"From all that we did have some differences with Justice Mahon\'s argument that the plane, in his phrase I think, \'was programmed to fly into the mountain from the moment it left [New Zealand]\'."

Justice Mahon\'s widow Margarita was horrified Air New Zealand were in on the advisory group meetings.

"Muldoon wanted to make Air New Zealand into the seventh wonder of the world. Nothing, nothing was going to damage it. That was my understanding. They had no right to be there. No one should have had any knowledge of what was in that report at all."

- THE HERALD ON SUNDAY

============================================

[ZK-NSJ]

i think my grantparents are having a small get together with other family members to remember my great great aunty who died in the crash

[crocodile redundee]

Food for thought- That, of the crew, only one expressed extreme angst verbally several times in those last minutes ,that the aircraft wasnt where it was supposed to be , & that was the Flight Engineer !!!!!!!!! R.I.P. indeed !!!!!

[Taildragger67]

crocodile redundee

Maybe not - take a look at Peter Mahon's book, Verdict on Erebus.

The official CVR transcript was made by the NTSB in Washington, but Mahon had the tape analysed by the AAIB at Farnborough, which apparently had more advanced equipment at the time. Some of the words ascribed in Washington were interpreted differently in Farnborough.

Some words also appear to be misleading. For example, the (official) Washington transcript has a reference to a 'Bert', apparently made by a flight crew member, yet according to Mahon, no-one has been able to trace a 'Bert' on the flight deck.

One thing we do know from the CVR is, that the GPWS went off when the DC10 crossed the Ross Island cliffs and the engines hadn't had time to spool-up after Capt. Collins called for go-round power, before impact.

[Eastwest Loco]

My then office had a passenger onboard the DC10.

TAA Burnie had booked the wife of the Port of Burnie Authority on the ill fated 3 holer. An anniversary present.

It was devastating for all of us, but not nearly as devestating as for the relatives.

I just find it hard to believe it has been 25 years, and what has gone in between.

Having read in depth the bad press the DC10 gained over the years, I was determined to fly on one before they were relegated to the wilds of Africa and South America. I am pleased to say I did, with Garuda.

If any aeroplane could have got them out of the corner management put them in, I am sure they were in the right one.

Solid, reliable and powerful.

Please, where have those 25 years gone?

God rest all the souls onboard.

Best all

EWL

[amos2]

Go back in history croc and I think you will find that the F/O was showing some concern before the big bang also!

[Samuel]

I second that comment on robroy; a cretin if ever there was one.:ok:

RIP "Brick"Lucas, ex-RNZAF Nav, who in all probability expressed the "I don't like it" comment.

[gaunty]

Eastwest Loco

DC10 :ok:

Spent many a relaxed hour with a Chivas in one hand on those very fine, quiet and comfortable aircraft.

Typical Donald Douglas, built like the proverbial and somehow felt like it.

Every pilot I know who has flown (as distinct from operated :rolleyes) them loved them dearly.

A true pilots aircraft and a passengers delight, well in J anyway.

As for Erebus, lessons learnt culprits exposed and deepest sympathies to the crew and pax.

It might be safe to speculate now on what would have been the consequences if they had survived the accident and how prepared are we for this sort of recovery anywhere in this form of wilderness zillions of miles from anywhere.:{

[HGW]

A very hard time 25 years ago. I was working in NZ at the time and knew someone on the plane. A whole nation was in shock.

[TAY 611]

I think that all Kiwi's, over the age of about 35, can remember where they were and what they were doing when the news of the lost antarctic DC10 first went to air. I was just embarking on a flying career at the time and remember it well. I also knew a passenger on board that aircraft as I suspect many kiwis did. Interesting to note how accident investigations have changed in the past 25 years with Mahon's systemic approach during the commision, appearing outrageous to some back then, being the accepted norm now. A mention of Gordon Vette is worthy here as he was very involved with Justice Mahons findings. Both Mahon and Vette were clearly well ahead of their time in the process of accident investigation.
The now famous "Orhestrated Litany of Lies" has to be one of the bravest accusations in 20th century aviation.

[prospector]

TAY 611,
I would like to offer a different view than that you put in your post.

Gordon Vette made criticism of the Accident report put forward by The Chief Inspector of Air Accidents at the time, Mr R Chippendale, based on the supposed lack of experience of Mr Chippendale in any dealings with "Large Civil Airliners."
Compare Mr Chippendales aeronautical experience with that of Mr Justice Mahons and who had the lack of experience in the aeronautical field is glaringly obvious.

The statement "Orchestrated litany of lies" has been shot down by so many people, including Mahons peers, his superiors, and up to the Privy Council, it is hard to understand why it is still quoted.

At this point in time anybody who has read and digested all the many words written about this accident would have formed there own opinions as to the cause and no great purpose is served going into all the detail again.

I would like to point out that there are many who do not agree with the findings of Mr Mahon or with the case put forward by Mr Vette.

Prospector

[ZK-NSN]

HGW- Well said mate. Theres a time and a place..This is neither.

[Kaptin M]

At this point in time anybody who has read and digested all the many words written about this accident would have formed there own opinions as to the cause The cause of the crash was the DC10 flying into Mt Erebus!
The REASON they flew into it was because an Air N.Z. ground personnel altered the (Lat & Long) co-ordinates of the previously established route - that would have taken the flight over McMurdo Sound - to take them direct to Mount Erebus but he didn't TELL anyone :mad:

The subsequent attempt to cover up his actions, by shredding all relevant documentation, and Ian Gemmell's actions of secretly removing the flight plan from the crash site, and his "evasiveness" in court, when questioned as to whether he had recovered and removed the same from the flight deck of the crashed aircraft..."There was no flight deck as such"...., and Air N.Z.'s denial that they promoted the flight on the low level flyover around Erebus, certainly showed the company's actions to be "orchestrated" and deceitful, in trying to move the blame from themselves, and place it squarely on the flight crew.

Indeed, for such a tiny country, with a population of only just over a couple of million at that time, it had a devastating emotional effect.

[prospector]

Kaptin M,
You would appear to belong to the school that supports Mahons statement that the aircraft "was programmed to fly into the mountain from the time it left (NZ)".

If that was the case why bother having a crew in the sharp end??

Gordon Vettes investigations attempted to show why they never saw Erebus, not why they were down at the altitude they were.

Bloodshot VFR at 1500ft, 260 kts, in an area that neither of the drivers had ever been to, and the CVR recording of uncertainty as to position, this was the fault of the company??

As stated previously, bringing up bits of the enquiry in isolation means nothing, opinions have been formed and held for many years now.

Prospector

[Kaptin M]

Bloodshot VFR at 1500ft, 260 kts, in an area that neither of the drivers had ever been to, and the CVR recording of uncertainty as to position.. Ever heard of "whiteout", prospector - the visual illusion created in certain landscapes, where one is led into believing that he is visual with an indiscernible horizon, created by the overhead (lowering) cloud base merging with the (rising) terrain?this was the fault of the company??The idiot who altered the co-ordinates - without telling anyone - placed the crew in an area where they believed they were over flat terrain.
They were at that altitude because Air New Zealand PROMOTED these flights - via brochures - as "once in a lifetime" opportunities to fly at low level in the vicinity of Erebus.

On this particular flight, an non-pilot employee of Air New Zealand DID programme the aircraft to fly into the mountain, as a result of an unfortunate chain of events.

The ensuing attempt by the company to "cover up" their liability is what stinks!!

[prospector]

Kaptin M,
It would help if you read all the available reports and findings before bursting into print.

Whiteout, as generally understood, had no direct bearing on the incident. Captain Vette spent a great deal of time to show that it was sector whiteout that hid Erebus and therefor wrote the final chapter of this sorry saga. This particular phenomenem was not well understood prior to the accident.

At the altitudes approved for the operation whiteout would not have been a problem. There were flights that went below these altitudes, that is a fact, but they did not hit Erebus, or anything else, this flight would not have either if the approved let down procedure had been complied with.



Prospector

[Kaptin M]

prospector, try opening your eyes, reading what is written, and engaging brain before hitting the “submit” button.”whiteout”…..the visual illusion created in certain landscapes, where one is led into believing that he is visual with an indiscernible horizon, created by the overhead (lowering) cloud base merging with the (rising) terrain There were flights that went below these altitudes, that is a fact, but they did not hit Erebus, or anything else.. Of course they didn’t – because the co-ordinates used kept the aircraft well AWAY from Erebus (about 25 nm from memory).

On this particular flight, the co-ordinates were (secretly) changed, thus aiming the aircraft DIRECTLY into the mountain!
The crew were not advised of the altered course by the company, and the conditions (which appeared to be VFR in Antarctica), provided the crew no reason to suspect that they had been set on a collision course with Mount Erebus.

You consistent defence of Air New Zealand, in light of ALL the evidence that came out PROVING them culpable – and attempting to cheat and lie their way out of it – leads me to believe your “head in the sand” attitude is as a result of your close personal association with culprits involved this tragedy.

You are attempting to defend the indefencible, prospector!!

[prospector]

Kaptin M,
Let us just deal with the known facts, there was one approved let down procedure and it was as follows taken direct from Company paper.

Delete all reference in briefing dated 23/10/709. Note that the only let-down procedure available is VMC below FL160(16000ft) to 6000ft 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 degree Grid to 270 degree Grid from McMurdo Field, within 20 nm of TACAN CH 29.
4. Descent to be coordinated with local radar control as they may have other traffic in the area.

You will note that this is the ONLY let down procedure approved by the Company and the CAA. The crew was aware of this requirement as a copy of the memorandum was recovered from the cockpit wreckage.

No doubt your study of the accident will have appraised you of the fact that at no time was a DME lockon achieved, and it is possible, but only possible, that the radar may have got one or two returns.

As the descent was commenced long before any of the compulsory requirements were established, the fact that the waypoint was changed was sloppy operating granted, but was not the cause of the accident.

The weather at McMurdo was well below the minima required for the company approved letdown procedure, this being established then the alternative flight plan should surely have been adopted rather then improvising there own letdown procedure. The choice was not theirs to make, there was only one Company and CAA approved letdown.

One would think that you placed more importance on Company publicity blurbs on their brochures than on standing orders. If the weather was not suitable for the letdown at McMurdo, and it was not, the passengers were well briefed that an alternative would be required.

With your obviously limited knowledge of this incident you are taking a lot upon yourself to call people derogatory names. Check on the facts and see how many times that last waypoint had been changed, and for what reasons.

Prospector

[henry crun]

Further to the points under discussion, an article in todays Dominion Post about the accident quotes the conversation that a Ted Robinson (deputy leader, Scott Base) had with Jim Collins.

Robinson, was at the time, sitting in the radio room doing routine checks with field parties when Collins called for a chat and a weather report.

Quote "Collins made contact and I informed him of the weather conditions, how it was a complete whiteout". He, Robinson, told Collins that it would be unwise to come to McMurdo as passengers wouldn't see anything.

He suggested that Collins fly over the Dry Valleys where the weather was clear.
Robinson also told Collins that a work party on the sea ice some 64 kms from Scott base and at Vanda Station had clear conditions.

Shortly after Collins accepted that information he changed frequency to McMurdo station and Robinson did not speak with him again.
Robinson was never called to give evidence at the enquiry.

[Rogeramjet181]

For such a sacrifice made by the many and the lessons learned, may it never happen again, rest in peace all.

[Casper]

Silberfuchs,

Thank you for a most informed comment on the case. IMHO, Justice Mahon displayed an extraordinary degree of intelligence (for the legal profession) in identifying not only the cause of the disaster but the attempt by ANZ to "cover-up."

The fact that the homes of both pilots were broken into during preparation of the Royal Commission remains shameful. So far as I am led to believe, Justice Mahon's appeal to the Privy Council was dis-allowed on legal technicalities only.

Is it also true, that the judiciary of the Appeals Court in NZ that ruled against Justice Mahon's findings included members who had vested interested in Air NZ? That is important! (Ruling 5-3??)

[Pharknose]

Silberfuchs you old fox I totally agree..

In the last 25 years we have been given the James Reason "Swiss Cheese" model along with the practice and theory of systemc analysis and error chains etc that support Mahon and Vette's assertions and make Chippendales investgation appear absurd by todays standards. Chippendale was either unskilled and ignorant in accident investigation or was under direction from the Muldoon Government via ANZ. I am sure there are still a few out there that can't lie straight in bed knowing that they contributed, comitted purgery and covered up for ANZ, and thus Muldoon.

[prospector]

One last contribution, as stated earlier no one will change their views at this stage, but some obviously have not perused all that was published regarding this accident.

From Captain Derek Ellis who has been Concorde Capt, 747 Capt and as BALPA representative involved in many airline incidents and accidents. He covers many points but the following is very relevant.

"The effect of reading Gordon Vette's book, which is dedicated to supporting the views of the Commissioner, has in fact been to convince me that the findings of the New Zealand Office of Air Accidents Investigation are infinitely more realistic."

There would be few people more qualified and experienced than Capt Ellis in this field to offer an opinion.

Then we go to the findings of the Privy Council;
In their judgememnt, delivered on 20 Oct 1983, the five Law Lords of the Privy Council dismissed the commissioners appeal and uphel the decision of the Court of Appeal decision,which set aside the costs order against the airline, on the grounds that Mahon had committed clear breaches of natural justice. They demolished his case item by item, including Exhibit 164 which they said could not "be understood by any experienced pilot to be intended to be used for the purposes of navigation", and went even further, saying there was no clear proof on which to base a finding that a plan of deception, led by the company's chief executive, had ever existed.

And that is what has been found by probably one of the most experienced Pilot's in the world, and by the top British legal court.

Can anyone with views to the contrary match these qualifications and experience?? or have been supplied with more information on which to base their views?


Prospector

[The_Cutest_of_Borg]

Macarthur Job's "Air Disaster" series deals with this accident and I would recommend it to anyone wanting to find out more.

In it, there is a sequence of photos shot from a RNZAF Iroquois which was carrying Justice Mahon as they retraced the flight path of the DC-10. By some uncanny quirk, a sector whiteout formed just as the chopper approached Erebus, completely obscuring the mountain and providing an extraodinary illustration of the phenomena.

It is quite easy to see from the photos how the crew thought they were flying in VMC conditions with unlimited visibility.

25 years on, I am not sure if the blame game is appropriate. Maybe the educational lessons for us all are a more valid aspect to take on.

[Kaptin M]

To clarify sector whiteout, the following is from an aviation safety newsletter:-

Whiteout
Whiteout is a snow related phenomenon that can prove exceedingly serious. There are two types of whiteout: one caused by blowing snow, the other by lack of definition and texture. Both can cause loss of orientation.

Blowing Snow
This phenomenon usually occurs on or close to the ground in otherwise good weather, when snow on the ground gets blown either by the wind or by the propeller or engine blast. Suddenly, you find yourself in IFR conditions, unable to see very much, but usually in a VFR frame of mind. The sudden and unexpected transition can catch you unaware. Helicopter pilots have to be particularly careful about the blowing snow phenomenon.

Sector Whiteout
The second type, known as sector whiteout, is much more insidious than the first, because it can occur in VFR weather with no blowing snow. Sector whiteout happens under a low to medium overcast in snow-covered areas with featureless terrain. When the sun is in a certain position, its rays are reflected back and forth between the surface and the overcast and cause all texture on the ground to disappear, with no discernible distinction between the ground and the clouds. Because our minds are programmed to observe a line between ground and sky, any slight shadow can cause us to believe it is the horizon.

This type of whiteout was one of the major contributing causes of the accident where a DC-10 flew straight into Mount Erebus in the Antarctic though visibility was 50 miles. The particular cloud that day, combined with the position of the sun, caused the mountain slopes to merge visually with the overcast. The crew, having no visual cues from the ground, did not realize the terrain was rising.

btw, prospector, I don`t see the relevance of Derek Ellis` experience as a Concorde pilot to this subject :confused:

[prospector]

Kaptin M,
I quite believe that you could not see the relevance, probably/possibily because you only use one eye.

Prospector

[Wirraway]

Mon "Dominion Post"

http://www.stuff.co.nz/inl/common/imageViewer/0,1445,171205,00.jpg
SNOW SORROW: Buried for years under snow, a section of the fuselage of the DC10 that crashed into Mt Erebus has re-emerged just as New Zealand marks the 25th anniversary of the tragedy.

Erubus
TIM PANKHURST/Dominion Post

Remnants of the crashed DC10 on Mt Erebus have emerged from the Antarctic snow and ice as New Zealand remembers its worst peacetime tragedy.

A party that flew to the crash site for a 25th anniversary memorial service yesterday morning was stunned to see a section of the fuselage with the letter "a" and the Air New Zealand colours clearly visible.

A jet engine and orange cargo netting lay further up the slope.

The wreckage has not been seen for years but a light snow year and an unusually warm spring have combined to reveal a stark reminder of the tragic end of flight TE901, with the loss of all 257 people aboard.

On a clear, relatively mild day of

- 6 degrees celsius, those present could only ask again: How could this have happened?

The jet, flying on the wrong co-ordinates and in whiteout conditions, struck Erebus just 500 metres above sea level.

An enormous iceberg is now lodged below the crash site and the open sea is far on the horizon.

In a simple, poignant ceremony yesterday, water from Mt Cook/Aoraki, gifted by Ngai Tahu, was sprinkled at a memorial cross on a bare rocky rise one kilometre above the speck of wreckage.

The Very Rev Peter Beck, Dean of Christchurch, said the water was a symbol of blessing and of love.

He donned a white robe – an alb – and a purple stole over thermal survival clothing to conduct the short ceremony.

His mukluk snow boots peeped from beneath the robe as he prayed.

Three wreaths were laid in this place of unparalleled solitude and grandeur, where there is no sound but the wind.

Foreign Affairs Minister Phil Goff represented the Government; chairman Paul Hargreaves, Antarctica NZ, and Scott Base services manager Major Graeme Tod stood in for Air New Zealand.

As well as 200 New Zealanders, citizens of the United States, Japan, Britain, Australia, Canada, Switzerland and France died in the crash.

The party returned by helicopter from Erebus across the frozen sea ice and Ross Ice Shelf to Scott Base for a public ceremony that included Americans from nearby McMurdo Base. The half-hour remembrance included hymns and readings, a specially commissioned poem by Bill Manhire, read by Sir Edmund Hillary, and music composed by Christopher Cree Brown.

The ceremony was moved inside to the base mess after the skies clouded and the temperature dropped to - 12.

Dave Bresnahan, National Science Foundation representative at McMurdo both now and at the time of the crash, spoke movingly, his voice breaking, of the frustration of not knowing what had happened.

"We, just like those in New Zealand, waited and waited and waited. All afternoon.

"Shortly after midnight we got personnel to the site and learnt that no one survived the impact. I can't express how that felt.

"I clearly remember walking back from our control centre back to my quarters about 2 o'clock in the morning.

"It was dead quiet. No wind. Very calm. People all over McMurdo were hanging out the windows, looking out the doors, watching me walk across. Not a word was spoken. Everyone knew."

Sir Ed, who was due to be on the flight as commentator but was replaced by climbing and polar companion Peter Mulgrew, said he lost his best friend that day.

Mr Goff said time and nature had healed the scars on the mountain but those who lost loved ones would be grieving on the anniversary.

He told The Dominion Post it was quite possible the truth of what happened lay somewhere between the view of Chief Inspector of Air Accidents Ron Chippindale – that the pilots erred – and that of royal commissioner Justice Mahon, who blamed Air New Zealand's "predetermined plan of deception" and "orchestrated litany of lies".

"Most certainly the co-ordinates were wrongly programmed; the pilots were not advised of that.

"Other measures ought perhaps to have been taken by the crew at the time when they were uncertain of their position."

But the debate at this point was less important than simply to remember the tragedy and the lives lost.

"Our hearts go out not only to those who had friends who were passengers but to the families of the crew, who have suffered a great deal."

At 11.49am (Antarctic time) – the moment of impact – people moved outside Scott Base and stood, heads bowed, in a bitter wind before the New Zealand flag flying at half mast.

In Auckland, about 1000 people, including Governor-General Dame Silvia Cartwright, attended a service at Holy Trinity Cathedral, the main New Zealand commemoration.

Dame Silvia said it seemed everyone in New Zealand knew of someone who was on the flight.

Bottles of water from snow scooped from Mt Erebus were brought to New Zealand for sprinkling at services yesterday at all seven Anglican cathedrals.

===========================================

[outofsynch]

It may be interesting to see what is visible in Jan 2006 !!!

Just so so so sad that we all learnt such lessons at such huge cost.

There is no point in arguing who is right. No one was, totally, and never will be.

[Nuckinfuts]

Did anyone ever see the real documentary that was made after the Erebus accident? There was a 'docu-drama' filmed with actors playing the characters roles which has been shown on TV a few times, but before that was made, I saw a documentary (4 corners - maybe) that showed actual video footage of the real people giving evidence in court in front of Justice Mahon.

When watching that documentary, (and I honestly have no agenda here) it seemed obvious to me, that many of the Air New Zealand personnel were lying on the witness stand. When Justice Mahon made the ‘orchestrated litany of lies’ statement, as a viewer I just ‘knew’ he was correct.

[compressor stall]

KM and others,

My understanding of the Sector whiteout phenomenon goes a little further than just the sun angle.

One form of this white out occurs during high sun angles and a layer of (higher) cloud.

Those wavelengths of light not filtered out during the light's passage through the cloud layer are able to be refelcted from the (white) ground almost in their entirety. (Normally only a percentage of light is reflected by the snow). The upshot of that is that sky and ground merge into one with obvious consequences.

[prospector]

Pharknose,
Your comments re Ron Chippendale are far from the truth, it would really help if you did a bit of research on these people before printing such garbage. I have taken the following from "New Zealand tragedies,Aviation" compiled by John King.

Ron Chippendale was the first witness to take the stand when the hearing began in an Auckland office building on 7 July 1980.

But while Mahon praised his witness for being a model witness, composed, impertuble and sure of his position, he belittled the capabilities of both the Chief Inspector and his staff. None of them, he said had ever been jet pilots, etc etc

The commissioners assessment of his first witness ignored Chippendales considerable experience as a flight instructor and transport pilot in the RNZAF.He had been formally involved in military flight safety and accident investigation for several years before being seconded to similar duties in civil aviation, and his standing in the world community is such that as someone scrupulously fair and independant, he has been asked to help investigate some accidents of a particularly delicate political nature. (Recently, for instance, he was appointed to the five strong United Nations team to investigate the loss of the Korean Airlines Boeing 747 airliner, Flight KAL007, shot down by a Soviet fighter near the Island of Sakhalin in 1983.)

Credentials far from the garbage you have printed.

Prospector

[WITCH]

At the 2004 meeting of The International Society of Air Safety Investigators (ISASI) held on the Gold Coast of Australia, Ron Chippendale was the recipient of the coveted Lederer Award. The award is conferred by ISASI to outstanding lifetime contributions in the field of aircraft accident investigation and prevention.

ISASI noted that one of Chippendale's most illustrious investigations was the 1979 crash of the ANZ DC10. "As Investigator in Charge of the accident his work on that case has been described as nothing short of brilliant, gaining international attention and respect. With a very small team, he managed an investigation that is said to be New Zealand's equivalent of TWA800. The investigation was conducted in a very difficult environment, both politically and culturally. Political pressures challenged his findings, but he survived, steadfastly expressing himself and standing by his principles on behalf of safety".

[Kaptin M]

Sector whiteout (as opposed to whiteout caused by increasing intensity of snow fall, and corresponding visibility to whiteout conditions) is probably something many of you may have experienced, but may not have realised it at the time eg. driving on a cloudy/misty day (or night) and ascending a hill or mountain - moreso is the effect noticeable ...or less obvious, if the ground is snow/sand covered.
Several years ago, driving to Mt Mackinley outside Anchorage, we in the car experienced this phenomenom - the horizon appeared slightly obscured and (slightly) indistinct, but nonetheless there, with the road disappearing hazily into it, and as we were still able to see the flat, snow covered fields on either side it appeared that we would continue our journey under the overcast.
As the car continued its ascent, it was obvious that we were slowly entering into the base of the cloud, and visibility dramatically reducing.

It appears to me, prospector, that your ONLY knowledge of this accident wrt airline and flying operations, has been gained through books, and is thus extremely limited.
You appear to me, to be devoid of any ACTUAL commercial, operational flying experience, and the ability of crews to SAFELY carry out a visual descent, without completing a full instrument approach.

Capt Collins would have been quite "legal" in descending to the enroute MEA, or the MSA, and then continuing further down if visual contact with the terrain had been made.
From the reports I have read, I believe that that was indeed the case, however, due to the undulating, featureless nature of the Antarctic terrain, a positive "fix" would have been difficult to confirm.

But making it IMPOSSIBLE, was the fact that the final co-ordinates had been changed, and the position of the aircraft was not where the crew were expecting it to be, from the briefings they had received.

Your half-smart, 1-line quip from an earlier post still leaves my question of why Derek`s Concorde experience is relevant, unanswered (yes, I know the gentleman - I flew with him in SQ (747).....and Ian Gemmel during his time at Ansett New Zealand[737]).

[Desert Dingo]

Prospector:
Ron Chippendale may have great credentials and produced a magnificent report, but I think that he got it wrong
The probable cause of the accident was the decision of the captain to continue the flight at low level towards an area of poor surface and horizon definition when the crew were not certain of their position, and the subsequent inability to detect the rising terrain which intercepted the aircraft’s flight path.
Captain's decision? Pilot error? Pigs a*se!

It seems pretty obvious to me after reading the reports, as you so kindly instruct us to do, that the crew knew EXACTLY where they were – they were flying down the middle of McMurdo sound AS PLANNED because
a) They were ON TRACK according to their INS and
b) they were MAINTAINING VMC and could see the cliffs of the shoreline in the distance on either side and the broad flat expanse of snow and ice in front of them.
c) CVR: “Where is Erebus in relation to us at the moment?” “Left, about 20 or 25 miles…about 11 o’clock.”


However, some six hours before departure the coordinates of the destination waypoint were changed by ANZ navigation section and
MCMDO MCMURDO 7753.0S16448.0E 188.9 (the track) became
MCMDO MCMURDO 7752.7S16658.0E 188.5
THE CREW WERE NOT INFORMED OF THIS CHANGE and this was fed into the nav system. Chippendale did not seem to think this was significant. !

So, in actual fact, the crew were 27 miles to the east of where they (and McMurdo ATC) thought they were. What they took to be the cliffs of the shoreline of McMurdo sound were actually the cliffs of the shoreline of Lewis Bay. Mt Erebus was in front of them, but invisible in the sector whiteout. They reacted within 5 seconds of the GPWS going off, but could not outclimb the slope.

Prospector is a bit selective in his memory too
Gordon Vettes investigations attempted to show why they never saw Erebus, not why they were down at the altitude they were.
They were down at that altitude because it was legal. (Regulation 28 of the New Zealand Civil Aviation Regulations) The 6000/20 was a COMPANY sector safe altitude used in the application for route approval. It had not been complied with by any of the flights in the previous 2 years. Flying at low level had the tacit approval of the company and featured in many publications including their own magazine. The air traffic controllers at McMurdo had never been advised of this company requirement. They were well known to be happy to issue a clearance to descend in VMC to an aircraft tracking down the middle of McMurdo sound, as this was the inbound RNC route used by the military traffic and designed to keep clear of high terrain.
Bloodshot VFR at 1500ft, 260 kts, in an area that neither of the drivers had ever been to, and the CVR recording of uncertainty as to position, this was the fault of the company??
CVR recording of uncertainty as to position??. Crap. They had re-engaged NAV tracking after the descent orbits. They were certain of their position. The only problem was that they were wrong.

CVR extracts: (Air Disaster Vol2 - Macarthur Job)
00:45:00z “Now at 6000, descending to 2000. VMC
00:46:39z “Where is Erebus in relation to us at the moment?” “Left, about 20 or 25 miles…about 11 o’clock.”
00:47:43z “Might have to drop down to 1500 feet here, I think”
00:48:46z “Actually, these conditions don’t look very good at all.”
00:49:24z “I don’t like this.”
00:49:30z “We’re 26 miles north. We’ll have to climb out of this.
00:49:40z GPWS
00:49:49z “Go-around power please”
00:49:50z Impact

It seems very convenient for the airline that the document recovered from the wreckage referred to the company sector altitude which was not complied with. Strange that the briefing documents showing the original track down McMurdo sound were not recovered, although Capt Collins family knew he had plotted the track himself on an old school atlas for his own information. A company representative went to the home of F/O Cassin the day after the accident and recovered his briefing documents and they were (surprise!) never seen again. Later investigation just happened to reveal that all briefing charts showed a track down McMurdo Sound to the west of Mt. Erbus.
On January1 1980 the CEO Mr Davis denied reports that the destination coordinates had been changed and the crew not told (a lie) and asserted that when the aircraft left Auckland the correct coordinates had been in the computer system of the aircraft. (true, but…)

The Royal Commission report said
In my opinion… 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. 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.

The part of Justice Mahon's report that will forever be remembered despite protestations of airline innocence will beThe palpably false sections of evidence which I heard could not have been the result of mistake, or faulty recollection. They originated, I am compelled to say, in a predetermined plan of deception. They were very clearly part of an attempt to conceal a series of disasterous administrative blunders and so, in regard to the particular items of evidence to which I have referred, I am forced reluctantly to say that I had to listen to an orchestrated litany of lies.

Justice Mahon’s report was later overturned, which was very nice for the government owned airline. But as they say, you can’t beat city hall. The New Zealand government must have been kicking itself for breaking a fundamental political rule: Never have an inquiry if you cannot determine the outcome in advance as it is so difficult and embarrassing to have to get things reversed.

[prospector]

Kaptin M,
We have been down this road before, your assumptions as usual are pathetic, by the look of your photo in the Hanmer Springs thread I would have had my first 5000 hours up before you got out of short pants.

However I will try once more, you will no doubt be aware that the RNZAF and the USAF require, from memory, some twenty hours of flight in Antarctic conditions before being let loose as P1. The Air NZ captains did not have the benefit of this training, that is why the descent restrictions were so restrictive.
There was never any requirement for the flight to ever contemplate landing on the ice, therefor, if the flight was not taken below 6000ft there would be no problem with whiteout. The Company standing order for descent is as already posted, you will note that descent from MSA, FL160, which was derived from the height of Mt Erebus, plus 2000ft buffer, had to meet the required conditions to even go to 6,000ft. 6000ft was the minimum descent altitude approved by NZCAA for these flights.

If this descent had of been Safely carried out, and it would have been if it was carried out in the manner approved by both the company and the NZCAA and as was known to the crew as a mandatory requirement, then this discussion would not be taking place.

The MSA was calculated using the height of Erebus as the first flights were in fact routed directly over this mountain.

Perhaps if you were to take the time to read the post by WITCH you may appreciate the standing of Mr Chippendale in the arena of aircraft accident investigation, and the weight his peers have put on his findings on this accident.

Capt Ellis, his qualifications were mentioned to show those who do not know him, that he had risen to the top of his profession, and that his views would therefor carry considerable weight.

Perhaps seeing that you obviously disagree with these highly qualified and experienced people you will post your pedigree so we can all judge who would have the most educated viewpoint??????

Desert Dingo,
You got it in one,
"The only problem was that they were wrong"

Prospector

[Desert Dingo]

Attaboy Prospector... Keep trying. You have almost got it.
Desert Dingo,
You got it in one,
"The only problem was that they were wrong"
And they were wrong because ......??

[Douglas Mcdonnell]

A sad day indeed.

DM

[Uncommon Sense]

The debate about Chippendale / Mahon / The Privvy Council Appeal / Morris has been going on for 25 years - you will not resolve it on this thread. Nobody is probably going to definitively decide it.

Anyway wasn't the point of this thread to just agree that whatever happened, and whoever was responsible and with whatever proportion, the event was an absolute tragedy - especially to a country of it's size, and one that was very close knit?

Family and friends of mine are often surprised at how, like other avaition people, I can dispassionately look at accident reports and photographs and seek information out of them about what went wrong and why. But when I see the photos of Erebus, I still get a shiver up my spine - it is the difference of association I guess, remember what an absolute tragedy it was for NZ and the effect on the psyche of the whole country at the time. It sounds melodramatic, but anyone who lived there at the time I am sure will attest to the enormity of it at the time.

My father worked for the company in flight ops and was working at Mangere that night - we watched the newsreader on NZTV (Dougal Stevenson was it?) reading the fateful newsflash. Living in the western hills of Auckland overlooking the Manakau we were surrounded by ANZ families and it was a tough couple of months leading up to Christmas - as they say everybody in NZ knew someone connected to Erebus - but around our neck of the woods everybody seemed to know a few.

My fathers first story of the night after getting home was the embarassment of seeing the MD Davis stumbling down the escalators at the airport clearly drunk whilst relatives of the families looked on - it was not ANZ's finest hour with respect to PR. As I recall they had just started up their 'Nobody does it Better' advertising campaign, which was quickly ditched. The PR campaign got worse when the homes of the operating crew were broken in to and documents removed.

The only comfort I take from the whole tragedy is that for the occupants of ZK-NZP the end looked mercifully swift.

The pain of the families , including around where I lived, was unneccessarily drawn out, and continues to be today, by stupid politics.

It is said that NZ grew up that day - more is the pity. It was to grow up further in the following couple of years witnessing the mire of political manipulation.

[Pharknose]

Prospector
Just because someone was a Concorde Captain with British Airways it doesn't mean that we have to grant them much authority on a New Zealand aircraft accident in Antarctica. I have no doubt that Chippendale was brilliant in the field or in the technical aspects of investigation, however history has shown us, that his final conclusion in this case, was somewhat pointed in one direction and failed to include or place importance on a lot of the subsequent findings of Mahon and Vette. Mahon was a legal person not predisposed by aviation culture and Vette was an Air New Zealand DC 10 Captain who knew the company and industry well. They both appear to have taken a more systemic approach when trying to establish the cause of this accident and not without personal and professional peril, offered conclusions, along with Mahons famous statement on what he found to be a cover up that rankled right through to the Prime Minister of the time. The arguement that Chippendale was a "Nuts and Bolts" man incapable of expanding into a bigger picture or that he had been influenced from above will probably rage for another 25 yrs. Would his report have had the same conclusion if the crew had survived? Prospector why can't you see that the crew contributed along with the company and also a whole host of other factors resulting in this accident? To assert that the pilot screwed up, end of story, no one else at fault, would indicate that you are most likely well over the hill or have some sort of other personal interest in the outcome. :}

[prospector]

Pharknose,
No doubt you will have noted that in my original post I stated that people had made there minds up long ago as to the cause. One either went along with the findings of Mahon or Chippendale. Mahon was a judge who never had any aeronautical experience and whose findings were overturned by an appeal court and the Privy Council.

Chippendale was a very experienced pilot, and accident investigator, agreeing with his findings were a number of highly qualified aviation experienced people, including Capt Ellis.

What has not been mentioned thus far is the findings of Judge Harold H. Greene of the US District Court in Washington DC when an attempt was made to sue the United States Government for alledged failure of the US Navy air traffic controllers at McMurdo to warn flight TE901 that it was in danger.

Judge Greene said the operational crew of Flight TE901 acted unreasonably in several respects, including not plotting their actual position from the AINS and descending below 16000ft, contrary to both prudent airmanship and Air New Zealand policy, without first ascertaining what was there or following the other requirements for such descent.

"It is clearly established, when the pilot told Mac Centre that he wished to descend VMC he effectively informed the controllers that he could see where he was going, is so doing he took sole responsibility for separating the airplane from other aircraft and terrain'

There was more along the same lines but this court concluded that the disaster was the fault of both Air New Zealand and the flight crew.

This would appear to be the view of many, shared responsibility, but when the view of Mahon is quoted as being the definitive opinion, and it was the fault of the company only, then I feel the need, as quoted in my first post on this thread, to put forward the fact that there are many who believe he got it wrong.

Prospector

[56P]

Justice Mahon had a brilliant mind. Not only was he able to understand the causes of the disaster, he was also able to identify misleading and false testimony.

I still have the original video that includes live performance in the Royal Commission. If one forgets all about the causes of the crash, just ask a few simple questions.

Why was it necessary to break into the homes of the pilots?

Why was the folder of Captain Collins' diary recovered with all the pages missing?

Some outright lies were told under oath at that commission. Why was it necessary to lie? Of course, there was a cover-up!

[Kaptin M]

Thanks for a very succint summation, from a PROFESSIONAL point of view, Desert Dingo, vs ramblings of one obviously swayed by titles and types!

The tragedy of TE901 was made only worse by the actions of Air New Zealand management's attempts to shirk their responsibility.
You, prospector appear to STILL be acting in collaboration with the proven guilty party of that disgraceful, orchestrated, pack of vultures........the same people responsible for:-
(i)attempting to hide their actions of changing the waypoint co-ordinates,
(ii)stealing and secreting evidence from the crash site,
(iii)breaking and entering into the homes of the (deceased) crew members to remove evidence,
(iv)falsely testifying, under oath, in court
Air New Zealand - no-one does it better

Proud of yourself, prospector?

Thanks for the compliment - the vitamin tablets and Grecian 2000 (along with a little exercise) do wonders for one, don't they :cool:
But for the record..16,000 + hrs
B grade Oz Instructor rating
F27
DC9
B737 1/2/3/4/500
B767
B747
..and I've SEEN Concorde taking off at LHR :eek:

[Thump & Go]

Prospector, correct me if I'm wrong (all my literature on this subject is in storage - AKA at mum & dad's ;) ) but were Justice Mahon's findings[ overturned by the Privy council or did they suggest he had stepped outside his mandate with regard to the "litany of lies" statement and the aspersions he cast on the company's evidence?

WRT to Judge Greene's findings on the subject of Mac Centre, I would suggest they came about for the same reason GE and McDonnell Douglas had "experts" on site to "assist" the investigation - good old fashioned ar$e covering in litigation-mad US of A.

For the record, I believe the accident occurred for the same reason any major crash occurs - them old swiss cheese holes lining up.
Don't descend below MSA - don't crash
Don't programme A/C to fly at hill - don't crash
Adequately prepare crew for Sth Pole - don't crash
etc, etc
In other words, no one was at fault but all these things contibuted to the cause.

Surely this is apparent to everyone here????

[deadhead]

Here is one of my replies to an earlier post on this topic:

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

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

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

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

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

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

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

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


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

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

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

And no human should ever be put in that position.

dh, on a very sad day for me if the worst is true re the probable accident on Mt Egmont today. Bloody mountains.

[prospector]

Thump and Go,
Justice Mahon and the Privy Council: My reference states:

"In their judgement, delivered on 20 Oct 1983, the five Law Lords of the Privy Council dismissed the Commissioners appeal and upheld the decision of the Court of Appeal decision, which set aside the costs order against the airline, on the grounds that Mahon had committed clear breaches of natural justice. They demolished his case item by item, including exhibit 164 which they said could not 'be understood by any experienced pilot to be intended to be used for purposes of navigation'.and went even further, saying there was no clear proof on which to base a finding that a plan of deception, led by the company's chief executive, had ever existed.

Judge Greene: This case was brought by people from NZ, hardly arse covering by anybody in the USA.

"Surely this is apparent to everyone here???"

One would think so, but read Kaptin M last posting and some of the others and the only conclusion they can see as correct was that of Mahon. My postings have endeavoured to show that the company were not the only ones at fault.

Prospector

[Thump & Go]

You'll have to help me out with Exhibit 164 'cause I don't think it's fair to ask Mum to go look it up for me:)

I'm still unclear about the Appeal court/Privy Council - are they bagging his findings? (ie multiple factors - sector whiteout/company safety culture/flightplan alteration/lack of adequate preflight briefing etc) or; Are they not suggesting he had no proof that a cover-up existed,that if it did there is no proof it started with Morrie Davis and "thats not what you're here for anyway son" so leave it out?

Surely the only controversy with the Mahon report was his totalexoneration of the crew - otherwise, as someone said earlier it was ahead of it's time-the embryo of modern crash investigation.(ahh... so quotable :))

Mac Centre = US ATC no?:ok:

[Vampire 91]

It's interesting to note the level of angst that still exists regarding this accident and its aftermath. I recall watching TV that night when the program was interrupted by an announcement, and a still photo of an ANZ DC10, that an ANZ DC10 was overdue on a flight to the Antarctic and there was no possibility that the aircraft was still airborne. Chilling news. The following day I was on an ANZ domestic flight where, according to a friend on the crew, some passengers requested 'no ice in the drink today' as if it was some sort of joke.

Like many others I had some association with people on board the aircraft. I played a bit of rugby with Brick Lucas (I think that he was a nav prior to retraining as a pilot in the RNZAF), and a former school mate was a passenger on the flight. Some years later I was a passenger on an ANZ flight which had Judge Mahon on board. It was interesting to observe the warmth with which he was received by the crew.

It would provide some satisfaction to believe that the lessons learned from this accident have been incorporated into aircraft operations and investigation processes. Sadly, CFIT remains a major cause of accidents.

[prospector]

Thump and Go,
Exhibit 164:

The original chart (164) was photocopied from a Dept of Defence chart and evidence was given that this chart was discontinued in July 1976

"Exhibit 164 had no significance at all in the operations to McMurdo," says Keith Amies.

" However it was the only piece of evidence that could support the Commissioner's contention that the DC.10 was intentionally flight planned to anywhere other than McMurdo."

" At the Inquiry I demonstrated to those present exactly how this was done. Obviously Mr Mahon could not appreciate the necessity for this check, but anyone conversant with grid navigation would agree that it was prudent to carry out such a check"

"Weighing the evidence presented before him--and the crediblity of the witnesses themselves--Peter Mahon concluded that Exhibit 164 was the track and distance chart supplied to Antarctic crews, and Annex J was something the airline would rather have been found in the cockpit of the wrecked DC.10. That conclusion was one of the many later dismissed at both the Court of Appeal and Privy Council hearings."

Difficult to quote just pieces of this and keep it in context, or get accused of selective memory, but that should give you an idea of Exhibit 164, and the weight Mahon put on it, and the weight Appeal Court, Privy Council decided it was worth.

MAC centre, U.S. Navy air traffic controllers.

This statement by Mr Chippendale after analysing and correcting or refuting more than 70 statements made by the Commissioner.

"I regret the lack of consultation between the Commissioner and the Chief Inspector during this inquiry. It is a radical reversal of the procedure which had always taken place on the earlier public inquiries into aircraft accidents in New Zealand.
This lack of consultation together with the absence of the technical assessors provided for in the Civil Aviation(Accident Investigation)Regulations 1978 resulted in a decision which conflicts with the accepted views of the international aviation fraternity around the world.
The errors in the briefing were serious but not an absolute excuse for the accident when the means were readily available for the pilot in command to make certain he knew where he was."

And as you have seen, you either agree with Mahon or Chippendale.

Prospector

[TAY 611]

I guess Chippendale would say that as he would have felt he had some sort of ownership on the origional report, that if refuted, made him look like he hadn't done his job very well.
Correct me if I am wrong but wasn't Gordon Vette advising Peter Mahon at the time of the commission and he appears not to be a lightweight in DC10 operations either.
Its all the talk of dodgey things like breaking into homes, giving false statments and shredding evidence that adds weight to Mahons Litany of lies remark and is something you seem to avoid comment on there Prospector. :confused:

[prospector]

TAY 611,
Why talk about those things??? Did they cause the accident??

Read the last sentence of Chippendales statement in my last post.

Were the briefings seriously in error?? Yes they were.

Were means available for the crew to establish their exact position???? Yes they were.

Prospector

[56P]

A police officer recovered the diary of Capt Collins, complete with all pages. That officer was not required to appear at the commission. When the diary was presented in court, all the pages were missing despite the good condition of the binder. The witness who presented the binder advised that he could not recall removing the pages!

No wonder Justice Mahon had doubts regarding some of the statements from some of the witnesses.

Many factors contributed to this disaster. There was no need to attempt a cover-up. The purpose of any accident investigation is NOT to apportion blame but to identify the cause so that steps may be taken to avoid any recurrence. Any cover-up negates the purpose of any investigation.

[Desert Dingo]

It seems that the apologists for the airline make much of the fact that Captain Collins did not comply with a company requirement to observe the FL160 MSA approaching Mt Erebus (and then a 6000 ft limit when past it to the south).
The airline briefing notes stated “ if VMC cannot be maintained, FL160 is the Minimum Safe Altitude.” Even Chippindale’s report states “He was not violating any local restriction by descending to 1500 feet in VMC”
Anyone care to explain how the NZ regulations require flight above the MSA when operating in VMC? OK, then perhaps are we agreed that it was only a company requirement.?

Justice Mahon observed that in the 2 years prior to the disaster, NOT ONE PREVIOUS FLIGHT HAD COMPLIED WITH THIS RESTRICTION. They all happily flew in VMC below the MSA. Perhaps they were all crazy line pilots breaking the rules, lucky not to be reported, and the company knew nothing about it ?? Who would like to bet that no management pilots ever commanded one of these flights?? Come on! It cannot be disputed that the airline promoted the whole thing as a low level sightseeing flight, and the airline cannot escape the fact that Captain Collins was endeavoring to do what the airline expected him to do.

There is no doubt that Chippindale produced a magnificent report with detailed analysis of thousands of pieces of evidence. However, I think it was a classic case of “not seeing the wood for the trees..” You only need to stand back and metaphorically squint a bit and two monumental facts stand out.
1) The crew thought they were flying in VMC, and they were not.
2) The crew thought they were in McMurdo Sound, and they were not
Change either of these facts and the disaster would not have happened.

Can you blame the crew? I think not. Collins appeared to be meticulous in maintaining VMC.

CVR extracts:
35:36 “Presently through FL130. VMC. Intention to descend to 10,000”
38:23 “I’ve got to stay VMC, so I’ll be doing another orbit.”
42:49 “We’re VMC around this way, so I’m going to do another turn.”
45:00 “Now at 6000, descending to 2000, VMC.”
Then when it appears that VMC is becoming marginal…
47:43 “Might have to drop down to 1500 feet here, I think.”
48:46 “Actually these conditions don’t look very good at all”
49:24 “I don’t like this”
49:30 “We are 26 miles north. We’ll have to climb out of this.”

They are hardly the words of someone recklessly ignoring regulations.

Can he be criticized for not climbing at the first indication that conditions were deteriorating?
47:43 “Might have to drop down to 1500 feet here, I think.”
Once again, I think not. It was still a legal altitude, and he believed he was over the flat expanse of McMurdo Sound.

There is one part of Chippindale’s report I find utterly incredible.

2.5 The flight plan was printed for each flight from a computer stored record which, until the night before the flight, had the longitude for the McMurdo destination point incorrectly entered ………….
……… In the case of this crew no evidence was found to suggest that they had been misled by this error in the flight plan shown to them at the briefing.

No evidence to suggest that they had been misled by this error ????
They flew into a mountain they thought was 25 miles away fercrissake !!!

CVR:
46:39 “Where is Erebus in relation to us at the moment?” “Left. About 20 or 25 miles…about 11 o’clock.”

And also this little conversation in the cockpit.
Alt Cap
Ross Island there
Yes
Alt Hold
Erebus should be here
Right
fifteen hundred
Capture
Alt hold
Hold on both, nav track

Anyone happen to notice that NAV TRACK callout? As far as the crew were concerned, they were locked onto the planned track they had been briefed on and they were in the middle of McMurdo Sound.


Our airline apologists try to tell us that Justice Mahons findings were “overturned.” They were not. Justice Mahon's finding that the crew was blameless was not overturned. What happened was that Air NZ challenged Justice Mahon’s findings of a cover-up on the grounds that if such an accusation was to be made it should have been put to it at the inquiry.
The Court of Appeal agreed, and set aside the costs order against the Airline, on the grounds that Mahon had committed clear breaches of natural justice. The Privy Council subsequently found that Justice Mahon, as Royal Commissioner, had acted in excess of his jurisdiction and contrary to natural justice regarding those allegations.

It appears to me that once again nit-picking lawyers let criminals go free. There was still the cover-up of course, but the poor darlings were not told at the correct time that it was going to be made public.

Here is some of John Roughan’s column in the New Zealand Herald

Erebus eventually became the story of a cover-up. That was the conclusion of the inquiry conducted by Justice Peter Mahon and his story received eager treatment in the news then and ever after. It will be widely rehearsed again this weekend, the 25th anniversary of the crash.
Mahon decided the root cause of the disaster was the airline's navigational computer in which the pilots had absolute faith but which had been unwittingly programmed to fly into the mountain. Further, he believed Air New Zealand had realised it was at fault and had tried to pull the wool over his eyes.

It was a great story and Mahon was a great writer. I was back here and covering the High Court by the time his Erebus report became contentious. Justice Mahon was well-regarded by his peers. His decisions were written with crystal clarity and wry elegance. His report was a work of dedicated investigation, human insight and controlled fury.

Then it turned into a personal disaster. Air NZ challenged the fairness of his findings of a cover-up on the grounds that if such an accusation was to be made it should have been put to it at the inquiry. Mahon's peers at the Court of Appeal agreed.

When they found his report to be a breach of natural justice, he resigned from the judiciary and died some years later, said to be broken in spirit.

Most people's sympathies, including mine, were with Justice Mahon, particularly since the agent of his downfall was suspected to be the ever-domineering Prime Minister, Sir Robert Muldoon.


Prime Minister?
Airline?
Shonky dealings?
Why am I not surprised?
It’s Deja-vu ..all over again.

[TAY 611]

Prospector
When 257 people paid a hefty price in this accident why not talk about these things? It may not have directly caused the accident but it sure exposed a corporate culture that allowed it to happen then tried to whitewash their own involvement.
3 issues to look at here
(1) Chippendales report (you give it a glowing report)
(2) Mahon aided by Gordon Vette commission result (condemned by you and you prefer to acknowledge a concorde pilot's opinion before even acknowledging Vette's view)
(3) Mahon's suspicions and exposure of a cover up (the only comment you have here is why talk about it)
Which eye have you got closed there and which tunnel are you looking through?
TAY :yuk:

[prospector]

Dessert Dingo,
I for one am certainly not an apologist for ANZ, in fact over the years, and particularly about the time of the crash had very little time for them.

If the company requirement for descent was complied with then there would have been no crash, it was as simple as that.

If you wish to quote from the CVR go back a little further,
"We're maintaining 10,000 presently 34 miles to the north of McMurdo"

34 miles North, 10000ft, no DME lock on, no VHF contact, no radar contact. what would that tell you???

From Peter Mulgrew, the expert ice man, the only one who had been down there.

"I still can't see very much at the moment-- as soon as I see something that gives me a clue as to where we are I'll let you know"

That statement descending between 10000ft and 6000ft.

As you say there was a lot of "They thought"

If you consider the crew blameless, as apparently Mahon did, after flying a perfectly serviceable aeroplane into a mountain carrying out a procedure that was against a Company Standing order then so be it.

TAY 611,
Mahon made all his own decisions unassisted by any ANZ crew in any official capacity, there was I believe an RNZAF officer meant to be assisting him in a technical capacity, but his name was not mentioned once in the report I dont believe.



Prospector

[56P]

34 miles North, 10000ft, no DME lock on, no VHF contact, no radar contact. what would that tell you??
--------------------------------------------------------------------------
Prospector

They "thought" that they were 34 miles north because, so far as they were aware, the NAV system indicated it. They thought that they were 34 miles north in the centre of McMurdo Sound because that was where they expected the nav system to take them. I do not beleive that was an unreasonable assumption. And remember that they thought that they were in VMC.

Trying to remain objective, I see errors on all sides. The error in the coordinates inserted into the nav system without advice to the crew was a major one. Likewise, it is difficult to understand the time elapsed between a hard GPWS warning and the request for go-around thrust. Again, maybe the crew had difficulty to understand the warning because, in their opinion, they were no where near high terrain.

[Kaptin M]

Your continuing defence of the undefencable - that Air New Zealand management KNEW that THEY would be viewed as the primary causal factor, as proven by their many and various underhanded tactics - has me wondering why you doggedly persist in trying to shift the blame AWAY from them, prospector.
Your posts indicate a good knowledge of the reports written about this accident, but very little PRACTICAL aviation operational knowledge, from a pilot's point of view.
Your comment, "I still can't see very much at the moment-- as soon as I see something that gives me a clue as to where we are I'll let you know"

That statement descending between 10000ft and 6000ft." indicates your inability, or unwillingness to concede that Capt Collins was in VMC conditions - the "I can't see very much at the moment", indicates to me that due to the flat, icy, featureless terrain, he was merely commenting that he couldn't see any positively identifiable landmarks to confirm their position - however he could see that they had terrain clearance, and (mistakenly) knew that as long as the aircraft continued tracking on the Company supplied flight plan route, they would remain well clear of high ground.
Obviously, had whiteout conditions not existed, the crew would have seen the mountain, and their proximity to it.

Just to clarify some previous comments of some contributors - the crew didn't THINK that they were visual - they WERE visual, prior to encountering the whiteout phenomenom.

I give Desert Dingo's account 2 thumbs up:ok: :ok: for a well-written, well thought out expose :ok:

[prospector]

Kaptin M, Dessert Dingo, 56P,

If you consider it acceptable to conduct a flight with so many "thoughts" "assumptions" and "mistakes" please advise which airlines employ you so I can ensure that I dont "mistakenly" get on your aircraft that I "thought " was to be operated in accordance with SOP's and not by "assumptions" that you know better than the people that make the rules.

Prospector

[Kaptin M]

Visual approaches have been included in the SOP's of all (5) major airlines for which I've worked, prospector.
In your case, a little knowledge is a dangerous thing - how's the adage go..."It is better to appear a fool and say nothing, than to open one's mouth and remove all doubt!"
Why the "vested interest" though?
Was it YOU who was responsible for changing the co-ordinates?

[HANOI]

That is probably the most disgusting thing you have ever said on this forum.

[prospector]

Kaptin M,.
Well you have certainly done that.

The SOP for McMurdo stated the only descent available and the reason for that has been stated many times, the fact that the weather was below the minimums required for that descent does not authorize a crew to invent their own visual descent.

I willingly accept the fact that I am not a GOOD pilot, I lasted 45 years without hurting me or any of my passengers. From Agricultural to Airline, and with a break as an Air Traffic Controller, and some 5,000hrs Single Pilot IFR ops.

In that time I have read many many many accident reports, and one thing they all appear to have in common is how good the pilot was.

Prospector

[amos2]

So, tell me, prospector... which airline was it that hired you with a CPL only?

And why is it that you still have a CPL only?

[prospector]

Amos 2,
Imperial Airways, been retired for a number of years now.

Prospector ;) ;)

[AerocatS2A]

Prospector, the problem with 'thoughts', 'assumptions', and 'mistakes' is that those who have them don't generally know it. The differencing between thinking something and knowing something is that in the later case you can not be wrong. A person who thinks something based on assumptions most likely is under impression that he knows it until something shakes his mindset. This makes it exceptionally hard to guard against.

One thing you can do to guard against it is to have a set of clearly defined SOPs and a company culture that makes it clear that these are to be followed. ANZ appears to have had the SOPs in place, but no one was following them. This is not to say that the pilots were blameless but that they had been setup as the last line of defence in the error chain. As the last line, they screwed up, but they should never have been put into that position in the first place.

Deadhead, you said:

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

Are you sure that you can not cruise below LSALT on an IFR flightplan in NZ? In Australia you can (in day VMC) but I accept that there are different rules for different countries.

[prospector]

AerocatS2a,

Your second paragraph says it very succinctly, no one party was completely responsible.

The Chairman of the ANZ Board, Bob Owens at the time, if I remember correctly,said something like 60% Company 40% aircrew, and those percentages should be the only thing that is up for discussion. And that will never be answered to the satisfaction of everybody.

Prospector

[amos2]

So, tell us more about Imperial Airways, prospector!

Like, is this heavy jet stuff? Or perhaps light aircraft stuff?

Or, perhaps, pre 1940 stuff?

[wing_nut]

amos2

looks pretty old to me - well before the jet-age.....have a look

here (http://www.imperial-airways.com/)

[56P]

I think that we've done this one to death!

[SeekingAnswers]

I would like to say straight off that I am not a pilot and that I do have a vested interest and inside knowledge that leads me to be on the side of the crew.

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

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

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

Oh and I'm not sure if I would agree that Ron Chippendale could be seen as "independent" as stated in one posting and so therefore indisputable. An air inspector should always remain afar from all culpable parties. My question would be, how far removed did he remain? I could refer you to articles over the years that have been less than flattering on this point. I think you'd agree it does undermine your confidence in that "independence".

Even though I am on the side of the crew, it would be nice to think there was something they could have done differently;defy their bosses of the only large commercial airline they had in NZ by not descending to an altitude that EXPERIENCED antartic pilots had descended to over the past two years, been suspicious of seeing white (light) where they expected white (ice) to be, been suspicious of their computer, listened to a man on a radio telling them he was in whiteout and go elsewhere when they could see sea, and ice, and cliffs clearly...but to do this, they would have had to have made assumptions...that the airline was acting dangerously in suggesting that height, that all the previous pilots were acting dangerously, that the computer was faulty, that the man on the ground knew the weather better in his little hut then they at 6000ft with a birds-eye view...and I guess we've acknowledge how dangerous assumptions can be...quite deadly in fact...

Its funny, as many people as there were, 257, when you're involved, it just comes down to one, the one you knew that died.

[Far Canard]

When the employee of a company flies one of its perfectly good aircraft into the ground, it is called "Controlled Flight Into Terrain".

The reasons are many, but mainly a lack of situational awareness. The world has moved on from the Erebus CFIT accident and the thousands of others and has produced TAWS.

When humans are involved you will always be potentially seconds from disaster.

No airline would ever let one of it's aircraft fly without insurance, even if the pilot was "ACE OF THE BASE", simply far too risky.

Put this one to bed and thank technology for TAWS. The next step will be taking the pilot completely out of the picture as an added safeguard.

[Chimbu chuckles]

man I hope I live long enough to see pilotless planes...finally we'll actually see how many accidents are avoided by fallable human pilots...then the beancounters, and computer nerds will finally be put back in their box permanently...in fact as a show of faith in their infallable machinery 30% of all pax should be beancounters, and computer nerds, 30% should be Lawyers, and 30% should polliticians...the remaining seats can be used by deathrow inmates.

Might as well put the technology to good use!!

[Far Canard]

The old story of the pilot and the dog on the flight deck. The dog bites the pilot if he touches anything.

Technology has replaced the navigator, the flight engineer and so will go the pilot. When?

When the baby boomers are long gone and the next generations have taken over. The ones that have been raised on Microsoft Windows, cellphones and American fast food. Their life expectancy will be nothing so risking a ride on a pilotless plane won't be much of a concern.

[Pinky the pilot]

Chuckles and Far Canard; Gentlemen that sounds somewhat cynical coming from you both.
However you had better move over a bit because I tend to agree with you.
One day someone may indeed invent some piece of technology that may replace the PIC of whatever passes for an aircraft in the future. However I'm bloody sure of one thing; It won't be in any of our lifetimes!!

You only live twice. Once when
you're born. Once when
you've looked death in the face.

[jokova]

There are significant anomalies in the appendices of "Impact Erebus". The reconstructed track from TOD with marked CVR notations does not accord with the time signatures in the CVR transcript. The photographs recovered from the cameras of one or more passengers and the captions in the book to some of those photos are also markedly at odds with actual terrain, as a close study of local charts shows. It is not possible to raise questions arising with the author as he is indisposed and likely to remain so indefinitely. Any light that can be thrown on this by anyone who has gone over the published material thoroughly, or who has specialist knowledge, would be welcome. [COLOR=blue] [email protected]

[limetree2005]

Bit thick here, eh Bert?

Or putting it another way.

If captain prospector had been in charge of 901 with that flightplan, I suppose he would have tooled around at 20000ft for a while and then flown back...knowing that you can\'t trust the flightplan or INS. Just like no captain should ever trust ATC in case they give you a wrong heading or FL.

Those guys were doing a job, and that was sightseeing, not IMC training.

[4SPOOLED]

i have no doubt that Aircraft will be far more automated in the near future, HOWEVER

There will always be 1 or 2 guy's that are professional aviators in the cockpit monitoring the systems just as there is today...whether the conditions have got so bad that they are offering to work for free is another thing.....

[4Greens]

The only thing you know for certain about any accident is that there is never a single cause.

As an additional factor, it may be worth remembering that there was a conflict between safe operations and the need to show the passengers something to make the trip worth while.

[limetree2005]

Thank you 4greens, that was what I was trying to say.

I crashed an aeroplane once...don't 'arf ruin your day!

It was my fault, because I was PIC, but then again, I didn't know something that I should have known, which was not my fault. etc etc right down the chain of contributing factors...

I think the lasting taste from Erebus is the discussion about the way that they jump on pilot error. In my case, I was lucky enough to be surrounded by people who realised that it could have happened to them, and the whole thing was dealt with in a gentlemanly (not sexist, I hope. Is it stewardesses or cabin attendants, or passenger management consultants we have these days? I should really get back in the bit behind the cockpit more often!) way.

That is, I was lucky enough to have the opposite treatment to what the capt and fo get when there is money involved; and I'm sorry - we are not talking about deaths here - 6000 people or so die on the roads in the UK alone every year! - we are talking about MONEY.

It is why they put the cockpit in the sharp end... the pilots are to first to know if they are "negligent".

[pakeha-boy]

There are certainly some great posts in this thread.Prospector,I reckon you have done the thread proud mate!!!.My only hope is that for all that have posted ,you have also read the book.I believe we have learned much from this sad affair....arohanui

[Fantome]

. . . . . your post last month. . . five or six back from this . . .in which you write that "given all the factors at play in this accident. . .(I cannot say). . . it would not have happened to me. . .", I'm sorry, but as we do not know, and are unlikely to ever know, all the factors that caused that DC10 to crash, it is simply not valid to draw that conclusion in those terms.

On the evidence, Captain Collins, despite his exhaustive preparation, undoubted competency and superior airmanship, was deceived by more than the wrong coordinates.

For there are aspects of the final report that warrant further judicial examination, regardless of the passage of time. For one thing, the sequence of events from top of descent as detailed in the time-line tabled, taken from CVR and FDR, have significant anomalies that are minutes out of whack. How did that miss the scrutineers and those highly qualified to comment, such as Gordon Vette?

(The quotes you give from Mike Mullane, et al, are spot on, and despite my quibble with your initial assertion, I support fully your sentiment that you would not want to fly with the silly prick who thinks he's infallible.)

[Fantome]

Megan . . . not implying you were critical of Captain Collins, just that as "all the factors at play" will never be known I took (rather petty) issue with your opening sentence.

Far more to the point, I raise again the question of significant anomalies in the final report. These were carried over into the studies by Mahon and Vette. That Gordon Vette did not twig to these is extraordinary.

What I would like to see is someone truly full-bottle on the accident and financial enough to conduct the required research do what Tom Frame did for Voyager and that mob. I'm standing by with some pointers, but without holding of breath.

[snaga]

Prospector, while on the one hand you seem to agree that there are two points of view on this accident you don’t seem so willing to accept an entitlement to hold the other point of view. Worse, you seem to be to be quite selective, if not cavalier, in your presentation of information. For example, in one of your first posts you say: You would appear to belong to the school that supports Mahons statement that the aircraft "was programmed to fly into the mountain from the time it left (NZ)".I believe that this is a subtly pejorative representation of what was said. There is no hope of anything other than endless pointless argument if you don’t do your best to present such comments in as accurate and balanced a fashion as possible. Here are the actual words from Mr Justice Mahon’s report:393. In my opinion therefore, the single dominant and effective cause of the disaster was the mistake 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.It is a matter of fact that the key elements of this finding – the change of waypoint co-ordinates and the failure to tell the aircrew – are correct (for the unfamiliar, the waypoints were not loaded one by one by the crew). Of course the argument moves on from there to why the crew were where they were, etc. etc. … and it goes on and on and on thereafter with supporters of each side of the argument selecting bits of information to support their point of view.

May I also make the point that your reference to the “Orchestrated litany of lies” is also misleading? It was subsequently found that the evidence did not support the use of the word “orchestrated” (and I have no argument with this finding). However, what you seem to miss is that Mr. Justice Mahon was fully entitled to conclude that some witnesses had been less than truthful and that this finding was not overturned. The evidence for this finding in his report is (tellingly) supplemented by the account in his book “Verdict on Erebus” where he lays out exactly why and how he slowly turned from one point of view to another. Working from memory, a key reason for that change was the behaviour and evidence of certain witnesses.

I am familiar enough with the two points of view in this accident to know that any argument will go on endlessly, so I’ll let it go with an appeal for less strident approach towards those of us who disagree with you.

[prospector]

saga,

I fail to see where you could use the word strident for any of my replies. However, in answer to your assertion that Mahon was correct in his treatment of witnesses I put forward the following from "New Zealand Tragedies, Aviation" by John King.

"That last point was seized upon by the Air New Zealand people accused by Mahon of taking part in the conspiracy, the accusation receiving such widespread publicity both in New Zealand and overseas, and the $150,000 fine being such a large amount that it could not be ignored. 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. The airlines board of directors resolved to pursue its single option to protect the integrity of its employees, to challenge the conspiracy finding by way of a judicial revue.

Because of the public importance of the review proceedings and the fact that a High Court judge was involved, Air New Zealand applied for the normal High Court hearing to be bypassed and the case was heard by the five permanent judges of the New Zealand Court of Appeal in early October 1981. Their judgement was delivered just before Christmas 1981 and held that Mahon, in making the findings of criminal conspiracy, had exceeded his terms of reference. He also committed breaches of natural justice by failing to inform the affected witnesses of the charges he proposed to level against them, thus depriving them of the opportunity to defend themselves.

The Court of Appeal addressed several aspects that were brought to the Commissioners notice during the enquiry but ignored by him. The five judges unanimously quashed, the $150,000 costs order, imposed as punishment for the alleged conspiracy"

I do believe that covers what his peers in the Appeal Court, and later the Privy council, thought of this matter and his findings, in the matter of witnesses, were in fact overturned.

Prospector

[snaga]

Prospector 95% of your post is a quote from somebody else - the burden of which is to support the essence of what I acknowledged in my post when I said:It was subsequently found that the evidence did not support the use of the word “orchestrated” (and I have no argument with this finding). However, contrary to the comments in your citation there could have been no successful appeal had the word “orchestrated” not been used (and a fine imposed). Again from memory, the relevant Appeal court finding was essentially based on the fact that the judge did not properly elucidate the grounds on which he based his conclusion that there had been “orchestration”. I think the evidence does indeed confirm that the judge failed to do so (though I also note that a close reading of the evidence at the inquiry does suggest that, for some reason, the approach and testimony of some witnesses was not entirely consistent from the beginning to the end of the Royal Commission of Inquiry. Again the supplementary testimony from the Judge’s book adds useful perspective to this matter. After all it is direct testimony from somebody who was there listening to the evidence!).

I do not accept that there was ever a finding that Mahon “exceeded his terms of reference” and would be obliged if you could direct me to something other than a second hand opinion on this matter (in other words a statement or finding to this effect by the Appeal Court, or Privy Council).

The author from whom you quote claims that the Office of Air Accidents Investigation report “remains the sole official account” and says that it “has never been officially challenged”. I was rather under the impression that a Royal Commission of Inquiry was both official and that it presented findings that challenged that of the Air Accidents Investigation report. I think that it is a palpable fact that both reports exist as official documents, with findings that are contradictory. I suspect the reason that you claim to the contrary is that you have elevated to the status of fact the opinions of the author from whom you quote.

That authors attempt to use the Appeals Court and Privy Council findings to, in effect, argue that all of the findings of the Royal Commission were overthrown is an interesting argumentative strategy. While it appears to appeal to you, it does little for me. It certainly does little to advance our understanding as to why (a) this accident occurred, and (b) how to explain the (genuinely) intriguing puzzle as to how the evidence can be (convincingly) marshalled to support two utterly contradictory findings.

If we better understood (b) we would have advanced considerably in accident investigation. To that end it serves no purpose to treat those who support the point of view we like as wise and wonderful and to denegrate as misguided, or worse, those who support the contrary point of view. Regrettably much of the debate around this accident has tended to to head in that direction.

[prospector]

snaga,
You said,
"However, what you seem to miss is that Mr. Justice Mahon was fully entitled to conclude that some witnesses had been less than truthful and that this finding was not overturned"
I said,
"I do believe that covers what his peers in the Appeal Court, and later the Privy council, thought of this matter and his findings, in the matter of witnesses, were in fact overturned."
You followed with,
"That authors attempt to use the Appeals Court and Privy Council findings to, in effect, argue that all of the findings of the Royal Commission were overthrown is an interesting argumentative strategy. While it appears to appeal to you, it does little for me. It certainly does little to advance our understanding as to why (a) this accident occurred, and (b) how to explain the (genuinely) intriguing puzzle as to how the evidence can be (convincingly) marshalled to support two utterly contradictory findings."

You will perhaps note that the argument was in the matter of witnesses, it had nothing to do with the rest of the findings of the Royal Commission. I will attempt to locate a copy of the Appeal Court findings, and the Privy Council findings in this matter. You will note that the fine of $150,000 was imposed by Mahon as punishment on the Company for this so called conspiracy, this fine was quashed by the Appeal Court, that is a well known fact.

It appears you are drawing your information for your opinions from the book Mahon wrote after the event, "Verdict on Erebus". This can only be his version of events, The reference I quote, by John King, first published 1994, has the opinions of many people involved, and has the advantage of much hind sight.

Prospector

[Casper]

Prospector,

In your search for the findings of the Appeals Court, please also try to ascertain whether, as claimed in a TV documentary, some of the judges in that Appeals Court had vested interests (through relatives) in Air New Zealand at that time.

Thanks in advance.

[56P]

Casper

I also saw that documentary although I can't remember its name. It claimed that 3 of the 5 judges had such vested interests.

[Brian Abraham]

fantome - you are quite correct in that we can never know where there are no survivors. And even when there are survivors each has a different take on events. Interested in your pointers - if you dont want to post here please PM.

[prospector]

For anyone interested in the findings of the Appeal Court into the matter of Justice Mahon's Royal Commission of Enquiry into the Erebus disaster it can be found here, the Privy Council findings can be found with a Google search.

http://www.gutenberg.org/files/16130/16130-h/16130-h.htm

Casper,
That question was raised, but to date no one has made any comment about the Privy Council having any "vested interest" and they upheld the Appeal Court findings.

Prospector

[Casper]

Thanks for that site, Prospector.

Despite the findings by both the Appeal Court and the Privy Council, it was still necessary for "someone" to break into the pilots' homes for whatever purpose before the Royal Commission.

There is also the problem of the pilots' nav bags that were never returned to their families. I read of one report by a member of the investigation (policeman, I think) who had found the "binder" of Captain Collins and who stated that the binder was complete with pages that somehow went missing prior to the Royal Commission.

It would appear that some skullduggery was conducted by persons unknown - for whatever purpose!

[prospector]

Casper,
Presume you have not read fully the contents of that finding. Admittedly it is very wordy, but, you will no doubt note that Mr Woodford was not called to give evidence, you will also note it was stated in a previous post that an actual weather report at Mc Murdo was passed to the crew advising of whiteout conditions at Mc Murdo and not to bother with any sightseeing in that area, this experienced AntArctic observer was also not called to give any evidence, why would this be? these people obviously had information that was very relevant, or did it not fit into Mahons theories?

"Dear Sir,

At the time of the DC10 crash I was employed in Antarctica by D.S.I.R. as a survival instructor/mountaineer assistant. I was one of the three mountaineers who made the initial inspection of the site for survivors. I was also one of the three mountaineers who accompanied Messrs David Graham (Investigator) Ian Gemmell & Ian Wood (Air NZ) during their initial inspection of the aircraft. During the first six days after the accident I was at the crash site at all times when the site was occupied.

In regard to evidence reported in the Christchurch Press today, 5 Dec 1980, I can state unequivocally that:

(1) Captain Gemmell did not spend any time inspecting the aircraft without other people being present.

(2) Captain Collins flight bag was found by me the day after the crash, this being three days before any Air N.Z. personnel or crash investigators reached the site. My recollection is that it was empty when I first inspected it. It certainly contained no diaries or briefing material.

(3) Captain Gemmell did not remove any items from the persons of deceased lying in the area...."

Counsel proceeded to read from the letter which goes on to refer to instructions concerning the crevassed area of the ice-slope.

No challenge was made to the views expressed by Mr Woodford nor was he called to give evidence. And no evidence to any contrary effect was given by anybody. Yet apart from the passing reference to the matter in paragraph 349 of the Report the point of view Mr Woodford expressed seems to have been given no attention. The extent of the evidence which could have been given by Mr Woodford if he had been called as a witness is indicated by his affidavit now put before this Court. The importance of the letter seems obvious. The bag being empty when it was seen only 18 hours after the aircraft had crashed it is difficult to understand how it could have any significance when found in that same condition three days later. Yet in this part of the Report it is left as a central issue. Mr Woodford's own concern about all this is indicated in the lengthy affidavit which he prepared for the purpose of exonerating Captain Gemmell. It was sworn by him on 21st May 1981 not very long after the Report of the Royal Commission had been made public.
------------------------------------------------------------------------------------------------
That to my way of thinking explains the so called missing documents from the flight bag. Nobody made any claims of vested interest by Mr Woodford.

Prospector

[Casper]

Thanks for the info, Prospector. I've read more of the report now. I was also unaware of the earlier wx report to the crew indicating whiteout conditions. Such conditions are not included in the following extract from the CVR transcript:
----------------------------------------------------------------------
00:18 MC We have a low overcast in the area at about 2000ft and right now we're having some snow, but visibility is still about 40 miles and if you like I can give you an update on where the cloud areas are around the local area.
FO Yes 901, that would be handy. We'd like to descend and maintain flight level one six zero.
MC Kiwi 901, Mac Centre descend and maintain flight level one six zero.
MC 901, this is the forecaster again. It looks like the clear areas around McMurdo area are at approximately between 75 and 100 miles to the northwest of us but right now over McMurdo we have a pretty extensive low overcast. Over.
00:19 FO Roger, New Zealand 901, thanks.
FE That'll be round about Cape Bird, wouldn't it?
FO Right, right.
FE Got a low overcast over McMurdo.
CA Doesn't sound very promising, does it?
MC Within range of 40 miles of McMurdo we have radar that wil, if you desire, let you down to 1500ft on radar vectors. Over.
-----------------------------------------------------------

I understand that it remains a reported fact that the pilots' homes were entered illegally by persons unknown before the Royal Commission.

In any event, it remains a sad lesson in CFIT.

[Desert Dingo]

I see Prospector seems a little reluctant to link directly to the privy council appeal findings.
Maybe because this, the final official analysis of the investigation, completely demolishes his arguments that the crew were at fault. :{

Allow me to quote:
(836 onwards)
The Royal Commission Report convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged.

Care to read that again slowly ?
The Royal Commission Report convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged.

It continues on to explain why Mr Chippindale’s finding of pilot error was wrong:

The judge was able to displace Mr. Chippindale's attribution of the accident to pilot error, for two main reasons. The most important was that at the inquiry there was evidence from Captain Collins' widow and daughters, which had not been available to Mr. Chippindale at the time of his investigation and was previously unknown to the management of A.N.Z., that after the briefing of 9 November 1979 Captain Collins, who had made a note of the co-ordinates of the Western Waypoint that were on the flight plan used at that briefing, had, at his own home, plotted on an atlas and upon a larger topographical chart the track from the Cape Hallett waypoint to the Western Waypoint. There was evidence that he had taken this atlas and chart with him on the fatal flight and the inference was plain that in the course of piloting the aircraft he and First Officer Cassin had used the lines that he had plotted to show him where the aircraft was when he switched from nav track to heading select in order to make a descent to 2,000 feet while still to the north of Ross Island which he reported to ATC at McMurdo and to which he received ATC's consent. That on completing this descent he switched back to nav track is incapable of being reconciled with any other explanation than that he was relying upon the line he had himself plotted of the flight track on which he had been briefed. It was a combination of his own meticulous conscientiousness in taking the trouble to plot for himself on a topographical chart the flight track that had been referred to at his briefing, and the fact that he had no previous experience of "whiteout" and had been given no warning at any time that such a deceptive phenomenon even existed, that caused the disaster.

The other principal reason why the judge felt able to displace Mr. Chippindale's ascription of the cause of the accident to pilot error was that certain remarks forming part of the conversations recorded in the CVR of the crashed aircraft and attributed by Mr. Chippindale to the flight engineers had suggested to him that shortly before the crash they were expressing to the pilot and navigator uncertainty about the aircraft's position. The tape from the CVR which had been recovered from the site of the crash proved difficult to interpret. The judge, with the thoroughness that characterised him throughout his investigations, went to great pains to obtain the best possible expert assistance in the interpretation of the tape. The result was that he was able to conclude that the remarks attributed by Mr. Chippindale to the flight engineers could not have been made by them, and that there was nothing recorded in the CVR that was capable of throwing any doubt upon the confident belief of all members of the crew that the nav track was taking the aircraft on the flight path as it had been plotted by Captain Collins on his atlas and chart, and thus down the middle of McMurdo Sound well to the west of Mt. Erebus.

Then they confirm that Justice Mahon was correct in castigating the airline

The judge's report contains numerous examples and criticisms of A.N.Z.'s slipshod system of administration and absence of liaison both between sections and between individual members of sections in the branch of management that was concerned with flight operations. Grave deficiencies are exposed in the briefing for Antarctic flights; and the explanation advanced by witnesses for the airline as to how it came about that Captain Collins and First Officer Cassin were briefed on a flight path that took the aircraft over the ice-covered waters of McMurdo Sound well to the west of Mt. Erebus but were issued, for use in the aircraft's computer, as the nav track a flight path which went directly over Mt. Erebus itself, without the aircrew being told of the change, involved admissions of a whole succession of inexcusable blunders by individual members of the executive staff. None of this was challenged before their Lordships. No attempt was made on behalf of A.N.Z. to advance excuses for it.

OK. Are we all clear now ?
The privy council appeal verdict did not overturn any of Justice Mahon’s conclusions as to who was to blame for the disaster. It was the airline !

What the privy council appeal verdict did do was reluctantly agree that Justice Mahon went a bit too far in paragraph 377 of his report :
************************************************************ ********
"No judicial officer ever wishes to be compelled to say that he has listened to evidence which is false. He always prefers to say, as I hope the hundreds of judgments which I have written will illustrate, that he cannot accept the relevant explanation, or that he prefers a contrary version set out in the evidence. But in this case, the palpably false sections of evidence which I heard could not have been the result of mistake, or faulty recollection. They originated, I am compelled to say, in a pre-determined plan of deception. They were very clearly part of an attempt to conceal a series of disastrous administrative blunders and so, in regard to the particular items of evidence to which I have referred, I am forced reluctantly to say that I had to listen to an orchestrated litany of lies."
************************************************************ *********

Back to the Privy council :

These appalling blunders and deficiencies, the existence of which emerged piecemeal in the course of the 75 days of hearings, had caused the loss of 257 lives. Their Lordships can well understand the growing indignation of the judge when, after completing the hearings and for the purpose of preparing his report, he brought them together in his own mind and reflected upon them. In relation to the three matters that were principally canvassed in this appeal and upon which he based his finding that there had been a pre-determined plan to deceive the Royal Commission and a conspiracy to commit perjury at its hearings, their Lordships have very reluctantly felt compelled to hold that, in the various respects to which their Lordships have referred, the judge failed to adhere to those rules of natural justice that are appropriate to an inquiry of the kind that he was conducting and that in consequence it was not open to him to make the finding that he did in paragraph 377 of his report.
To say of a person who holds judicial office, that he has failed to observe a rule of natural justice, may sound to a lay ear as if it were a severe criticism of his conduct which carries with it moral overtones. But this is far from being the case. It is a criticism which may be, and in the instant case is certainly intended by their Lordships in making it to be, wholly disassociated from any moral overtones. In an earlier section of this judgment their Lordships have set out what they regard as the two rules of natural justice that apply to this appeal. It is easy enough to slip up over one or other of them in civil litigation, particularly when one is subject to pressure of time in preparing a judgment after hearing masses of evidence in a long and highly complex suit. In the case of a judgment in ordinary civil litigation this kind of failure to observe rules of natural justice is simply one possible ground of appeal among many others and attracts no particular attention. All their Lordships can remember highly respected colleagues who, as trial judges, have had appeals against judgments they had delivered allowed on this ground; and no one thought any the worse of them for it. So their Lordships' recommendation that the appeal ought to be dismissed cannot have any adverse effect upon the reputation of the judge among those who understand the legal position, and it should not do so with anyone else.

You can find the full report at http://www.uniset.ca/other/css/1984AC808.html
It is compelling reading.
(Edited to correct spelling)

[snaga]

Prospector if it was not clear to you that I already understood much of what you have again re-presented, our exchange is destined to rapidly become a mutual waste of time. I was merely responding to the specific claims you advanced.

In particular you seem to have missed why I cited Mahon’s book in the context of your remarks and quotation (because it gives direct testimony as to how his thinking evolved, his role as a Royal Commissioner, etc). I find it strange that you clearly prefer a second hand source to the direct testimony of a Judge of the High Court. Mahon’s testimony may be assessed and evaluated (and even found wanting), but it is obviously of more substantive worth than – of all things – a book “published in 1994” with “the opinions of many people involved” and having the “advantage of much hind sight”. Moreover, this raises another question. Would you have the same respect for a book with the exact same characteristics as the one you used, but which disagrees with your point of view?! Think about that for a second.

Interestingly, such a book exists: published in 1995 it examines, in the light “hindsight” on advances in Human Factors accident analysis the Erebus accident (among others). It re-analyses the accident and avoids the dead end of attacking witnesses and participants and tries to draw the relevant lessons. It has four authors with an international reputation. It is called “Beyond Aviation Human Factors” (published by Ashgate).

Your deduction that I am relying on Mahon’s book for my opinions is thus misdirected. It is but one source and I regret that what I wrote above did not clarify why I felt that particular source would be helpful to you. You also say: You will perhaps note that the argument was in the matter of witnessesI agree that is where we started. But your citation from the book went well beyond dealing with the matter of witnesses and makes significant and broader claims with which I profoundly disagree and could not let go unchallenged (Desert Dingo’s post contains much of the evidence that demonstrates such claims to be just plain wrong). Moreover, your citation is but the opinion of one person and it does not seem to me to reflect sufficient familiarity with, for example, the materials cited by Desert Dingo.

If, as appears to be the case, you are new to much of the original testimony and documentation ad that you are merely dipping in to extract opinions and sentences that agree with your point of view, you seem destined to an argumentative journey without much light at the end. I commend to you the approach of Desert Dingo. He has cited original material, made a clear argument and highlighted the bits that elucidate his argument. It doesn’t make him right, but he has made some exceedingly telling points when judged against the quote you used to me.

In concluding, may I just say that the addition of the words “so called” and “conspiracy” (the latter being a serious word which goes well beyond “orchestration”) in your reply to me suggests we are like ships passing in the night. As it is likely that these exchanges will go on ad infinitum to no particular purpose I think I will take this opportunity to bow out. Wishing you the best of luck.

[Casper]

Thanks, Desert Dingo. That really puts it into the correct perspective. The video on the Royal Commission into the Mt Erebus disaster is invaluable in CFIT training. Let no pilot think that any operator would be any different!

[pierrem-m]

G'day Folks, When I read the exchanges in this forum on the 901 disaster it brought back to me both the shock I felt on hearing of the crash and my feeling of empathy for my then Air New Zealand Colleagues. (At the time I worked for Ansett Airlines in Melbourne). These exchanges got me thinking again and I came to the realization that both sides of the debate are right. (And until now I had firmly believed Chippendale to be completely wrong). As a matter of strict fact Chippendale was correct when he wrote - "The probable cause of this accident was the decision of the captain to continue the flight at low level toward an area of poor surface and horizon definition" and he was also correct when he wrote - "and the subsequent inability to detect the rising terrain which intercepted the aircraft's flight path." (I disagree with Chippendale when he wrote the phrase that separates the above two quotes - "when the crew were not certain of their position" as all the evidence that I have read supports the interpretation that those parts of the CVR that Chippendale relied on for this quote are "unintelligible".) What Chippendale did not state and what Mahon aided by Vette et al went on to discover was that there was no way that the Collins, Cassin , Mulgrew or, indeed, anyone on the aircraft could have been aware that the aircraft was heading straight for Mt Erebus. As far as Collins and Cassin were concerned the aircraft was operating VMC at a safe altitude above ice and heading up McMurdo Sound and the visual cues they were getting confirmed/re-enforced the mindset they had obtained from their briefing and the information they were receiving from the DC10's instruments. They were unaware that the aircraft had been re-programmed to fly over Mt Erebus and neither were they aware of the insidious dangers of “sector whiteout”. (A phenomena then poorly understood but, thanks in part to Vette, we now know a great deal more about) I believe Vette was correct when he wrote concerning the GPWS warning “They must still have believed that they were getting a false warning signal”. That Mahon was found by the Court of Appeal to have exceeded his brief is, to me, a mere technicality as I am firmly of the view that he was quite correct when he referred to “a pre-determined plan of deception” and to “an orchestrated litany of lies”. (It's only necessary to watch the video of the documentary of the Royal Commission to be convinced of this) As to who exactly did the planning and orchestrating, well I have my own ideas on that but the laws of defamation preclude me from expressing these. I realize that my views will quite possibly be considered unfavourably by the more passionate supporters of both sides but I hope that the above may contribute something to this debate. In conclusion, both my Brother (who has identical views to myself on this) and I would really like to get a copy of the video of the Royal Commission. I did have a copy that I'd taped from a TV broadcast but whilst the tape was in storage some years ago it was severely damaged by damp. If anyone either has a copy or can advise me where to get one I'd really like to hear from you.

[Casper]

I have a copy (slightly damaged) of the video of the Royal Commission. I should be able to have it on a DVD in the near future.

[pierrem-m]

Thanks Casper. My Brother and I are much obliged to you I'll take two copies when you have them available. Regards Peter

[Taildragger67]

Same here please Casper.

Cheers
TD67

[pakeha-boy]

Pierrem-m....youve dug deep,and you have only,I believe said what has already been published,Vette as you have stated has done an outstanding job and there is more information availible than a bull can ****e......I too subscribe to your point ,but that is a personal one..

My Question,....by procuring a copy of the video stated,and your theory that you might know who may have been responsible for these/those actions.....are you planning on re-opening the Erebus case???...PB

I ask this as this post sort of finished up in Jan

[400Rulz]

I suspect most of the respondents in this thread are professional aviators. What was one of the first lessons you were taught when you started flying?
"the PiC is responsible for the safe conduct of the flight." It doesn't matter who did the flight planning, it is the PiC who has sole responsiblity for safe conduct, and that includes separation from terrain. Jim Collins was the best man at my father's wedding. I knew his girls , and his wife. I am friends with F/O Cassins daughter (also a professional aviator), and I was on the flight deck of a DC10 into HKG when the news came through that the flight in question was overdue. My father's first comment was "Jim's hit Erebus".
Those pilots who had flown to the South Pole before Jim were incredibly lucky. They had good viz and clear conditions. I had a friend on Capt Vette's flight - apparently "he flew so low over McMurdo, you could see in the door of the mess hall". Vette was a cowboy, and is a grandstander. Any lawyer will tell you that the best form of defence is attack. Had anything come out about Vette being below 1000ft over McMurdo, the sh*t would have hit the fan, but it didn't. Crediblity is his case is lacking.
Ron Chippendale is an experienced air accident investigator, who doesn't loose site of the facts, the primary one being that "the PiC has responsibilty for the safe conduct of the flight". If your a/c is stuffed, you don't take it. If the E/R weather is crap, you delay. If there is windshear, you go around. AND IF THERE IS NO VISUAL REFERENCE, YOU DON'T DESCEND BELOW MSA! Simple stuff.
I have the greatest respect for Jim and his family, and for that of all the flight crew. There were alot of distractions on the flight deck that day, none of which was conducive to the safe operation of a large jet aircraft. However, it is still the PiC's responsibility to manage HIS/HER flight deck. The company route was published on the flight plan - and the a/c had INS. The a/c charts had grid co-ords. If you are unsure, plot (ref. my remark about distractions on the flight deck).
There is no disrespect intended for those flight crew or passengers who lost their lives. You only can do your best on the day. Sometimes, that best isn't good enough, and when the REASON Model (for CRM) gives you the right alignment for an accident, it'll happen. The last line of defence is the flight crew, AND THEY FAILED TO SPOT THE ERROR. Air New Zealand was not flying the aircraft, the crew were. And the buck should stop there.

[pakeha-boy]

400Rulz....that is an interesting piece,and a personal perspective.....read it several times just to take it in,and personally think its very balanced...dont have an issue with your opinion as I too agree that the PIC is responsible no matter what happens....I live in that box everyday,so I hope you my previous post didnt allude you to the fact that I dont think Collins was not responsible...because he was,I have no issue with that......

Those Erebus flights were not Regular daily flights and from day one there were issues about who was certified to fly them etc.....but to lump this whole sagarso on one person..the PIC...and say it was his "fault" which it was,(because the PIC IS ALWAYS RESPONSIBLE) is a double standard...
for this "type" of operation

I have no doubt about what you say about the low flying....did it myself around the North pole and many places around Mtns and Glaciers in the "Far North"....it was my choice as PIC....Dangerous???? only if you pranged it......

I do respect your position,but this issue has deeply divided opinions....getting past the PIC thing is more my intention....like you ...much respect for those that were affected.....have one myself....PB

[Brian Abraham]

Firstly, there should be an acknowledgment that if and when the pilot makes a mistake, his will probably be the final enabling one at the apex of a whole pyramid of errors down below. This will, in turn, take the heat off investigations – the ‘we intend to find and punish the culprit’ syndrome.

Yet it is only recently that very dubious management malpractices are being identified and their contribution to accidents given sufficient weight. For though the pilot’s actions are at the tip of the iceberg of responsibility, many other people have had a hand in it – faceless people in aircraft design and manufacture, in computer technology and software, in maintenance, in flying control, in accounts departments and in the corridors of power. But the pilot is available and identifiable.

Research has shown that internally generated thought can block the simultaneous taking up of externally generated information, i.e. that from the outside world. Originally, our ability to blank out too many unwanted stimuli was a survival advantage. But we get nothing for nothing.
The natural adaptations that in past times helped us to survive may now in the technological age be one of our greatest threats. A capacity for conscious representation had survival value for those creatures possessing it, but to achieve its time-saving purposes, conscious experience had to be of very limited capacity.
According to Professor Dixon, formerly Professor of Psychology at University College, London, ‘Conscious awareness is a small flawed barred window on the great tide of information which flows unceasingly into, around and out of the four hundred thousand million neurones and hundred billion synapses which comprise the human nervous system.’ And under stress – the stress of landing, the stress of take off – awareness narrows and the window becomes a tunnel.

A mental ‘set’ is a readiness for a particular thought process to the exclusion of others, resulting in fixation. ‘Set’ is another of the survival characteristics we have inherited. The human brain evolved to help individuals live and survive circumstances very different from our own. It pre disposes us to select our focus on that part of the picture paramount at the time – a vision often so totally focused that it ignores the rest of the environment. The pattern of selectivity programmed into humans by the ancient world is totally obsolete in the present day, where a flexible scanning throughout the visual environment is required. The human beings in the cockpit have to steer a difficult course between too many and too few visual stimuli.

High arousal contributes to ‘set’. The mind becomes tunnelled on a particular course of action. Add to that the ingredient of fatigue or stress and it is not difficult to see that a ‘set’ as hard as concrete can result. Furthermore, ‘set’, particularly in the captain, is infectious. There is a follow-my-leader syndrome. So it is easy to see why most aircraft accidents are caused by ‘silly’ mistakes in the approach and landing phase.

Professor Reason in Human Error (1990) distinguishes between active error, the effects of which are felt almost immediately, and latent error, the adverse consequences of which may lie dormant within the system for a long time. This can clearly be seen in aviation, where pilots at the sharp end make an active error, while latent error lies behind the lines within the management support system. Many of these are already there awaiting a trigger, usually supplied by the pilot. ‘There is a growing awareness within the human reliability community that attempts to discover and neutralise those latent failures will have a greater beneficial effect upon system safety than will localised efforts to minimise active errors.’

As long ago as 1980, Stanley Roscoe wrote that:
The tenacious retention of ‘pilot error’ as an accident ‘cause factor’ by governmental agencies, equipment manufacturers and airline management, and even by pilot unions indirectly, is a subtle manifestation of the apparently natural human inclination to narrow the responsibility for tragic events that receive wide public attention. If the responsibility can be isolated to the momentary defection of a single individual, the captain in command, then other members of the aviation community remain untarnished. The unions briefly acknowledge the inescapable conclusion that pilots can make errors and thereby gain a few bargaining points with management for the future.
Everyone else, including other crew members, remains clean. The airline accepts the inevitable financial liability for losses but escapes blame for inadequate training programmes or procedural
indoctrination. Equipment manufacturers avoid product liability for faulty design,. Regulatory agencies are not criticised for approving an unsafe operation, failing to invoke obviously needed precautionary restrictions, or, worse yet, contributing directly by injudicious control or unsafe clearance authorisations. Only the pilot who made the ‘error’ and his family suffer, and their suffering may be assuaged by a liberal pension in exchange for his quiet early retirement – in the event that he was fortunate enough to survive the accident

The operating crew are the last line of defence for every ones mistakes.

Relying on human beings not to be human in a safety related business is insanity

EGPWS (Electronic Ground Proximity Warning System)– Even Good People Will make an error Some day

400Rulz - the above are a collection put together from various professional authors. It is indeed most interesting that your father on hearing of the accident was instantly able to determine its fate. How so? What other holes in the Swiss cheese do you think there may have been, if any? Might I ask what your aviation credentials are?

[400Rulz]

:} Hi BA,
You may indeed ask - 11600 hrs widebody (767/747), 1000 hrs F27, 900 odd hours military fast jet and transport. My old man took one of those flights down to McMurdo. The briefing material was all there - the onus was on the operator on the day to swot up. One of the problems was that a lot of the material was anecdotal from previous flights (incidentally, that's how Route Guides are established), so if a different route was being flown on the day, it was up to the crew to ascertain if the route was the same. Collins was a fastidious person, and there is no doubt in my mind that he and his crew had briefed thoroughly. HOWEVER, the grid MORAs on the chart are there for a reason. No visual reference, no descent below MSH. I have a strong suspicion that it was more of a commercial decision to descend in order to give the pax value for money. That is a decision made on the flight deck.
The discussion on this will continue for many years to come. Nearly everybody in NZ knew someone on that flight - personally I knew half a dozen. But that is also why the issue is highly charged - it is emotive. I do not disagree that AirNZ should have been allocated some of the blame as there were a lot of "bad management practices" at the time (and there still are) but that does not absolve the crew of the final responsibility for the safe conduct of the flight. We are the last defence.
PB thanks for the reply

[Brian Abraham]

400Rulz and PB. A follow up to the previous.
Sidney Dekker
Associate Professor
Centre for Human Factors in Aviation, IKP
Linköping Institute of Technology
SE - 581 83 Linköping
Sweden
[email protected]
Punishing People or Learning from Failure?
The choice is ours
Disinheriting Fitts and Jones '47
Abstract
In this paper I describe how Fitts and Jones laid the foundation for aviation human factors by trying to understand why human errors made sense given the circumstances surrounding people at the time. Fitts and Jones remind us that human error is not the cause of failure, but a symptom of failure, and that "human error"—by any other name or by any other human—should be the starting point of our investigations, not the conclusion. Although most in aviation human factors embrace this view in principle, practice often leads us to the old view of human error which sees human error as the chief threat to system safety. I discuss two practices by which we quickly regress into the old view and disinherit Fitts and Jones: (1) the punishment of individuals, and (2) error classification systems. In contrast, real progress on safety can be made by understanding how people create safety, and by understanding how the creation of safety can break down in resourcelimited systems that pursue multiple competing goals. I argue that we should de-emphasize the search for causes of failure and concentrate instead on mechanisms by which failure succeeds, by which the creation of safety breaks down.
Keywords: human error, mechanisms of failure, safety culture, human factors, classification, creation of safety
Introduction
The groundwork for human factors in aviation lies in a couple of studies done by Paul Fitts and his colleague Jones right after World War II. Fitts and Jones (1947) found how features of World War II airplane cockpits systematically influenced the way in which pilots made errors. For example, pilots confused the flap and gear handles because these typically looked and felt the same and were co-located. Or they mixed up the locations of throttle, mixture and propeller controls because these kept changing across different cockpits. Human error was the starting point for Fitts' and Jones' studies—not the conclusion. The label "pilot error" was deemed unsatisfactory, and used as a pointer to hunt for deeper, more systemic conditions that led to consistent trouble. The idea these studies convey to us is that mistakes actually make sense once we understand features of the engineered world that surrounds people. Human errors are systematically connected to features of people's tools and tasks. The insight, at the time as it is now, was profound: the world is not unchangeable; systems are not static, not simply given. We can re-tool, re-build, re-design, and thus influence the way in which people perform. This, indeed, is the historical imperative of human factors understanding why people do what they do so we can tweak, change the world in which they work and shape their assessments and actions accordingly.
Years later, aerospace human factors extended the Fitts and Jones work. Increasingly, we realized how trade-offs by people at the sharp end are influenced by what happens at the blunt end of their operating worlds; their organizations (Maurino et al., 1995). Organizations make resources available for people to use in local workplaces (tools, training, teammates) but put constraints on what goes on there at the same time (time pressures, economic considerations), which in turn influences the way in which people decide and act in context (Woods et al., 1994; Reason, 1997). Again, what people do makes sense on the basis of the circumstances surrounding them, but now circumstances that reach far beyond their immediate engineered interfaces. This realization has put the Fitts and Jones premise to work in organizational contexts, for example changing workplace conditions or reducing working hours or de-emphasizing production to encourage safer trade-offs on the line (e.g. the "no fault go-around policy" held by many airlines today, where no (nasty) questions will be asked if a pilot breaks off his attempt to land). Human error is still systematically connected to features of people's tools and tasks, and, as acknowledged more recently, their operational and organizational environment.
Two views of human error
These realizations of aviation human factors pit one view of human error against another. In fact, these are two views of human error that are almost totally irreconcilable. If you believe one or pursue countermeasures on its basis, you truly are not able to embrace the tenets and putative investments in safety of the other. The two ways of looking at human error are that we can see human error as a cause of failure, or we can see human error as a symptom of failure (Woods et al., 1994). The two views have recently been characterized as the old view of human error versus the new view (Cook, Render & Woods, 2000; AMA, 1998; Reason, 2000) and painted as fundamentally irreconcilable perspectives on the human contribution to system success and failure.
In the old view of human error:
• Human error is the cause of many accidents.
• The system in which people work is basically safe; success is intrinsic. The chief threat to safety comes from the inherent unreliability of people.
• Progress on safety can be made by protecting the system from unreliable humans through selection, proceduralization, automation, training and discipline.
This old view was the one that Fitts and Jones remind us to be skeptical of. Instead, implicit in their work was the new view of human error:
• Human error is a symptom of trouble deeper inside the system.
• Safety is not inherent in systems. The systems themselves are contradictions between multiple goals that people must pursue simultaneously. People have to create safety.
• Human error is systematically connected to features of peoples tools, tasks and operating environment. Progress on safety comes from understanding and influencing these connections.
Perhaps everyone in aviation human factors wants to pursue the new view. And most people and organizations certainly posture as if that is exactly what they do. Indeed, it is not difficult to find proponents of the new view—in principle—in aerospace human factors. For example:
"...simply writing off aviation accidents merely to pilot error is an overly simplistic, if not naive, approach.... After all, it is well established that accidents cannot be attributed to a single cause, or in most instances, even a single individual. In fact, even the identification of a 'primary' cause is fraught with problems. Instead, aviation accidents are the result of a number of causes..."
(Shappell & Wiegmann, 2001, p. 60).
In practice, however, attempts to pursue the causes of system failure according to the new view can become retreads of the old view of human error. In practice, getting away from the tendency to judge instead of explain turns out to be difficult; avoiding the fundamental attribution error remains very hard; we tend to blame the man-in-the-loop. This is not because we aim to blame—in fact, we probably intend the opposite. But roads that lead to the old view in aviation human factors are paved with intentions to follow the new view. In practice, we all too often choose to disinherit Fitts and Jones '47, frequently without even knowing it. In this paper, I try to shed some light on how this happens, by looking at the pursuit of individual culprits in the wake of failure, and at error classification systems. I then move on to the new view of human error, extending it with the idea that we should de-emphasize the search for causes and instead concentrate on understanding and describing the mechanisms by which failure succeeds.
The Bad Apple Theory I: Punish the culprits
Progress on safety in the old view of human error relies on selection, training and discipline— weeding and tweaking the nature of human attributes in complex systems that themselves are basically safe and immutable. For example, Kern (1999) characterizes "rogue pilots" as extremely unreliable elements, which the system, itself safe, needs to identify and contain or exile:
"Rogue pilots are a silent menace, undermining aviation and threatening lives and property every day.... Rogues are a unique brand of undisciplined pilots who place their own egos above all else—endangering themselves, other pilots and their passengers, and everyone over whom they fly. They are found in the cockpits of major airliners, military jets and in general aviation...just one poor decision or temptation away from fiery disaster." (back cover)
The system, in other words, contains bad apples. In order to achieve safety, it needs to get rid of them, limit their contribution to death and destruction by discipline, training or taking them to court (e.g. Wilkinson, 1994). In a recent comment, Aviation Week and Space Technology (North, 2000) discusses Valujet 592 which crashed after take-off from Miami airport because oxygen generators in its forward cargo hold had caught fire. The generators had been loaded onto the airplane without shipping caps in place, by employees of a maintenance contractor, who were subsequently prosecuted. The editor:
"...strongly believed the failure of SabreTech employees to put caps on oxygen generators constituted willful negligence that led to the killing of 110 passengers and crew. Prosecutors were right to bring charges. There has to be some fear that not doing one's job correctly could lead to prosecution." (p. 66)
Fear as investment in safety? This is a bizarre notion. If we want to know how to learn from failure, the balance of scientific opinion is quite clear: fear doesn't work. In fact, it corrupts opportunities to learn. Instilling fear does the opposite of what a system concerned with safety really needs: learn from failure by learning about it before it happens. This is what safety cultures are all about: cultures that allow the boss to hear bad news. Fear stifles the flow of safety-related information—the prime ingredient of a safety culture (Reason, 1997). People will think twice about going to the boss with bad news if the fear of punishment is hanging over their heads. Many people believe that we can punish and learn at the same time. This is a complete illusion. The two are mutually exclusive. Punishing is about keeping our beliefs in a basically safe system intact.
Learning is about changing these beliefs, and changing the system. Punishing is about seeing the culprits as unique parts of the failure. Learning is about seeing the failure as a part of the system. Punishing is about stifling the flow of safety-related information. Learning is about increasing that flow. Punishing is about closure, about moving beyond the terrible event. Learning is about continuity, about the continuous improvement that comes from firmly integrating the terrible event in what the system knows about itself. Punishing is about not getting caught the next time. Learning is about countermeasures that remove error-producing conditions so there won't be a next time.
The construction of cause
Framing the cause of the Valujet disaster as the decision by maintenance employees to place unexpended oxygen generators onboard without shipping caps in place immediately implies a wrong decision, a missed opportunity to prevent disaster, a disregard of safety rules and practices.
Framing of the cause as a decision leads to the identification of responsibility of people who made that decision which in turns leads to the legal pursuit of them as culprits. The Bad Apple Theory reigns supreme. It also implies that cause can be found, neatly and objectively, in the rubble. The opposite is true. We don't find causes. We construct cause. "Human error", if there were such a thing, is not a question of individual single-point failures to notice or process—not in this story and probably not in any story of breakdowns in flight safety. Practice that goes sour spreads out over time and in space, touching all the areas that usually make practitioners successful. The "errors" are not surprising brain slips that we can beat out of people by dragging them before a jury. Instead, errors are series of actions and assessments that are systematically connected to people's tools and tasks and environment; actions and assessments that often make complete sense when viewed from inside their situation. Were one to trace "the cause" of failure, the causal network would fan out immediately, like cracks in a window, with only the investigator determining when to stop looking because the evidence will not do it for him or her. There is no single cause. Neither for success, nor for failure.
The SabreTech maintenance employees inhabited a world of boss-men and sudden firings. It was a world of language difficulties—not just because many were Spanish speakers in an environment of English engineering language, as described by Langewiesche (1998, p. 228):
"Here is what really happened. Nearly 600 people logged work time against the three Valujet airplanes in SabreTech's Miami hangar; of them 72 workers logged 910 hours across several weeks against the job of replacing the "expired" oxygen generators—those at the end of their approved lives. According to the supplied Valujet work card 0069, the second step of the sevenstep process was: 'If the generator has not been expended install shipping cap on the firing pin.' This required a gang of hard-pressed mechanics to draw a distinction between canisters that were 'expired', meaning the ones they were removing, and canisters that were not 'expended', meaning the same ones, loaded and ready to fire, on which they were now expected to put nonexistent caps. Also involved were canisters which were expired and expended, and others which were not expired but were expended. And then, of course, there was the simpler thing—a set of new replacement canisters, which were both unexpended and unexpired."
And, oh by the way, as you may already have picked up: there were no shipping caps to be found in Miami. How can we prosecute people for not installing something we do not provide them with? The pursuit of culprits disinherits the legacy of Fitts and Jones. One has to side with Hawkins (1987, p. 127) who argues that exhortation (via punishment, discipline or whatever measure) "is unlikely to have any long-term effect unless the exhortation is accompanied by other measures... A more profound inquiry into the nature of the forces which drive the activities of people is necessary in order to learn whether they can be manipulated and if so, how". Indeed, this was Fitts's and Jones's insight all along. If researchers could understand and modify the situation in which humans were required to perform, they could understand and modify the performance that went on inside of it. Central to this idea is the local rationality principle (Simon, 1969; Woods et al., 1994). People do reasonable, or locally rational things given their tools, their multiple goals and pressures, their knowledge and their limited resources. Human error is a symptom—a symptom of irreconcilable constraints and pressures deeper inside a system; a pointer to systemic trouble further upstream.
The Bad Apple Theory II: Error classification systems
In order to lead people (e.g. investigators) to the sources of human error as inspired by Fitts and Jones '47, a number of error classification systems have been developed in aviation (e.g. the Threat and Error Management Model (e.g. Helmreich et al., 1999; Helmreich, 2000) and the Human Factors Analysis and Classification System (HFACS, Shappell & Wiegmann, 2001)). The biggest trap in both error methods is the illusion that classification is the same as analysis. While classification systems intend to provide investigators more insight into the background of human error, they actually risk trotting down a garden path toward judgments of people instead of explanations of their performance; toward shifting blame higher and further into or even out of organizational echelons, but always onto others. Several false ideas about human error pervade these classification systems, all of which put them onto the road to The Bad Apple Theory.
First, error classification systems assume that we can meaningfully count and tabulate human errors. Human error "in the wild", however—as it occurs in natural complex settings—resists tabulation because of the complex interactions, the long and twisted pathways to breakdown and the context-dependency and diversity of human intention and action. Labeling certain assessments or actions in the swirl of human and social and technical activity as causal, or as "errors" and counting them in some database, is entirely arbitrary and ultimately meaningless. Also, we can never agree on what we mean by error:
• Do we count errors as causes of failure? For example: This event was due to human error.
• Or as the failure itself? For example: The pilot's selection of that mode was an error.
• Or as a process, or, more specifically, as a departure from some kind of standard? This may be operating procedures, or simply good airmanship. Depending on what you use as standard, you will come to different conclusions about what is an error.
Counting and coarsely classifying surface variabilities is protoscientific at best. Counting does not make science, or even useful practice, since interventions on the basis of surface variability will merely peck away at the margins of an issue. A focus on superficial similarities blocks our ability to see deeper relationships and subtleties. It disconnects performance fragments from the context that brought them forth, from the context that accompanied them; that gave them meaning; and that holds the keys to their explanation. Instead it renders performance fragments denuded: as uncloaked, context-less, meaningless shrapnel scattered across broad classifications in the wake of an observer's arbitrary judgment.
Second, while the original Fitts and Jones legacy lives on very strongly in human factors (for example in Norman (1994) who calls technology something that can make us either smart or dumb), human error classification systems often pay little attention to systematic and detailed nature of the connection between error and people's tools. According to Helmreich (2000), "errors result from physiological and psychological limitations of humans. Causes of error include fatigue, workload, and fear, as well as cognitive overload, poor interpersonal communications, imperfect information processing, and flawed decision making" (p. 781). Gone are the systematic connections between people's assessments and actions on the one hand, and their tools and tasks on the other. In their place are purely human causes—sources of trouble that are endogenous; internal to the human component. Shappell and Wiegmann, following the original Reason (1990) division between latent failures and active failures, merely list an undifferentiated "poor design" only under potential organizational influences—the fourth level up in the causal stream that forms HFACS. Again, little effort is made to probe the systematic connections between human error and the engineered environment that people do their work in. The gaps that this leaves in our understanding of the sources of failure are daunting.
Third, Fitts and Jones remind us that it is counterproductive to say what people failed to do or should have done, since none of that explains why people did what they did (Dekker, 2001). With the intention of explaining why people did what they did, error classification systems help investigators label errors as "poor decisions", "failures to adhere to brief", "failures to prioritize attention", "improper procedure", and so forth (Shappell & Wiegmann, 2001, p. 63). These are not explanations, they are judgments. Similarly, they rely on fashionable labels that do little more than saying "human error" over and over again, re-inventing it under a more modern guise:
• Loss of CRM (Crew Resource Management) is one name for human error—the failure to invest in common ground, to share data that, in hindsight, turned out to have been significant.
• Complacency is also a name for human error—the failure to recognize the gravity of a situation or to adhere to standards of care or good practice.
• Non-compliance is a name for human error—the failure to follow rules or procedures that would keep the job safe.
• Loss of situation awareness is another name for human error—the failure to notice things that in hindsight turned out to be critical.
Instead of explanations of performance, these labels are judgments. For example, we judge people for not noticing what we now know to have been important data in their situation, calling it their error—their loss of situation awareness.

[Brian Abraham]

Fourth, error classification systems typically try to lead investigators further up the causal pathway, in search of more distal contributors to the failure that occurred. The intention is consistent with the organizational extension of the Fitts and Jones '47 premise (see Maurino et al., 1995) but classification systems quickly turn it into re-runs of The Bad Apple Theory. For example, Shappell & Wiegmann (2001) explain that "it is not uncommon for accident investigators to interview the pilot's friends, colleagues, and supervisors after a fatal crash only to find out that they 'knew it would happen to him some day'." (p. 73) HFACS suggests that if supervisors do not catch these ill components before they kill themselves, then the supervisors are to blame as well. In these kinds of judgments the hindsight bias reigns supreme (see also Kern, 1999). Many sources show how we construct plausible, linear stories of how failure came about once we know the outcome (e.g. Starbuck & Milliken, 1988), which includes making the participants look bad enough to fit the bad outcome they were involved in (Reason, 1997). Such reactions to failure make after-the-fact data mining of personal shortcomings—real or imagined—not just counterproductive (sponsoring The Bad Apple Theory) but actually untrustworthy. Fitts' and Jones' legacy says that we must try to see how people—supervisors and others—interpreted the world from their position on the inside; why it made sense for them to continue certain practices given their knowledge, focus of attention and competing goals. The error classification systems do nothing to elucidate any of this, instead stopping when they have found the next responsible human up the causal pathway. "Human error", by any other label and by any other human, continues to be the conclusion of an investigation, not the starting point. This is the old view of human error, re-inventing human error under the guise of supervisory shortcomings and organizational deficiencies. HFACS contains such lists of "unsafe supervision" that can putatively account for problems that occur at the sharp end of practice. For example, unsafe supervision includes "failure to provide guidance, failure to provide oversight, failure to provide training, failure to provide correct data, inadequate opportunity for crew rest" and so forth (Shappell & Wiegmann, 2001, p. 73). This is nothing more than a parade of judgments: judgments of what supervisors failed to do, not explanations of why they did what they did, or why that perhaps made sense given the resources and constraints that governed their work. Instead of explaining a human error problem, HFACS simply re-locates it, shoving it higher up, and with it the blame and judgments for failure. Substituting supervisory failure or organizational failure for operator failure is meaningless and explains nothing. It sustains the fundamental attribution error, merely directing its misconstrued notion elsewhere, away from front-line operators.
In conclusion, classification of errors is not analysis of errors. Categorization of errors cannot double as understanding of errors. Error classification systems may in fact reinforce and entrench the misconceptions, biases and errors that we always risk making in our dealings with failure, while giving us the illusion we have actually embraced the new view to human error. The step from classifying errors to pursuing culprits appears a small one, and as counterproductive as ever. In aviation, we have seen The Bad Apple Theory at work and now we see it being re-treaded around the wheels of supposed progress on safety. Yet we have seen the procedural straightjacketing, technology-touting, culprit-extraditing, train-and-blame approach be applied, and invariably stumble and fall. We should not need to see this again. For what we have found is that it is a dead end. There is no progress on safety in the old view of human error.
People create safety
We can make progress on safety once we acknowledge that people themselves create it, and we begin to understand how. Safety is not inherently built into systems or introduced via isolated technical or procedural fixes. Safety is something that people create, at all levels of an operational organization (e.g. AMA, 1998; Sanne, 1999). Safety (and failure) is the emergent property of entire systems of people and technologies who invest in their awareness of potential pathways to breakdown and devise strategies that help forestall failure. The decision of an entire airline to no longer accept NDB approaches (Non-Directional Beacon approaches to a runway, in which the aircraft has no vertical guidance and rather imprecise lateral guidance) (Collins, 2001) is one example of such a strategy; the reluctance of airlines and/or pilots to agree on LASHO—Land And Hold Short Operations—which put them at risk of traveling across an intersecting runway that is in use, is another. In both cases, goal conflicts are evident (production pressures versus protection against known or possible pathways to failure). In both, the trade-off is in favor of safety. In resource-constrained systems, however, safety does not always prevail. RVSM (Reduced Vertical Separation Minima) for example, which will make aircraft fly closer together vertically, will be introduced and adhered to, mostly on the back of promises from isolated technical fixes that would make aircraft altitude holding and reporting more reliable. But at a systems level RVSM tightens coupling and reduces slack, contributing to the risk of interactive trouble, rapid deterioration and difficult recovery (Perrow, 1984). Another way to create safety that is gaining a foothold in the aviation industry is the automation policy, first advocated by Wiener (e.g. 1989) but still not adopted by many airlines. Automation policies are meant to reduce the risk of coordination breakdowns across highly automated flight decks, their aim being to match the level of automation (high, e.g. VNAV (Vertical Navigation, done by the Flight Management System); medium, e.g. heading select; or low, e.g. manual flight with flight director) with human roles (pilot flying versus pilot not-flying) and cockpit system display formats (e.g. map versus raw data) (e.g. Goteman, 1999). This is meant to maximize redundancy and opportunities for double-checking, capitalizing on the strengths of available flightdeck resources, both human and machine.
When failure succeeds
People are not perfect creators of safety. There are patterns, or mechanisms, by which their creation of safety can break down—mechanisms, in other words, by which failure succeeds. Take the case of a DC-9 that got caught in windshear while trying to go around from an approach to Charlotte, NC, in 1994 (NTSB, 1995). Charlotte is a case where people are in a double bind: first, things are too ambiguous for effective feedforward. Not much later things are changing too quickly for effective feedback. While approaching the airport, the situation is too unpredictable, the data too ambiguous, for effective feedforward. In other words, there is insufficient evidence for breaking off the approach (as feedforward to deal with the perceived threat). However, once inside the situation, things change too rapidly for effective feedback. The microburst creates changes in winds and airspeeds that are difficult to manage, especially for a crew whose training never covered a windshear encounter on approach or in such otherwise smooth conditions. Charlotte is not the only pattern by which the creation of safety breaks down; it is not the only mechanism by which failure succeeds. For progress on safety we should de-emphasize the construction of cause—in error classification methods or any other investigation of failure. Once we acknowledge the complexity of failure, and once we acknowledge that safety and failure are emerging properties of systems that try to succeed, the selection of causes—either for failure or for success—becomes highly limited, selective, exclusive and pointless. Instead of constructing causes, we should try to document and learn from patterns of failure. What are the mechanisms by which failure succeeds? Can we already sketch some? What patterns of breakdown in people's creation of safety do we already know about? Charlotte—too ambiguous for feed forward, too dynamic for effective feedback—is one mechanism by which people's investments in safety are outwitted by a rapidly changing world. Understanding the mechanism means becoming able to retard it or block it, by reducing the mechanism's inherent coupling; by disambiguating the data that fuels its progression from the inside. The contours of many other patterns, or mechanisms of failure, are beginning to stand out from thick descriptions of accidents in aerospace, including the normalization of deviance (Vaughan, 1996), the going sour progression (Sarter & Woods, 1997), practical drift (Snook, 2000) and plan continuation (Orasanu et al., in press). Investing further in these and other insights will represent progress on safety. There is no efficient, quick road to understanding human error, as error classification methods make us believe. Their destination will be an illusion, a retread of the old view. Similarly, there is no quick safety fix, as the punishment of culprits would make us believe, for systems that pursue multiple competing goals in a resource constrained, uncertain world. There is, however, percentage in opening the black box of human performance—understanding how people make the systems they operate so successful, and capturing the patterns by which their successes are defeated.
Acknowledgements
The work for this paper was supported by a grant from the Swedish Flight Safety Directorate and its Director Mr. Arne Axelsson.

[prospector]

Well, you can either accept that the buck stops nowhere, and nobody is responsible, or, as many people do, accept the opinion of Sir Geoffery Roberts, a very experienced aviator and Airline administrator. He is quoted as saying,
"I say quite flatly, the main cause was the fact a pilot failed to locate himself in relation to ground features and flew his aircraft into the side of a mountain".

[Desert Dingo]

...Or you may like to think a little more deeply and consider the statement from the privy council appeal, where they said The Royal Commission Report convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged. :=

[400Rulz]

Hey DD.
If that finding is unchallenged, then plz explain why so many professional aviators have a problem with the findings? Their Lordships had no aviation training, and had to rely on third parties for perspective. In an aircraft under my command, the onus is on me to ensure the passengers I carry arrive at their destination. Or at least arrive. Somewhere.
As for causal factors, I have no doubt that there was a deal of contribution the the accident by AirNZ. It would be totally unreasonable to suggest otherwise, but as a professional, I must also accept my responsibility as P-i-C to ensure the safe conduct of my flight. There were laid down procedures for a letdown to McMurdo - these were not followed.
There were distractions on the flight deck, these were not ignored. And, of course, there were commercial pressures to ensure the "punters" got what they paid for. HOWEVER, these two factors should be not be a consideration when YOU are in charge of an aircraft. Company SOP's are there for a reason. You have to have a damn good reason to ignore them. I didn't see (or hear) of one good reason from any of the written submissions or the verbal transcript that suggested otherwise. What other pilots did on the run should have had absolutely no bearing on what happened on the day. Unfortunately, mindset determined what would happen, not professional dictum.
Any pilot who suggests he is beyond reproach, is one to avoid flying with. We are only human, and as such are prone to making errors. But when we do err, lets accept that it was our responsibilty to be the final stopgap. If you can't accept that as a condition of your employment, perhaps you should be looking elsewhere. It doesn't matter what a judge or jury determines, it is about accepting responsibility. I daresay if Jim had have lived, he would have accepted that. It was the sort of person he was.
400R

[pakeha-boy]

DD...yeah, well mate...the privy council doesnt live in the world I live in ......a bold statement to think these blokes were experienced aviation individuals??? in what fields are we talking about???....as suggested ...3rd parties provided info so that they were able to give/pass judgement.....

The combination of 400,s and Brians arguments is where I feel we must find common ground,this is not the first incident of this kind and it certainly wont be the last.....

I constantly try to find reasoning in decisions I make,some worthy of extra training,some absolutly brilliant,more so the first than the last......but at least I,m critical of myself and of no other......

the bottom line ....as PIC ....dont pass the buck,you are an will be responsible for the conduct of your flight,if your not up to it,dont take it,and as 400 stated and I believe this,Jim would have found himself accountable whether it was is cockup or not....that is the PIC,S resonsibilty....

thats the other problem inherant in aviation....it can never be a combination of people and problems,someone has to be the scapegoat....we need to nail "someone"....one individual has to be responsible.In case,s like this,it is just not the case

Brian,great reading mate,actually copied it and fwded to several people in my Ops dept for reading...if you dont mind......PB

[chimbu warrior]

Justice Mahon's royal commission of inquiry into the 1979 Erebus crash has changed the way many of the world's transport accident inquiries are handled, says retired investigator Ron Chippindale.

Mr Chippindale, who was among those who received a special service medal this week for their work on Erebus after the DC10 crash which killed 257 people, said the broad approach taken by Justice Mahon had since been adopted internationally.

Justice Mahon's inquiry pointed the finger at Air New Zealand management rather than the DC10 pilots. A section looking at possible airline management issues contributing to accidents is now included in all International Civil Aviation Organisation accident inquiries.

Mr Chippindale said that, at the time of his inquiry, the objective was to sift through the information and come to a proximate conclusion as to the probable cause - the last critical error that made the crash inevitable. He found the probable cause was the captain's decision to continue flying at a low level toward an area of poor visibility when the crew were uncertain of their position.

Justice Mahon disagreed with the investigator's approach, of attempting to find a single cause. This had long since been discarded by the legal profession. He set the pattern for allocating a number of causes without giving priority to any particular one.

Though that had now been taken up overseas, Mr Chippindale said he still took issue with Justice Mahon's exoneration of the pilots. He instead blamed the airline for changing the computer flight coordinates without telling the pilots, and the optical illusion of a "whiteout", which made it look as though they were flying over flat ice when, in fact, the ground was rising quickly.

Mr Chippindale said the pilots had instructions not to descend unless the air was "gin clear". "They had practised that in the simulator and they had written instructions to that effect.

" Had they stayed above minimum safe altitude the accident wouldn't have happened. That's called airmanship.

"They were down at just under 1500 feet at high speed and not sure of their position. In my opinion that was inexcusable." Though the airline had changed flight coordinates without telling the pilots, he wondered whether they had coordinates in the first place. "We examined the briefing which was shoddy, pathetic and hopeless. If they (the pilots) had maintained the minimum safe altitude, the wrong coordinates would not have made a difference."

Judge Mahon came to a different conclusion about the written instructions, saying that Air New Zealand had not objected to other flights going to low altitude and that the airline had therefore condoned it.

"He omitted to mention that all the other aircraft had descended in clear conditions, where this one descended through a gap in the cloud and that made a critical difference," Mr Chippindale said. "Just because a lot of people get away with going up a one way street in the wrong direction doesn't mean it's allowed."

[prospector]

Still begs the question, Even if they were in the position where they thought they were, following the track they thought they were on, why could they not see a 12,000ft mountain that they knew, or should have known was some 40 miles away, this in an area of renown brilliant visibility in excess of 100 miles. Sector whiteout, it would appear, explains why they never saw this mountain, but if they had never, as no one else at the time had, heard of sector white out how do you explain a descent without even wondering why they could not see this mountain.??

How can anyone not agree with Mr. Chippindales findings??

[13370khz]

Hello !

Anybody know if the TVNZ docudrama "Erebus-The Aftermath"
is available as video tape or DVD ?

[cjam]

Having spent the last hour reading this whole thread I feel inclined to align myself with prospector & co.
I believe that there were many factors leading to the crash but at the end of the day I can't go past the fact that the SOP's mandated no descent below FL160 unless VMC and no descent below 6000' ....period.
When I read John Kings book a few months back on the crash, one pilot who had conducted a previous flight testified that although he had unlimited visibility, and although he was an ex strike pilot with plenty of low level experience, and although he dearly wanted to, when McMurdo ATC invited him to do a low run down the strip he declined and remained at 6000'. If that chap was PiC of flight 901 would the accident have happened? I don't believe so.That is not a dig at J Collins...just what I believe to be most likely.
Jim C had his flight plan mucked up, he didn't know that, but he did know that it was a new environment for the whole crew and that he expected VHF contact earlier, and radar contact earlier, and TACAN reception, and he also knew the SOPs for letting down.
Lots of people made mistakes, Collins' mistake is easy to take a shot at. No one person is totally to blame. Many people carry a share of the blame.

[VH-MLE]

Hi all,

I have always felt that the crew were made scapegoats in this accident, however having read 400Rulz posts on the subject, I have changed my view on the cause of this accident somewhat to acknowledge that the crew were the last line of defence in preventing this accident, however I still steadfastly stick to the view that ANZ must share responsibility in this accident.

I note the relevant comments about the Privvy Council having little or no aviation experience, however I also note that Sir Geoffrey Roberts may have had a bias in ANZ's favour.

Regards.

VH-MLE

[bushy]

Brian Abraham that is valuable information that we should all reflect on for a long long time. Probably the most valuable post I have ever seen on here.
On Sept 11th 2001? I was in Adelaide, watching those aircraft fly into the WT Centre. I had flown down to hear Professor James Reason speak at a breakfast meeting the following morning. (the only time I ever got a free feed from CASA. I had to fly 3000 km to get it.)
I remember very clearly that James Reason said emphatically and repetitively that the "blame game" was counter productive, and it is obviously damaging. It fixes nothing.
From another source, I remember the saying "I don't care who is to blame, I want to know who is going to fix it, and how"
We have to decide whether we are going on a witch hunt to find a politically convenient outcome of an investigation, or if we are genuinely trying to improve safety by finding the traps that the players fell into, and fixing them. This has been known since 1947, and it has been denied since 1947. It is being denied today. I heard a saying today "the fools are in charge, but the wise men are shouting louder".
Did Capt Collins know he was going to fly into a mountain? Of course not. He had a reputation as a competent, reliable, stable pilot, so we can reasonably assume that he considered what he was doing was safe. And when faced with information that challenged that safety he took steps to climb out. Too late. I think the CVR backs up that.
There is much evidence that Capt Collins was tricked by false information, and lack of essential knowledge about whiteout and visual tricks in that region.
It has been said that he descended below the level allowed by SOP's. It also appears that he had a long history as a safe, responsible pilot. Why then did he descend lower than the SOP'S permitted? Did he know the SOP's?.
Does this tell us something about the credibility of the SOP's
Powerful forces are involved. Air NZ was a government owned airline, and the regulator was the govt, and a large English insurance company, all had much deeper pockets than the pilots could ever have. The legal and financial possibilities were frightening.
Mr Chippendale did what he thought was right, and it was a convenient outcome for many. It followed the normal pattern of accident investigation, but was it right?
The other pilots and the Judge did not think so, and the final outcome was decided by their lordships in another country. A country where the big insurance company lived.
Many things could have been done better
but the NZ people are not silly and they quietly re-organised things. Today most of the people who were involved at the time of the Erebus crash have long gone. I had great respect for the head of the navigation section who stood up in court and said "I did it wrong". Air NZ is not a newcomer. They have been operating (earlier as TEAL) for more than half a century.
But the inappropriate, simplistic, military style administration system still prevails, in our society, and the knowledge which has been available to us since 1947 is still denied.
It's convenient for our administrators that way. That's why we have to have independent legal systems to pull them into line sometimes. Checks and balances.
And Air NZ operates today as a safe, respected airline, as it should, because someone challenged the system.

[bushy]

One day I got the "phone call from hell".
It was ASA, and the voice said "one of your aeroplanes has had an engine failure at Woop Woop and has landed on the road. Do you want me to call the police, or will you do it?"
After I had stared at the wall for about a minute I phoned the refueller at Woop Woop and asked him to provide a vehicle, and go out and look after the pilot and passengers until I could get another aeroplane to pick them up. (refuellers know everything, and control the resources out there). Then I phoned the LAME who looked after that aeroplane.
Within five minutes I got a call from the Woop Woop refueller to say"they put AVTUR in that aeroplane". It had a piston engine and should have had AVGAS. The LAME was pleased to hear this news, but I was not.
So this is a simple case isn't it? The pilot stuffed up. So you sack him, and get on with the work. Problem solved. Isn't it? Or is it?
That's not what happened. When the pilot got back to base, I shook his hand, and thanked him for saving the aeroplane and passengers. I told him to take a week off work, and that his job was safe.
Then I talked to the Woop Woop refueller and found a couple of things I did not expect. The avtur drums and the avgas drums were stored in close proximity, in the the same compound. I remember the old drums used to have large areas of bright colour as well as small lettering to indicate what grade of fuel they contained. This company painted all of the drums the same colour, and the small identifying lettering was a different colour for each grade. One layer of the swiss cheese had been removed. But the one I did not expect in Australia was THE REFUELLERS COULD NOT READ!!!
The Woop Woop refueller agreed to make sure the different types of fuel were stored at different sites, and to be more carefull allocating labour. He was normally present himself, but was not on this occasion). He built more fences.
I talked to our ever helpful FOI and he promised to speak to the fuel company about more prominent labeling on fuel drums.
Sure, the pilot could have done it better. Couldn't we all? He had had a very valuable lesson (one you cannot buy) and did lot's of good work for me before going on to bigger and better things with my recommendation and support.
Let him who is without sin throw the first stone.
Had I just sacked the pilot, the trap would still be out there for others, and no-one would know. This would have been the simplistic, military style convenient pseudo solution that is too common in aviation. And it would have adversely affected one of the industry's better pilots.
A much better outlook was described in 1947, and is still being denied.

[werbil]

Bushy :ok::ok::ok: (both posts)

[Taildragger67]

Bushy,

Re your distinction between the work of Chippendale and Mahon - I suggest they were both right, because they were looking for different things. Chippendale was correct in stating that the actions of the pilots placed the aircraft in a situation where it suffered CFIT - and that is CFIT - it was not a person in Auckland who disconnected the A/P and descended the a/c to 1600'. So he was looking at the actual actions in the immediate lead-up to the impact. That's understandable, he was a copper.

However Mahon then looked at why the crew thought it was ok to act as they did - that is, what they (as competent, experienced aviators) were thinking - and he found that there was background to it which did stretch back to Auckland.

One was looking at 'what has happened'? - an a/c hit a mountain; the other was looking at 'what caused the a/c to be in a position to hit the mountain?' - human factors and the ol' chain...

[bushy]

They were both right. In their own way. According to their own culture and standards. But thank god for Gordon Vette and the courts, and in particular Justice Mahon.

[stillalbatross]

From memory in the accident report there were 5 factors required by Air NZ SOPs for you to descend below the MSA. You needed all 5, not a couple, not near enough, and they descended without all 5. And yes, the captain has the final authority to operate the aircraft as he sees fit but the SOPs are what the AOC is legally based on in a court of law. When you add in the fact that the US military did an awful lot of training to operate in that environment and had pretty strong reservations about Air NZ doing what they were doing. It was crazy to think that widebody longhaul anywhere else on the Air NZ network could prepare you for VFR polar ops. There were so many holes lined up the second someone in marketing first suggested "let's do antartica" it doesn't bare thinking about.

[pakeha-boy]

Bushy Quote........"But thank god for Gordon Vette and the courts, and in particular Justice Mahon".

yeah mate!! well said...at least he was an advocate for the pilots....he took a lot of strife....but a very interesting and smart fella.....met him quite a few years back,briefly as I recognised him from photos,.......last I heard he was not doing well....anyone know

[malcolmyoung90]

Hello !

Anybody know if the TVNZ docudrama "Erebus-The Aftermath"
is available as video tape or DVD ?


13370khz,

How did you go? Any favourable responses?

I have been trying (in vain) for several years to obtain a copy of this (award winning) TV docu-drama. I vaguely recall watching it on TV here in Australia as a youngster, probably around 1988 when it was released. I have since contacted the Australian Broadcasting Commission, who have said that they don't have the rights to this series. I've also contacted the TV station in NZ that screened it, as well as the NZ Film Commission, but have similarly had no success. It is almost as if there has been some type of intervention to prevent it from ever being released commercially (even on a small scale).

[Front Pit]

Now what would Justice Mahon have thought of this...... :(

Erebus article censor found at Air NZ
By JOHN HENZELL - The Press | Tuesday, 21 August 2007

An Air New Zealand computer was used to sanitise an online encyclopaedia article to make the airline look less culpable for its part in New Zealand's worst peacetime disaster.

An article about the 1979 Erebus crash on Wikipedia, an internet encyclopaedia able to be edited by users, was altered to state "pilots are divided to this day as to whether the responsibility ... should rest with the pilot or the flight planning department" over the deaths of 257 passengers and crew.

The alteration, which has since been deleted, was identified this month as coming from a computer using the Air New Zealand server.

An Air New Zealand spokeswoman said the company was investigating the allegation.

But Cabinet minister Jim Anderton said that, if true, the change was "outrageous (and) entirely erroneous".

It was a case of the airline – now 80 per cent owned by the Government – trying to rewrite history to make itself look better.

The airline's computers were implicated through a programme devised by self-described American "destructive technologist" Virgil Griffith to identify the computer systems used by those who made alterations to Wikipedia.

Computer experts contacted by The Press also tracked the altered entry back to Air New Zealand's computer server.

Anderton has previously called on the Government to make a formal declaration that Captain Jim Collins and co-pilot Greg Cassin were not to blame for the crash.

He said yesterday that to suggest there was disagreement over blame for the Erebus crash was unjustifiable and wrong.

Maria Collins, the widow of Jim Collins, said yesterday that it was of little importance what Wikipedia said about the crash.

"Whether Wikpedia says one thing or another and who wrote it or authorised it – so much has been written that is incorrect that I have stopped jumping up and down," she said.

The Wikipedia alteration left unchanged the findings by Justice Peter Mahon's Royal Commission that Air New Zealand executives had been behind an "orchestrated litany of lies" to cover up the cause of the accident, including disposing evidence and engaging in subterfuge.

It also made no change to the assertion that Mahon's findings remained, even though the Privy Council overturned the result because he had exceeded his powers and denied the airline a fair hearing.

Anderton said the alteration suggested that Air New Zealand remained sensitive to allegations of blame for the Erebus crash.

He said pilots' associations in New Zealand and internationally had endorsed Mahon's findings and the only dissent by pilots over the fault was from those who had a "vested interest" in upholding the original accident report overturned by the Royal Commission.

New Zealand Airline Pilots Association president Mark Rammell said there was no division among pilots.

"Justice Mahon's finding, that was the official finding of the Royal Commission and that was accepted in Parliament," Rammell said.

"Our pilots are completely happy with that finding, that it was not pilot error."

[prospector]

Mr Rammel is taking a lot upon himself,


"New Zealand Airline Pilots Association president Mark Rammell said there was no division among pilots."

Just reading this thread and others from other forums, it is patently obvious that there is much division among many pilots from many backgrounds.

As for the opinion of Mr Anderton, it is just that, his opinion, based upon what aviation knowledge or experience?. It is of as much value in determining blame as the Townsville refuellers opinion.

[400Rulz]

Well said, Prospector. Mr Rammell is obliged to take that stance as President of NZALPA. To state otherwise would be contrary to his mandate. The fact that Parliament accepted the findings says absolutely nothing. Not one of those idiots had a background in aviation, and all had a vested interest in getting re-elected - the "lets show outrage and the public will side with us" mentality that all politicians appear to have. Mr Anderton is no different. The polls suggest he may be history this time around, so best get name in the paper......
I'm sorry, Front Pit, but I have been in this game for 30 years now, and I have yet to find one of my peers who does not have a different slant on the accident and the subsequent findings. To state that all pilots are unified on the subject is pure cowsh. So what if some AirNZ worker used the mainframe to edit the article - Wikipedia is hardly what I would call an authoritative encyclopaedia. The mere fact that ANYBODY can edit an article negates the definition. Air New Zealand is so far past the Erebus incident - the culture, training, management and operating procedures have all changed (for the better, I might add). Surely we should all be moving on.
Hope you all had a good Christmas and New Year.
400R

[nick charles]

PRIVY COUNCIL FINDINGS

The Royal Commission Report convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged.

It continues on to explain why Mr Chippindale’s finding of pilot error was wrong:

The judge was able to displace Mr. Chippindale's attribution of the accident to pilot error, for two main reasons. The most important was that at the inquiry there was evidence from Captain Collins' widow and daughters, which had not been available to Mr. Chippindale at the time of his investigation and was previously unknown to the management of A.N.Z., that after the briefing of 9 November 1979 Captain Collins, who had made a note of the co-ordinates of the Western Waypoint that were on the flight plan used at that briefing, had, at his own home, plotted on an atlas and upon a larger topographical chart the track from the Cape Hallett waypoint to the Western Waypoint. There was evidence that he had taken this atlas and chart with him on the fatal flight and the inference was plain that in the course of piloting the aircraft he and First Officer Cassin had used the lines that he had plotted to show him where the aircraft was when he switched from nav track to heading select in order to make a descent to 2,000 feet while still to the north of Ross Island which he reported to ATC at McMurdo and to which he received ATC's consent. That on completing this descent he switched back to nav track is incapable of being reconciled with any other explanation than that he was relying upon the line he had himself plotted of the flight track on which he had been briefed. It was a combination of his own meticulous conscientiousness in taking the trouble to plot for himself on a topographical chart the flight track that had been referred to at his briefing, and the fact that he had no previous experience of "whiteout" and had been given no warning at any time that such a deceptive phenomenon even existed, that caused the disaster.

The other principal reason why the judge felt able to displace Mr. Chippindale's ascription of the cause of the accident to pilot error was that certain remarks forming part of the conversations recorded in the CVR of the crashed aircraft and attributed by Mr. Chippindale to the flight engineers had suggested to him that shortly before the crash they were expressing to the pilot and navigator uncertainty about the aircraft's position. The tape from the CVR which had been recovered from the site of the crash proved difficult to interpret. The judge, with the thoroughness that characterised him throughout his investigations, went to great pains to obtain the best possible expert assistance in the interpretation of the tape. The result was that he was able to conclude that the remarks attributed by Mr. Chippindale to the flight engineers could not have been made by them, and that there was nothing recorded in the CVR that was capable of throwing any doubt upon the confident belief of all members of the crew that the nav track was taking the aircraft on the flight path as it had been plotted by Captain Collins on his atlas and chart, and thus down the middle of McMurdo Sound well to the west of Mt. Erebus.

Then they confirm that Justice Mahon was correct in castigating the airline

The judge's report contains numerous examples and criticisms of A.N.Z.'s slipshod system of administration and absence of liaison both between sections and between individual members of sections in the branch of management that was concerned with flight operations. Grave deficiencies are exposed in the briefing for Antarctic flights; and the explanation advanced by witnesses for the airline as to how it came about that Captain Collins and First Officer Cassin were briefed on a flight path that took the aircraft over the ice-covered waters of McMurdo Sound well to the west of Mt. Erebus but were issued, for use in the aircraft's computer, as the nav track a flight path which went directly over Mt. Erebus itself, without the aircrew being told of the change, involved admissions of a whole succession of inexcusable blunders by individual members of the executive staff. None of this was challenged before their Lordships. No attempt was made on behalf of A.N.Z. to advance excuses for it.

The privy council appeal verdict did not overturn any of Justice Mahon’s conclusions as to who was to blame for the disaster. It was the airline !

What the privy council appeal verdict did do was reluctantly agree that Justice Mahon went a bit too far in paragraph 377 of his report :
**************************************************

[prospector]

It would appear some people still believe the world is flat.

[Desert Dingo]

...and some people appear to have trouble understanding
The Royal Commission Report convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged.
...but perhaps an armchair expert's opinion carries more weight than a Royal Commission Report :ugh:

(Go back and read post #88 slowly FFS
I'm with Nick on this one.)

[Front Pit]

It would appear some people still believe the world is flat.

Mount Erebus isn't flat but McMurdo Sound is. :rolleyes:


400R, Thanks had a great Christmas & New Year and hope everyone else did too. No need to say sorry, in this case I’m only the messenger. However, in altering information regarding the 1979 Erebus disaster in 2007 it appears that old habits die hard with some at Air New Zealand. Quite amazing. It’s also amazing, and quite appalling that some here wish to dance on the graves of Jim Collins & Greg Cassin for not actually seeing an optical illusion!!………. What a prospect!

Thanks for your interesting posts nick charles and desert dingo.

At the end of the 1981 documentary “Flight 901 – The Erebus Disaster” and the 1987 mini-series “Erebus – The Aftermath” they make similar quote’s from Justice Mahon’s finding’s ---- “For my purposes the most definitive illustration of the hidden peril’s of the Antarctic was the wreckage which lay on the mountainside below me, showing how the forces of nature, if given the chance, can sometimes defeat the flawless technology of man. The crash was a million to one chance caused by a series of disastrous administrative blunders, but the ultimate key to the tragedy lay here in the white silence of Lewis Bay, the place to which the airliner had been unerringly guided by it’s micro electronic navigation system, only to be destroyed in clear air, and without warning, by a malevolent trick of the polar light”.

I think that say’s it all.

May they rest in peace………….FP

[prospector]

"and the fact that he had no previous experience of "whiteout" and had been given no warning at any time that such a deceptive phenomenon even existed, that caused the disaster."
And that is exactly why the SOP's stated what requirements had to be met before any descent. It was because the crew did not comply, not just with some, but with none of the requirements for descent as laid down both by the company and CAA that caused the disaster.

Obviously this ground can be gone over and over again, as it has been, but for my money Mr Chippendale, who was an experienced Aviator, came up with the right conclusion as to what caused the disaster. Mr Mahon, who had never strapped an aeroplane onto his posterior was really out of his depth, and his findings were only an opinion that could not be appealed.

He admittedly came up with some new methods of ascertaining deep seated causes of mishaps, which was a breath of fresh air after years of all accidents being put down to pilot error, but in this particular case he ignored much really relevant evidence, and with no aviation background how could he ascertain what was relevant and what was not. He made very little use of the aviation expertise that was available to him in the form of a qualified consultant.

[400Rulz]

Nick,
I don't know if you have any sort of grounding in aviation. If you do, then I am surprised at some of your assertions. I suggest you read some of my previous posts, esp. regarding the responsibilities of the P-i-C. Regardless of what is on the CFP (Company Flight Plan) the Captain has the ultimate responsibility for the safe conduct of the flight. Once the aircraft is despatched (i.e. when the ground engineer signals "clear to taxi"), the Captain's decisions are the ultimate authority (see CAA regs.). It matters not what the airline has planned. What the Captain should be ultimately guided by are the SOP's. Once again, I reiterate, these were NOT adhered to (ref. Capt. Chippendale's testimony).
I am not saying that the Airline should not shoulder some of the responsibility - it should. Capt. Collins should have been advised of the change of flight plan. Having said that, he should have plotted the co-ordinates from the plan he was issued with, NOT what was done in the past - it was irrelevant. These flights were not a regular occurence and did not follow a CAA published route, therefore there was always the possibility of a routing change, and it is the duty of the flight crew to ascertain where the aircraft is going. The Reason model for accidents clearly states that there is seldom a single reason for an accident or incident, and that only by looking at ALL the causal factors, can we come up with the true cause of an accident/incident. HOWEVER, whichever way you look at it, the flight crew ARE the last line of defence. If they screw up (e.g. not following SOP's), then there are usually fatalities.
There were many factors that contributed to the loss of TE901. Both Air New Zealand and the flight crew were at fault. The fact that ANZ tried to cover up some of their errors is essentially irrelevant, because this in itself did not contribute to the accident. Shoddy management practices and poor administration did, however, and the judge was correct in pointing that out. One has to bear in mind, though, that it was NOT AirNZ who descended the aircraft below MSA (incidentally, the CFP had the aircraft crossing Erebus well above the summit), but the flight crew. HAD THE FLIGHT CREW STUCK TO THE FLIGHT PLAN, TE901 WOULD HAVE RETURNED SAFELY TO CHRISTCHURCH.
400R
PS. FP - whiteout is indeed an optical illusion, but it precludes the seeing of a visible horizon (been down to the ice enough to know). Think about the definition of VFR - clear of clouds and IN SIGHT OF GROUND OR WATER. If you can't distinguish between them, bug out, 'cause you're in a bad place. And I dance on no-ones grave - the crew were personal friends of the family.

[Front Pit]

HAD THE FLIGHT CREW STUCK TO THE FLIGHT PLAN, TE901 WOULD HAVE RETURNED SAFELY TO CHRISTCHURCH.


As other Antarctic flights had done, except that with this one the co-ordinates had been changed.

What you and other’s here sadly fail to come to grip’s with is that this was not a regular commercial flight from Auckland to LA at 35000 it was a SIGHTSEEING FLIGHT at low level for the enjoyment of all on board and with ample evidence from other pilot’s testimony and newspaper article’s confirming the flight’s were conducted, where permissible, at low level. Jim Collins and other pilot’s had been briefed, on the same day, of a flight plan down the flat ice of McMurdo Sound. The difference with the 28 Nov flight was that the co-ordinates had been changed and the Captain was NOT INFORMED when he quite obviously should have been. The family’s testimony was that the night before the flight Jim Collins examined his briefing notes and map’s and was showing them of the flight plan down from Cape Hallett across the flat ice to McMurdo……..well away from Mt. Erebus.

Yes the P-i-C is responsible for the safety of all on board, however, I do not believe you can be so rigid in enforcing that in light of the extraordinary set of circumstances involved with this flight. Circumstances bordering on disbelief that they could happen……but regrettably they did. And I for one won’t blame Jim with pilot error for not seeing an optical illusion. If Jim or the crew could have “seen” Mount Erebus then he would have taken the appropriate action and 257 people would have returned to NZ safely, however, the combination of a remarkable set of circumstances conspired against them, and is now history.

It appears we will just have to agree to disagree.

[400Rulz]

Come on, FP. You don't really believe that do you? Yes, it was a sight-seeing flight, but it was NOT planned at low level, at any stage. The company laid down strict criteria for a descent below minimum safety altitude. Not one of those criteria was fully satisfied, and therefore the flight should not have descended, and the crew not buckled to commercial pressure. My old man flew one of the flights to McMurdo, so I'm not just surmising. The flights were conducted under IFR, with the proviso that a let-down was acceptable in VFR conditions, in other words, NO VISUAL REFERENCE, NO DESCENT. And, as with any visual approach, if you lose visual reference, you go around. Had the crew initiated a go-around the moment they could no longer be sure of the horizon, there would have been no impact. This was ascertained in trials in the simulator following the accident.
I have no problem with agreeing to disagree, but if you are going to have an opinion, it should be informed.
400R

[Front Pit]

400 -- Bollocks yourself, a sightseeing flight which is not planned at low level at any stage, yeah right, how exciting would that be? People would be clambering over themselves to pay to see Antarctica from 35,000!!....or for that matter even 16,000... :rolleyes: They saw the horizon but unfortunately for them it was an optical illusion, until you take the blinkers off and accept the facts, and the umpire's decision that the pilot's were not responsible, then there's no hope for you. Poor soul. :(

[Desert Dingo]

400Rulz says:
The flights were conducted under IFR, with the proviso that a let-down was acceptable in VFR conditions, in other words, NO VISUAL REFERENCE, NO DESCENTCVR said:
35:36 “Presently through FL130. VMC. Intention to descend to 10,000”
38:23 “I’ve got to stay VMC, so I’ll be doing another orbit.”
42:49 “We’re VMC around this way, so I’m going to do another turn.”
45:00 “Now at 6000, descending to 2000, VMC.”

And you argue that he was not maintaining VMC? :ugh:

400Rulz says:
And, as with any visual approach, if you lose visual reference, you go around. Had the crew initiated a go-around the moment they could no longer be sure of the horizon, there would have been no impactSo when was it they could no longer be sure of the horizon?
CVR said:
00:46:39z “Where is Erebus in relation to us at the moment?” “Left, about 20 or 25 miles…about 11 o’clock.”
00:47:43z “Might have to drop down to 1500 feet here, I think”
00:48:46z “Actually, these conditions don’t look very good at all.”
00:49:24z “I don’t like this.”
00:49:30z “We’re 26 miles north. We’ll have to climb out of this.
00:49:40z GPWS
00:49:49z “Go-around power please”
00:49:50z Impact

Surely the whole point is that because of the whiteout visual illusion the crew believed that they were in VMC and did have visual references.

Note the 9 second delay from the GPWS and calling for Go-around power. Yes, if the reaction had been instantaneous AND they had turned in the correct direction the crash may have been avoided, as shown by the later simulator exercises.
However, as they believed they were over the flat surface of McMurdo sound, I think they should be allowed some WTF? reaction time. I know I would have needed it.

[nick charles]

Nick,
I don't know if you have any sort of grounding in aviation
----------------------------------------------------------------------
400Rulz,

Some 35 years experience in the military and on domestic and international RPT routes, 25 years as PIC - and even a short period in Antarctia. I'm really not interested in debating the issue any more.

Any operator that deems it necessary to break into the homes of pilots and remove private property does not meet the characteristics required by the holder of an AOC.

[400Rulz]

FP
Here is an extract from the Canadian AIP:
Whiteout (also called milky weather) is defined in the ‘Glossary of Meteorology’
published by the American Meteorological Society as an atmospheric optical
phenomenon of the Polar Regions, in which the observer appears to be engulfed
in a uniformly white glow. Neither shadows, horizon, nor clouds are discernible;
sense of depth and orientation is lost; and only very dark, nearby, objects can be
seen. Whiteout occurs over an unbroken snow cover and beneath a uniformly
overcast sky when, with the aid of the snowblink effect, the light from the sky is
about equal to that from the snow surface. Blowing snow may be an additional
cause. Light carries depth perception messages to the brain in the form of colour,
glare, shadows, and so on. These elements have one thing in common: they are
all modified by the direction of the light, and changes in light intensity. For
example, when shadows occur on one side of objects, we subconsciously become
aware that the light is coming from the other. Thus, nature provides many visual
cues to assist us in discerning objects and judging distances. But what happens if
all these clues are removed? Suppose these objects on the ground and the ground
itself are all white. Add to that a diffused light source through an overcast, which
is reflected back in all directions by the white surface, so that shadows disappear.
The terrain is now virtually devoid of visual clues, and the eye no longer discerns
the surface or terrain features. Since the light is so diffused, it is likely that the sky
and terrain will blend imperceptibly into each other, obliterating the horizon. The
real hazard in whiteout is the pilot not suspecting the phenomenon, because he is
in clear air. In numerous whiteout accidents pilots have flown into snow-covered
surfaces unaware that they have been descending, and confident that they could
‘see’ the ground. Consequently, whenever a pilot encounters the whiteout
conditions described above, or even a suspicion of them, he should immediately
climb if at low level, or level off and turn towards an area where sharp terrain
features exist. The flight should not proceed unless the pilot is prepared, and
competent, to traverse the whiteout area on instruments.

I have underlined the relevant point(s).

Nick, point taken, I agree with you re. the break in. Nasty stuff. And un-necessary. I didn't mean to imply you had no aviation knowledge, just wondered how you reached your conclusions.

DD.: The Company brief specified "Gin clear weather" not 1/8th or even 2/8th cloud. The mere fact that the aircraft had to orbit in order to find a way to remain VMC says it all. The crew did not meet the requirements as laid down by either the company or CAA. But in this case all were culpable, from CAA to the airline and finally to the crew on the day. All must share responsibility for an accident that should not have happened. The blame cannot be attributed to any single factor, but a multitude of errors that resulted in the loss of TE901. All I am trying to say here is that the crew CANNOT be exonerated, because if they had followed procedures, the "line of errata" would have been terminated, without the sad consequences. Suggest you read Brian Abraham's posting earlier on in the thread.

The problem with this issue is that it still remains a highly emotive subject. Most people made their minds up about culpability years ago. Developments in accident modelling since then have demonstrated that it is rarely the fault of a single individual that causes accidents, but usually a string of events that when "lined up" results in a situation where the crew are set up for an accident. In the final analysis, the crew are the last line of defence. If they fail to follow SoP's, give in to commercial pressure etc., then an accident is the result.

Pool Boy: Interesting one-liner. Hope you have the intelligence to back it up. Now go clean that skimming basket...

This will be my last post, but I will read any further discussion with interest.
400R

[Pool Boy]

Desert Dingo, exactly what i was thinking. methinks 400rulz has dug himself a large hole with his last post.

[jack red]

400Rulz

The company laid down strict criteria for a descent below minimum safety altitude.

do you believe in the Easter Bunny as well..........................?:ugh:

[prospector]

'And you argue that he was not maintaining VMC? "

This is not relevant, the requirements for descent were laid down both by the company and CAA. As has been stated ad infinitum, none of the requirements for descent were met. There is no doubt that the crew were in full knowledge of the requirements for descent, the requirements were there to prevent just such a disaster from taking place.

This was not an aircraft owned by the crew to do with as they wished, the Company owned it, held the AOC, and prescribed though SOP's how they wanted their aircraft operated. The CAA also laid down their requirements for these operations to take place. These requirements were ignored and we have all seen the results.

For anyone who has not yet seen these requirements here they are.

1. Vis 20 Km plus.

2. No snow showers in area.

3. Avoid Mt Erebus area by operating in an arc from 120 degrees Grid through 360 degrees grid to 270 degrees grid from McMurdo Field, within 20nm of TACAN CH29.

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

As has been stated many times not one of these requirements was adhered to. They were mandatory requirements, not as some would have us believe to be complied with if it suited but ignored if it did not suit.

[nick charles]

Desert Dingo,

Couldn't agree with you more. The crew THOUGHT that they were in VMC conditions. They were not INTENTIONALLY ignoring visual descent requirements. Prospector doesn't seem to understand that basic point.

If NO ONE at Air NZ was aware of sector whiteout, what the hell were they doing there and why did the NZ CAA give them approval to conduct flights to Antarctia? "No one does it better!"

[prospector]

How many times!!!!

Read at least requirement No 3 above. It gives no leeway for inventing a personal descent profile, it is very specific, and as it states it is there to avoid Mt Erebus.

I say again and again, this was a mandatory requirement by the owners of the aircraft and CAA, if it had been complied with, no matter what the weather, the aircraft would not have impacted Mt Erebus.

Surely the requirement to get the pax and the aircraft home safely was of more importance than breaking all the rules to see a landscape a bit closer, in an area that is known for great visibility.

Front Pit,

"It’s also amazing, and quite appalling that some here wish to dance on the graves of Jim Collins & Greg Cassin for not actually seeing an optical illusion!!………. What a prospect!"

Actually I find that statement quite disgusting, uncalled for and completely without foundation

[56P]

Some one starting with P must have Davis as a middle name!

[bushy]

If the company had not given the Captain incorrect information he would not have flown into the mountain.

[Front Pit]

Front Pit,

"It’s also amazing, and quite appalling that some here wish to dance on the graves of Jim Collins & Greg Cassin for not actually seeing an optical illusion!!………. What a prospect!"

Actually I find that statement quite disgusting, uncalled for and completely without foundation

A bit touchy aren't we.......I wasn't referring to anyone in particular .......but if the cap fits........or perhaps you were seeing an optical illusion?

[prospector]

No, no illusion, just dealing with facts.

[jack red]

If the company had not given the Captain incorrect information he would not have flown into the mountain................and Bushy it's as simple as that, no matter how much spin some people will try and put on it:ugh:

[stillalbatross]

Have to agree with 400rulz. There were about half a dozen requirements as to when the flight could descend below MSA and they had to have all of them, which they didn't. To say that they could descend below MSA in an area of terrain safe in the knowledge that the FM put them close to a mountain when it actually put them over it is garbage. Either way they were trying VFR below MSA without meeting the company requirements.

Mahon looked at what happened after descent below a safe altitude, not at why they were down there in the first place. Chippendale said that if they had abided by the SOP's, irrespective of where the plan had them going the aircraft would have remained safe. Mahon leaned heavily on explaining the white out phenomena, and Gordon Vette did amazing work in showing plenty of us a phenomena we had little experience with. But Mahon spent little time looking at the fact that the US military wanted nothing to do with the flights and cited a number of reasons why, with the unusual Antarctic met conditions being one of them.

Commercial pressures angle was garbage, the company had (has) an AOC and legally flies the aircraft from the procedures the CAA has based the AOC on. If the skipper want to go outside of these, he need good reason to do so. Giving the punters a good show is rarely one of them.

There is no way AirNZ at the time thought their procedures in flying a widebody to LA could easily accomodate VFR at the south pole. No doubt when planning sat down to put together a route guide they put in place a bunch of draconian requirements for VFR descent below MSA when down there.

If Collins et al had stayed above MSA the punters wouldn't have got much of a show, sales and marketing would have been told this by a bunch of unhappy customers, marketing would have then moaned to flt ops who would have said "sorry that's the best we can safely do" and after a few more, the flights would have been canned and we would be remembering the 10 for what a nice plane it was to operate instead of this.

It really is that simple.

[prospector]

Not as simple as that by any means, have a look at the definition of mandatory, that is what the descent requirements were, not make up your own descent profile, vmc or otherwise. And the descent profile that was required was designed to ensure that nobody flew into Erebus. The requirements were ignored with the results obvious. It matters not a whit that other crew had gone lower, they all complied with at least some of the requirements, including being identified on McMurdo radar. And they did not fly into Erebus.

[jack red]

And they did not fly into Erebus. No, they didn't because their aircraft was programmed to fly up McMurdo Sound NOT directly at Mt Erebus.:ugh:

[prospector]

And if that is your supposition, there is no point in continuing this discussion.
On such a note it is time to rest logical discussion.

[jack red]

Amen........................:ok:

[Brian Abraham]

Before I go spending $10 or more with CASA for a copy is anyone able to direct me to a copy of Chippendales report on line (have all the books etc but never seen the report)? Searched the usual suspects with no joy. Thanks in advance, Brian

[prospector]

It used to be available from the TAIC web, but it would appear to have been deleted for some reason.

Not even google comes up with anything on Flt 901, NZP, accident report 79-139. compiled by Ron Chippendale. Wonder why??

[Kiwiguy]

Adding my tuppence worth... The truth lies somewhere between both extreme positions here.

Pilots acted unwisely and did not consider or comprehend why if they were so close to McMurdo why they could not raise them on line of sight VHF.

On the other hand Air NZ screwed up with wrong INS co-ordinates giving crew a false sense of comfort.

There was obviously too, an element of management tolerance about not following SOPs.

Prospector asked:


The statement "Orchestrated litany of lies" has been shot down by so many people, including Mahons peers, his superiors, and up to the Privy Council, it is hard to understand why it is still quoted.


At the time of the enquiry, not only as Casper pointed out were the homes of pilots broken into (presumably by the NZ SIS on behalf Air NZ under Muldoon's instructions), but also according to my friend at the time, Tim Mahon son of Peter Mahon, the judge's house was also broken into.

Remember that in 1977 the SIS Ammendment Act was passed prohibiting publication of SIS activities, so what we had here was a politician abusing an instrument of state for political reasons and using statutory secrecy to conceal the facts.

Tim told me the only things taken from his father's house were papers relating to the Erebus enquiry.

That is why the phrase "orchestrated litany of lies" continues to hold currency. Because sadly, Prospector Mahon was right too.

Pilots were wrong on the day, but they were also corporate fall guys for a corporate which failed to properly manage this aviation goldmine and their drunkard CEO and a bombastic Prime Minister were unwilling to accept some of the responsibility (or financial liability) which rested with the airline.

[skol]

KIWIGUY

I was on the DC10 in those days-there were no SOP's.

[stillalbatross]

No, they didn't because their aircraft was programmed to fly up McMurdo Sound NOT directly at Mt Erebus.

Jackred you appear to have a slight grasp on MSA so allow me. Whether they flew up mcMurdo sound or around McMurdo sound or baked a cake and called it McMurdo Sound there was a rather large hill nearby that raised the MSA for the area. Unfortunately it isn't enough to look on the track on the chart and then decide a safe altitude for yourself based on how close the track line passes to the terrain the MSA is based upon.

You allow little room for nav or baro or wind error.

[bushy]

But not for 20 mile, company generated error.

[Desert Dingo]

Jackred you appear to have a slight grasp on MSA so allow me. Whether they flew up mcMurdo sound or around McMurdo sound or baked a cake and called it McMurdo Sound there was a rather large hill nearby that raised the MSA for the area. Unfortunately it isn't enough to look on the track on the chart and then decide a safe altitude for yourself based on how close the track line passes to the terrain the MSA is based upon.From post #48
The airline briefing notes stated “ if VMC cannot be maintained, FL160 is the Minimum Safe Altitude.” Even Chippindale’s report states “He was not violating any local restriction by descending to 1500 feet in VMC”
Anyone care to explain how the NZ regulations require flight above the MSA when operating in VMC? I don't think it is Jackred who has the slight grasp on MSAs.

[prospector]

And who has not got a grasp on a mandatory requirement? Got nothing to do with NZ regulations. VMC descents or whatever.

This was the requirement for descent on that flight,

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

1. Vis 20 Km plus.

2. No snow showers in area.

3. Avoid Mt Erebus area by operating in an arc from 120 degrees Grid through 360 degrees grid to 270 degrees grid from McMurdo Field, within 20nm of TACAN CH29.

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

[Kiwiguy]

skol wrote

KIWIGUY

I was on the DC10 in those days-there were no SOP's.


This sounds like an SOP to me ?


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

1. Vis 20 Km plus.

2. No snow showers in area.

3. Avoid Mt Erebus area by operating in an arc from 120 degrees Grid through 360 degrees grid to 270 degrees grid from McMurdo Field, within 20nm of TACAN CH29.

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


Prospector is right in the respect that pilots were in error, but unlike Prospector I don't believe that you need to dump it all on the crew. The company screwed up in several ways aswell and then attempted a cover up.

[prospector]

Kiwiguy,
I have stated on this forum and in this thread that my main concern with the findings of Justice Mahon are that many people appear to agree with this statement posted earlier in the thread.

"The Royal Commission Report convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged."

I have stated that I believe that the blame should be shared between everybody involved, Company, CAA and the crew. To take the crew out of the loop gives a completely wrong interpretation of the events of that day.

[Brian Abraham]

1. Vis 20 Km plus.

2. No snow showers in area.

And there's the rub Prospector. On my one and only trip to the ice as SLF we were flying in the high teens in what I took to be solid IMC. On looking down I could see what I took to be (after some deliberation) lakes of melt water. It took some time to realise that what I was seeing were the shadows of isolated puff ball clouds on the snow surface. The weather, I would guess, would have qualified as CAVOK. The vertical visibility to the shadows was gin clear so who knows what the horizontal visibility might have been. The overcast turned out to be in the low 20's. You would not have seen a snow shower until you had flown into it. Whiteout? Dangerous stuff for the uninitiated and inexperienced.

[prospector]

And that was the reason for making the descent requirements as they were.

If they had of been complied with there was no way the flight could have impacted on to Erebus.

[Kiwiguy]

I don't have any problem with the following comment:


I have stated that I believe that the blame should be shared between everybody involved, Company, CAA and the crew. To take the crew out of the loop gives a completely wrong interpretation of the events of that day.


I do think the airline created a culture that allowed descent criteria to be ignored not just on the flight which crashed but probably on earlier ones aswell.

I have always since the crash concluded for myself that lack of line of sight VHF contact was a glaring clue to the pilots that something was not right.

[Brian Abraham]

And that was the reason for making the descent requirements as they were.

If they had of been complied with there was no way the flight could have impacted on to Erebus

prospector, I have every reason to believe the crew fell foul of the whiteout condition presented to them at their 12 o'clock. 3 nautical miles (NM) prior to impact photographs show that the lateral visibility was at least 12NM from their 1,500 foot altitude. NZ's requirement was 20K vis (10.8NM). In my reading I don't see anywhere that they failed to maintain VFR below 16,000, but stand to be corrected.

[Capt Wally]

...........has it really been that long?......CFIT...............new then to some degree & still being performed now ! Sadly as long as humans are at the controls of machines we shall have events such as this.
Was a sad day for all who love aviation & the adventurous spirit it produces! I hope the loss to all those touched by this event are now at piece.

CW:)

[prospector]

Brian Abraham,
Please read post 156 this thread.

Note that this was the only descent procedure approved, it was formulated to allow these flights to be carried out knowing full well the lack of Antarctic experience that existed amongst ANZ crews. Whether they were VMC, VFR or whatever is irrelevant.

[skol]

KIWIGUY

There was instructions relating to that specific duty the same as there is now but there were NO SOP's relating to general operating procedures.
SOPs became part of the Route Guide about 15 years ago but is now a manual on its own.

[Desert Dingo]

Prospector says;
This was the requirement for descent on that flight,

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

1. Vis 20 Km plus.
2. No snow showers in area.
3. Avoid Mt Erebus area by operating in an arc from 120 degrees Grid through 360 degrees grid to 270 degrees grid from McMurdo Field, within 20nm of TACAN CH29.
4. Descent to be co-ordinated with local radar control as they may have other traffic in the area
and
Note that this was the only descent procedure approved, it was formulated to allow these flights to be carried out knowing full well the lack of Antarctic experience that existed amongst ANZ crews. Whether they were VMC, VFR or whatever is irrelevant. No - it was not the requirement for descent on that flight.


Justice Mahon’s report 40 (b) (my emphasis)

(b) The low altitude of the aircraft:

As stated already, it is beyond dispute that there is no danger in flying at 1500 feet over any flat terrain in clear weather. That altitude is in fact far higher than the minimum safe altitude prescribed for aircraft flights by regulation 38 of the Civil Aviation Regulations.. But it happened that when the Civil Aviation Division of the New Zealand Ministry of Transport had approved these antarctic flights early in 1977, they had prescribed special minimum safe altitudes.. The minimum safe altitude on the approach to Ross Island had been set at 16000 feet and there was a permitted descent of 6000 feet to the south of Ross Island so as to permit sightseeing. This 6000 permission was confined to a special limited sector over the Ross ice shelf to the south of Ross Island.

But as inquiries eventually established, these limits, which may or may not have been observed by the airline for the initial two flights .in February 1977, had not been observed at any time thereafter. In truth, the minimum safe altitude so prescribed by the Civil Aviation Division may have been quite satisfactory as part of an initial flight plan to be used for planning purposes on the first flight. But such minimum safe altitudes of 16 000 feet and 6000 feet, insofar as they were supposed to apply to all Antarctica flights, were misconceived. They had no relation whatever to the realities of sightseeing flights in Antarctica. They continued to be the officially approved levels as between the Civil Aviation Division and the airline from February 1977 right through to the date of the disaster. But in practice the airline disregarded those minimum altitudes, and in my opinion were justified in doing so.

Captains of antarctic flights were specifically briefed in 1978 and in 1979 that they were authorised to descend in the McMurdo area to any flight level authorised and approved by the United States air traffic controller. When Captain Collins accepted the invitation from the United States air traffic controller to descend to 1500 feet where he would find himself in clear air, and with unlimited visibility, he was acting in compliance with authority directly given to him by the airline's briefing officer and under conditions approved by the United States' air traffic controller. The proposed over-flight of McMurdo Sound in the areas specified by the air traffic controller was at a perfectly safe altitude. Contrary to what I think has been a public misconception over this altitude question, there was at no time on 28 November 1979 any unauthorised "low flying" by the crew of TE 901.

[prospector]

" No - it was not the requirement for descent on that flight."

From where do you get that statement, and how would you justify it??

It was certainly part of the briefing for the flight, a copy was found in the cockpit after the accident, so the crew certainly were aware of it.

"But in practice the airline disregarded those minimum altitudes, and in my opinion were justified in doing so."

Are you suggesting that an OPINION held by Justice Mahon is of more importance than the requirements of both the Company and the CAA??

"Contrary to what I think has been a public misconception over this altitude question, there was at no time on 28 November 1979 any unauthorised "low flying" by the crew of TE 901."

Once again, are you suggesting that the opinion of Justice Mahon, which incidentally could not be appealed, it was not a law court he was presiding over, is of more importance then the already mentioned many times,MANDATORY requirements for descent??

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

As the flight was never identified on the radar, then this requirement obviously could not be complied with. As the controller did not know their position how could he advise them of anything?? This question of the responsibilities of McMurdo radar were very well covered in the court of US judge Harold Greene. None of his findings agreed with Mahons theories or opinions.

From that court.
" It is clearly established that, when the pilot told Mac Centre he wished to descend VMC, he effectively informed the controllers that he could see where he was going. In so doing, he took sole responsibility for separating the airplane from other aircraft and the terrain, and he was on his own."

Considerably different from your rendition of Mahons opinion that he was invited down by the controller.

"When Captain Collins accepted the invitation from the United States air traffic controller to descend to 1500 feet where he would find himself in clear air, and with unlimited visibility"

[conflict alert]

On topic but as an aside....some of these posts are getting quoted in the local papers (NZ). Last few days have included articles siting PPRuNe, the thread, and quoting posts. Also stated is that ALPA are to set up a website to give the details of Erebus, as a result.

[Kiwiguy]

Also stated is that ALPA are to set up a website to give the details of Erebus, as a result.


That being so... truth will become the first victim. There is far more value in the debate taking place here than in one side or other creating it's own web page with one viewpoint only. Que Sera... History repeats

[Desert Dingo]

Prospector writes:
No - it was not the requirement for descent on that flight."
From where do you get that statement, and how would you justify it??

I get it from the Royal Commission Report and justify it because it was given in evidence (somewhat reluctantly, it would appear) by company management.
k) It was alleged that the crew descended below the officially approved minimum safe altitude either of 16000 feet or 6000 feet and that this was the predominant cause of the accident. Although the chief inspector referred from time to time in his report that descent to 1500 feet, even though suggested and authorised by McMurdo Air Traffic Control. was in breach of the MSA rules officially in force, nevertheless the chief inspector recognised that there were pilots who evidently had misinterpreted the conditions surrounding descent to 6000 feet as if they referred only to a cloud break procedure, and did not prevent descent to any lower altitude consistent with air safety.

The Civil Aviation Division. not unnaturally, placed the breach of its MSA conditions in the forefront of its case. The airline witnesses also, for a considerable period of time, were inclined to rely strongly upon descent below 6000 feet as being in breach of the airline's rules and consequently as amounting to a decisive cause of the disaster. However, after the Commission had been sitting for many weeks it was for the first time revealed by the evidence of Captain Wilson that when briefing air crews for Antarctica flights in 1978 and 1979 he had told them that the practice on antarctic flights was to descend to whatever level was authorised by McMurdo Air Traffic Control, and he said in his brief of evidence that he did not indicate any criticism of this course.

This new aspect of the RCU; briefing was a most surprising revelation. I noticed that it occurred at the very end of Captain Wilson's prepared brief. Without wishing to appear too pedantic, I also observed that this significant concession appeared to have been added to the end of the brief with a different typewriter, so that the decision to reveal this information was not only very late in the day but also seemed to have the hallmarks of a last-minute decision. It also appeared that the chief inspector had not been appraised of this unwritten feature of the antarctic briefings. I have already referred briefly to this disclosure in paragraph 168 above, and that it had not been previously mentioned to the chief inspector. So here there had been, up until this point, a sedulous reliance by the airline and by Civil Aviation Division upon a breach by Captain Collins of the prevailing MSA rules. that breach being treated as if it obliterated each and every error that might have previously been made by the airline or by Civil Aviation Division. But as from the time of Captain Wilson's admission, the MSA defence, if I may call it that, could not prevail against Captain Collins.

In the final submissions for the airline it was admitted that there were a number of pilots who testified that in VMC conditions they considered it permissible to descend below 6000 feet outside the specified safety sector. It was submitted that Captain Wilson had been under a misconception when he appeared to share the same opinion. Captain Wilson had said:
"In a visual strictly visual VMC letdown providing the weather was clear, very good weather, ceiling and visibility unlimited and provided that the Captain received permission of McMurdo, he could have descended outside that particular segment." (T 1224) The submissions for the airline went on to assert (at para. 7.85) that Captain Collins had carried out his descent outside the specified sector and below 6000 feet "which, on the face of it, constituted a breach of the briefing instructions". This latter submission is plainly wrong. When Captain Collins decided to descend to 1500 feet in VMC conditions with the specific authority of McMurdo Air Traffic Control, he was in fact acting in accordance with the authority given to him at his RCU briefing.

The final submissions for Civil Aviation Division proceeded upon the simple and unqualified basis that the MSA conditions laid down by the division had been contravened, not only in the present case but in previous cases. That of course may be a material factor as between the division and the airline, although I have already expressed my reservations as to the division's alleged lack of knowledge of the levels at which pilots flew in 1978 and in 1979 in the McMurdo area. But I am concerned here, of course, with the position as between the airline and its pilots and there can be no doubt, upon all the evidence, that the pilots were in fact authorised at the RCU briefings in 1978 and 1979 to descend below 6000 feet in VMC conditions to any altitude authorised by McMurdo Air Traffic Control. This allegation of pilot error must accordingly fail.

[Brian Abraham]

Kiwi, I think the full quote is "History is old, and repeats itself". Could add infinitum I guess.

If anyone has an "in" with the ALPA, and they set up the web site, could you see that they include Chippendales report which seems to have disappeared off the face of the earth.

[Desert Dingo]

Prospector again about the MSA requirements:
It was certainly part of the briefing for the flight, a copy was found in the cockpit after the accident, so the crew certainly were aware of it.

No. It was not found in the cockpit after the accident.
342. This instruction by the chief executive for the collection of all Antarctica documents had some unfortunate repercussions. Captain Gemmell. the chief pilot had gone to Antarctica with the Chief Inspector of Air Accidents, and with other officials, at about midday on 29 November 1979. It was alleged by counsel for ALPA that while Captain Gemmell was at Antarctica he had collected a quantity of documents from the crash site and brought them back to Auckland.

It was pointed out that of the documents collected at the wreckage site and produced to the Commission, there were only three which had been part of the flight documents carried by Captain Collins.

These three documents were:

(a) The RNC chart which set out track and distance diagrams for QANTAS and for Air Force flights but not for Air New Zealand. and which conveyed information as to various radio frequencies.

(b) A sample flight plan printed in October 1977 which contained among the list of co-ordinates the latitude and longitude of the NDB at McMurdo.

(c) The piece of paper containing Captain Johnson's notification on 8 November 1979 that the NDB facility was withdrawn and including a notification that the minimum safe altitude in the McMurdo area was 6000 feet.

343. It was suggested by counsel for ALP A that it was curious to find that the only flight documents recovered from the ice were each in favour of. the case which the airline was now attempting to advance. The RNC chart gave information about radio frequencies. The 2-year-old sample flight plan gave the co-ordinates of the McMurdo NDB. Captain Johnson's memorandum contained a reminder that the minimum safe altitude was 6000 feet.
344. It was pointed out that the following documents, which clearly had been carried in the flight bag of Captain Collins, along with the three just specified, had not been recovered:

(a) A map or maps upon which he had been working with plotting instruments the night before the fatal flight.

{b) The thick and heavy atlas upon which he had been working with plotting instruments the night before the fatal flight.

{c) The large topographical map issued to him by Flight Despatch on the morning of the .flight.

(d) The briefing documents handed to Captain Collins on 9 November 1979, which would have contained his own notations.

(e) The notebook which he almost certainly brought with him to the briefing of 9 November 1979 along with his atlas.

{f) The track and distance diagram showing the flight path to be down McMurdo Sound (Annex G to the chief inspector's report).

{g) Another track and distance diagram also showing the flight path to be down McMurdo Sound (AnnexH to the chief inspector's report).

(h) The Antarctica Strip Chart showing the military track down the centre of McMurdo Sound (Annex I to the chief inspector's report).

It was suggested that each of the documents just listed, but not located, would have tended to support the proposition that Captain Collins had relied upon the incorrect co-ordinates.
Strange that. If you like a conspiracy theory you could also wonder why FO Cassin’s briefing notes were collected by the company from his house and never seen again, why all the pages were missing from Captain Collin’s notebook, why the company became so enthusiastic about shredding documents, and who was behind the alleged burglaries at Captain Collins and Justice Mahon’s houses.

Prospector:
"But in practice the airline disregarded those minimum altitudes, and in my opinion were justified in doing so."
Are you suggesting that an OPINION held by Justice Mahon is of more importance than the requirements of both the Company and the CAA?? It was the Airline that disregarded the CAA minimum altitude requirement in their briefing to pilots. Justice Mahon then had an opinion that they were justified in doing so. The importance or otherwise of his opinion does not change the fact that “in practice the airline disregarded those minimum altitudes”. He suggests in his report that the CAA should take it up with the airline and not try to blame the pilots.

Prospector:
Once again, are you suggesting that the opinion of Justice Mahon, which incidentally could not be appealed, it was not a law court he was presiding over, is of more importance then the already mentioned many times, MANDATORY requirements for descent?? It was not mandatory. The company had specifically authorised descent below 6000 feet in VMC.
"there can be no doubt, upon all the evidence, that the pilots were in fact authorised at the RCU briefings in 1978 and 1979 to descend below 6000 feet in VMC conditions to any altitude authorised by McMurdo Air Traffic Control."

[prospector]

Desert Dingo,
You are doing nothing but quoting from Mahons book, in which he tries to justify his many opinions.

Try reading the reports compiled by very experienced aviation and administration personnel in the wake of the findings of the Commission being made public.

You could start with the Bolt/Kennedy report that was compiled by to look into the allegations of failure by the CAA made by Mahon.

Or the "Analysis of the Royal Commission report", compiled by C.H.N. L'Estrange. It is entitled "The Erebus enquiry: A tragic miscarriage of Justice".

Or the article by Captain Derek Ellis in the British Airline Pilots Association magazine the log of Aug 1985 in which he states "The effect of reading Gordon Vettes book, which is dedicated to supporting the views of the commissioner, has in fact been to convince me that the findings of the New Zealand Office of Air Accident Investigation are infinitely more realistic".

[Desert Dingo]

Thanks, Prospector. I'll try and read those books you mention.

I have been quoting from the Report of the Royal Commission, not "from Mahons book, in which he tries to justify his many opinions."

I have always thought Royal Commissions were to establish facts, not opinions.

Do you have any facts that disprove those found by the Royal Commission that completely demolish your argument that the pilots were not permitted "to descend below 6000 feet in VMC conditions to any altitude authorised by McMurdo Air Traffic Control." Are you suggesting that Captain Wilson's own evidence was wrong?

[prospector]

Yes I do, the requirements for descent that have been quoted ad infinitum.

It was only Mahons opinion that they did not apply. They were a legal requirement arrived at by CAA before approval for these flights was given, and for obvious reasons.

Why do you not also quote from Capt M. Hawkins, who stated "I was in no doubt at the briefing that the lower limit was 6000Ft, the weather on my flight was perfect, with clear skies and 100 miles visibility. Ice tower asked me for a low run, but I kept to 6000 feet".

Because the flight levels of 16000ft and 6000ft and the flight path over Mt Erebus still remained as part of the official approval of Civil Aviation Division as at 29 November 1979 Mahon wrote;

"This was the principal basis of the case for CAA and, as will be found from what I have already written, it was in my VIEW a basis without any justification whatever".

Once again Mahon believes his view overrides mandatory requirements from CAA. And remember, these views are from a man who had no intimate knowledge of aviation procedures.

[Desert Dingo]

It was only Mahons opinion that they did not apply.No it was not just "Mahon's opinion".
Captain Wilson testified that he briefed the pilots that it was OK to descend in VMC.
McMurdo ATC issued descent clearances contrary to those requirements because the company never advised them of those restrictions.Justice Mahon's opinion was that the descent restrictions were appropriate for the initial proving flights.
Justice Mahon established the fact that the company subsequently disregarded those restrictions on later flights.

You make some good points, but you can't get past the fact that the company briefed the pilots that they had approval to descend below 6000 feet VMC with ATC clearance.

[prospector]

"McMurdo ATC issued descent clearances contrary to those requirements because the company never advised them of those restrictions."

This is not correct, the Captain requested a VMC descent, in no way is that a clearance for anything. From an earlier post that hopefully you read.

From that court.
" It is clearly established that, when the pilot told Mac Centre he wished to descend VMC, he effectively informed the controllers that he could see where he was going. In so doing, he took sole responsibility for separating the airplane from other aircraft and the terrain, and he was on his own."

As they were never identified on McMurdo radar how could the controllers have cleared them for anything, they had no idea where they were.

I am sure that the clearance for a VMC descent mentioned by Capt Wilson was to be after they were identified by McMurdo Radar and position established positively.

[jack red]

Desert Dingo you are correct when you state but you can't get past the fact that the company briefed the pilots that they had approval to descend below 6000 feet VMC with ATC clearance. (See my post #135.)

Just watch someone jump out of the crowd soon and accuse you of illogical reasoning and terminating debate on the issue.......................

......................but don't worry they'll be back! :ugh:

[prospector]

jack red,

Very easy to get past that, it is not a fact. As stated above they requested a VMC descent, they were never CLEARED for anything.

[Brian Abraham]

As stated above they requested a VMC descent, they were never CLEARED for anything.

Not sure what you mean, or in what form you would want a "Clearance".

Chippendales words

On the Captain’s instructions the co-pilot asked “McMurdo Centre” for a clearance to let down VMC to 2,000 feet and proceed visually to McMurdo. Immediately after this approval was given a further descent was commenced. Report 79-139

and

ATC did give a clearance to descend to 2,000 ft VMC and proceed visually to McMurdo. Royal Commission

[prospector]

"It is clearly established that, when the pilot told Mac Centre he wished to descend VMC, he effectively informed the controllers that he could see where he was going. In so doing, he took sole responsibility for separating the airplane from other aircraft and the terrain, and he was on his own."

They approved his request for a VMC descent, as they had never identified him on radar, and had no means of knowing what the position of the aircraft how could they give them a clearance to descend????

" he took sole responsibility for separating the airplane from other aircraft and the terrain, and he was on his own."

This is what they requested, a VMC descent, MacCentre approved a VMC descent.

"ATC did give a clearance to descend to 2,000 ft VMC and proceed visually to McMurdo."

All they were doing, as the captain had assumed responsibility for his own terrain clearance and separation from other aircraft, with his request for VMC descent, was advising him of no known conflicting traffic.:ugh::ugh:

It is patently obvious that Mahon had no understanding of, and obviously got no accurate advice on, the meaning of a VMC descent. The controller had no way of knowing the position of the aircraft, or the weather it was encountering, the captain had by requesting VMC descent taken on all responsibility for terrain clearance and separation from other aircraft upon himself, in complete disregard of the mandatory requirements for descent.

Surely the end result speaks of the folly of this decision.

[Casper]

Prospector,

I don't doubt your knowledge of the guidelines to crew and I full know the responsibilities of the PIC BUT the fact remains that:
- the crew, without briefing or knowledge of "whiteout conditions," really believed that they were in VMC conditions; and
- really believed, due to their Air NZ briefing and navigational data provided by the operator, that they were proceding down the center of McMurdo Sound and that they were (or should be - from the CVR transcripts) well clear of Erebus.

Do you really believe that Air NZ is totally clear of blame in regard to this tragedy?

Do you really believe that Air NZ had considered every possibility of risk mitigation before authorising Antarctic flights?

[prospector]

"Do you really believe that Air NZ is totally clear of blame in regard to this tragedy?"

As stated many times, no.


"Do you really believe that Air NZ had considered every possibility of risk mitigation before authorising Antarctic flights?"

They never had the final say on approving these flights, CAA had that responsibility, they laid down the requirements for descent. It was because CAA were very lax in policing these requirements that they got their wrists smacked, in fact there was an airline inspector scheduled to go on that flight, because of a family illness he had to cancel. I would find it hard to believe that the flight would have been carried out the way it was if that inspector had of been onboard.

[Brian Abraham]

in complete disregard of the mandatory requirements for descent.

prospector - it is not quite clear to this dull knife which mandatory requirements you are referring to here, do you have a reference? As Pauline Hanson might say "Please explain". :ok:

really believed that they were in VMC conditions

You can have whiteout and be in VMC conditions. VMC is only defined in terms of class of airspace, altitude, visibility and distance from cloud. There is no requirement to have a horizon. The photographic evidence is that they were in VMC conditions. Chippendale said " Those who have not experienced whiteout are often sceptical about the inability of those who have experienced it, to estimate distance under these conditions and to be aware of terrain changes and the separation of sky and earth."

[prospector]

Brian Abraham,
"This was referred to in a Company memorandum to Antarctic crews, OAA:14/13/28 dated 8 November 1979. Headed McMurdo NDB NOT AVAILABLE, it was succinct and unambiguous.

Delete all reference in briefing dated 23/10/79. Note the the ONLY let-down procedure available is VMC below FL160 to 6000ft as follows.

1. Vis 20 Km plus.
2. No snow showers in area.
3. Avoid Mt Erebus area by operating in an arc from 120 degrees Grid through 360 degrees grid to 270 degrees grid from McMurdo Field, within 20nm of TACAN CH29.
4. Descent to be co-ordinated with local radar control as they may have other traffic in the area.

Despite some claims to the contrary, my information is that a copy of this memorandum was recovered from the cockpit wreckage.

What many people seem to ignore are these requirements, none were complied with, no radar contact, no lock on to TACAN, nowhere near the approved descent area, the weather as given to the crew was below their limits for the approved descent, so they designed their own descent. And the result being just exactly what these requirements were to designed to make sure never happened.

[Desert Dingo]

Prospector:
Despite some claims to the contrary, my information is that a copy of this memorandum was recovered from the cockpit wreckage.You are correct. Item (c) in my post #172 is the memorandum to which you refer. As there was no mention of the 16000 ft limit I thought it was a different document.

[Desert Dingo]

Brian,
Prospector is pushing the company argument that was convincingly demolished by the facts that came to light during the Royal Commission inquiry conducted by Justice Mahon.
151 (part)
…… But because the flight levels of 16000 feet and 6000 feet and the flight path over Mt Erebus still remained as part of the official approval of Civil Aviation Division as at 28 November 1979, both the airline and Civil Aviation Division immediately seized upon these official conditions as being the vital factor in the disaster. From the point of view of both organizations they could obtain, so they believed, absolution from their own numerous errors by merely ascribing the disaster to a failure by Captain Collins to observe a minimum flight level of 16000 feet ….. 164 (d)
The prepared text of the briefing and the constant reference to minimum safe altitudes of 16000 feet and 6000 feet were verbally contradicted by Captain Wilson in the 1978 and 1979 flights by indicating to the crews that they were authorized 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 presentations to which I have referred. Captain Wilson admitted this. (T. 1236) Although the descent restrictions remained in force, the airline consistently disregarded them, although protesting total compliance with them at the enquiry.
Prospector asks
Why do you not also quote from Capt M. Hawkins, who stated "I was in no doubt at the briefing that the lower limit was 6000ft, the weather on my flight was perfect, with clear skies and 100 miles visibility. Ice tower asked me for a low run, but I kept to 6000 feet".
Captain Hawkins (and others) may have been telling fibs.
In the Auckland Star of 22 October 1977 an article appears with “At the controls Captain Hawkins brings the DC10 down to 200m over Scott and McMurdo Bases – well below the towering volcano Erebus belching smoke only 40 km. away.”

Now I know we all have a pretty poor opinion of media accuracy about aviation, and the journalist later admitted that he should have said 400m not 200m ( just a slight exaggeration – how surprising) but I expect he could tell the difference in flight at 400m (1300 ft) and 6000 feet.

There are numerous other examples of press reports, company newsletters and publicity brochures confirming that flights were regularly conducted below 6000 feet.

Significantly, Mr B Thompson, Superintendent of the D.S.I.R., had been on four flights and testified that he believed they had all flown below the MSA rules. One of these flights (8 November 1977) was under the command of Captain Johnson, Flight manager Line Operations, who then testified that he had descended to 3000 feet. This was a breach in the otherwise unified front of the management pilots that nobody ignored the MSA rules. Justice Mahon says (rather tongue-in-cheek, I think) that he does not wish to suggest that Captain Johnson felt obliged to admit breaking the unified front because it could be so easily proved that he had descended below 6000 feet.
This is the same Captain Johnson who wrote the memo Prospector relies on so much in his arguments.

So, there is incontrovertible evidence that flights were being regularly operated below 6000 feet and that the crews were specifically authorized to do so during the briefing.
Note that this specific authority was orally given to flight crews during the course of the audio-visual presentations.

Orally.

This means that perhaps the only written record would be the notes taken by the pilots during the briefing.

Justice Mahon’s report shows that there were times when the company had control of documents recovered from the crash site, and he does not believe Captain Gemmel did not know about the changed waypoints when he had possession of those documents.

If you had a suspicious mind you might wonder why the only documents recovered at the crash scene and shown at the enquiry were ones that supported the company argument.

Why were there no pages left in Captain Collins’ otherwise undamaged ring-binder notebook?

What happened to the rest of the documents carried by Captain Collins on that flight?

Why did the company recover FO Cassin’s briefing notes, then they were never seen again?

Who was behind the burglaries?

Does “an organized litany of lies” apply here?

Believe in conspiracies and a cover-up? Who, me? :=

[prospector]

Desert Dingo,
The Mr Bob Thomson who you have brought into the debate also wrote in his "History of New Zealand Antarctic Research Program 1965-88".

"Air New Zealand and NZALPA went to some lengths to ensure that their senior pilots and members were seen as professionals who knew it all and did not therefor need to seek advice from elsewhere, such as the RNZAF, USAF USN, or the Division.



"Nor did Air New Zealand take advantage of the experience gained by the members of their aircrews who flew on earlier flights. Apparently the NZALPA saw the Antarctic flights as a special perk for their members and had an agreement with Air New Zealand that flight crews should be spread widely amongst its members.

Therefore aircrews, including aircraft captains, usually had not any previous experience on these flights, an experience which would have avoided the Erebus Disaster from ever happening"

It is interesting that you bring in Bob Thomson, he is not qualified aircrew, but has apparently over 75 trips to the Antarctic, at least 50 approaching from the North. He was in fact scheduled for the subject flight but had to change his plans. When asked that but for twist of fate he would have been on the fatal flight his reply was "Not at all, I always insisted on a complete circuit of Ross Island before letting down below 17000ft. That way I could get an idea of the complete situation and what the weather was like.

He also stated that "The Captain didn't give attention to problems he might have around there. These people were taking a Sunday drive. When I heard the transcript of the CVR I fell out of my chair."

"I always had a chart in the cockpit and checked the lat and long readout, but the crew of the fatal flight never referred to it"

"Your statement of oral briefing is a bit like oral history, gets changed in the telling. Not like the laid down mandatory requirements from CAA, that were written instructions and it is a known fact that the crew had access to them.

I would also like to add that your faith in the infallability of Justice Mahon is quite touching, if misplaced.

[Desert Dingo]

"Not at all, I always insisted on a complete circuit of Ross Island before letting down below 17000ft. That way I could get an idea of the complete situation and what the weather was like.It doesn't appear he was very successful with his insisting when he was on the four air New Zealand flights that he testified flew below 6000 feet.
"Your statement of oral briefing is a bit like oral history, gets changed in the telling. FFS Prospector! Does the fact that it was the sworn testimony of the person who gave the briefing mean anything to you. Are you suggesting he was another one telling fibs?
I would also like to add that your faith in the infallability of Justice Mahon is quite touching, if misplaced.I am not saying Justice Mahon is infallible. However, I do think he was pretty good at cutting through the BS and lies and getting to the facts.

[bushy]

The Erebus disaster and Justice Mahon brought to light a number of things that are usually swept under the carpet with the convenient "pilot error" finding. These things often occur in lots of other organisations, all over the world.
We ignore them at our peril.
One that we should give thought to is the perceived integrity, and therefore effectiveness of company or other instructions. Often it appears that the instructions are mainly to protect people who are not in the aeroplane. I have seen this situation elsewhere, where the company instructions were impractical and were ignored. In one case there was documented evidence in company files that this occurred, and no-one discussed it. The regulator did not either. It was perfectly safe procedure, but was contrary to company instructions.
I believe the latest description is "normalisation of deviance".
Pilots are reluctant to discuss such matters as they fear being labelled "undisciplined" or some other such term, and lose career opportunities.
I do not wish to comment on the instructions given by Air NZ for antarctic flights. Justice Mahon did that, much better than I could.
But I still cannot accept the simplistic, conclusion that "pilot error" was the cause of the disaster. Surely we are smarter, and more sincere than that.

[prospector]

Desert Dingo,

"It doesn't appear he was very successful with his insisting when he was on the four air New Zealand flights that he testified flew below 6000 feet."

On the contrary, they successfully missed Erebus every time.

" FFS Prospector! Does the fact that it was the sworn testimony of the person who gave the briefing mean anything to you. Are you suggesting he was another one telling fibs?"

Another one telling fibs?? was it only the people that disagreed with Mahons theories the ones that told fibs.

If you are so convinced Mahon was correct, how do you explain the following from the Privy Council???

In their judgement, delivered on 20 Oct 1983, the five Law Lords of the Privy Council dismissed thje commissioners appeal and upheld the decision of the Court of Appeal decision, which set aside the costs order against the airline, on the grounds that Mahon had committed clear breaches of natural justice. They demolished his case item by item, including Exhibit 164 which they said could not "be understood by any experienced pilot to be used for the purpose of navigation", and went even further, saying there was no clear proof on which to base a finding that a plan of deception, led by the company chief executive had ever existed.

They demolished his case item by item, including Exhibit 164 which they said could not "be understood by any experienced pilot to be used for the purpose of navigation",

Surely that from the highest law court available should tell you something, but perhaps not.

[deadhead]

Hi Prospector

Can you just confirm for me please, that, in relation to the quote you have provided from the Privy Council, you understand it to mean that the law lords demolished Mahon's case only in relation to his allegations that there had been a cover up, and not his "opinions" as to cause.

Please tell me yes.

dh

[prospector]

deadhead,

To my understanding it applies to all the findings.

Exhibit 164 from memory was a chart that Mahon based many of his theories on, certainly nothing to do with any alleged cover up.

The Court of Appeal addressed several aspects that were brought to the commissioners notice during the enquiry but ignored by him.

The Privy Council agreed with the Appeal Court decision.

It states "and went even further" making the finding of no cover up a separate issue.

There are many who believe the following is correct. The Mahon report remains unqualified, still the version quoted in law schools, without the rebuttals formed by the subsequent Court of Appeal and Privy Council judgements. There has been no movement to record those officially and correct the Mahon version of the reasons behind the disaster.

[deadhead]

OK, I am beginning to see a problem.

AirNZ appealed Mahon's finding that there had been a cover-up. They appealed to the Court of Appeal. The Court of Appeal upheld their appeal. In turn, Mahon appealed to the Privy Council, whereupon his appeal was dismissed. The appeals were only ever in relation to Mahon's claim that there had been a cover-up.

It is very common for people to assume that (and then praise) the law courts for "overturning" Mahon's conclusions as to "cause." What adds a certain irony is that these are the same people that tend to criticise Mahon for being a non-aviation judicial officer making some big calls in areas he knows little about. That may be so, but that is the nature of a Royal Commission. The Commissioner(s) need only take advice from specialists, which of course Mahon did.

The Judicial Committee went out of its way in praising Mahon's "painstaking" work and even stressed that the question as to cause was, in fact, not put before them. You can read the entire judgments of both the Court of Appeal at www.gutenberg.org (search for erebus) and I think you can access the Privy Council judgment online also. If you can't find the PC judgment, I will email it to you.

I have to say that your arguments have been impeccable thus far, but I do have to question your claim that the accident crew complied with none of the four points in the briefing paper. On the first point, there was no evidence to suggest that the visibility was less than 20KM, on the second point there was no evidence of any snow showers in the area, on the third point the aircraft was not equipped to receive azimuth signals from the TACAN, the only way they could have complied with this instruction would have been to use the INS (a task it was not set up to do, nor were the crew instructed in any way on ANY methods using the INS, the only possible method left was VMC, and this was what the crew were doing), and to the fourth point, the meaning of the requirement was only that descent be coordinated with the local radar controller. This was, in fact, taking place with the radar controller at "Ice Tower" through the "Mac Centre" controller on HF. Radar identification was not a requirement of the briefing condition, although there is no doubt that it should have been.

This leads me to an interesting question. Just what is a "VMC descent?" In New Zealand, the closest thing is a visual descent below MSA. The only way you can do that is by conducting a visual approach, or by radar. I agree that neither of these things applied to the accident flight, therefore I do not know what was going on there.

There should have been a clear cut prohibition on descents below 6000ft if that had been the intent of the briefing. That people who were there can argue about what the briefing said (or meant) attests to its complete failure to provide anything of the sort.

Briefings are supposed to assume that pilots are stupid. A safe system also assumes that pilots are stupid, and goes out of its way to help them discharge their responsibilities. In this case the system badly let down the captain and crew of this flight. You can argue all day about who carried the responsibility yada yada yada, but ultimately 257 people died because the captain was unable to outwit a stupid and flawed system that covertly obstructed him at every turn.

[Desert Dingo]

Prospector said:
If you are so convinced Mahon was correct, how do you explain the following from the Privy Council???

In their judgment, delivered on 20 Oct 1983, the five Law Lords of the Privy Council dismissed the commissioners appeal and upheld the decision of the Court of Appeal decision, which set aside the costs order against the airline, on the grounds that Mahon had committed clear breaches of natural justice. They demolished his case item by item, including Exhibit 164 which they said could not "be understood by any experienced pilot to be used for the purpose of navigation", and went even further, saying there was no clear proof on which to base a finding that a plan of deception, led by the company chief executive had ever existed.

They demolished his case item by item, including Exhibit 164 which they said could not "be understood by any experienced pilot to be used for the purpose of navigation",

Surely that from the highest law court available should tell you something, but perhaps not. C’mon Prospector, you are starting to lose the plot. You can do better than that. Please try to back up your assertions with some evidence. :ok:


The privy council did not demolish any of Justice Mahon’s conclusions as to the cause of the accident.


Yes, the Privy council did uphold the Court of Appeal decision which set aside the costs order against the airline, on the grounds that Mahon had committed clear breaches of natural justice. They thought that the “organized litany of lies” went a bit too far.


However, the privy council appeal verdict did not overturn any of Justice Mahon’s conclusions as to who was to blame for the disaster.

The privy council said (my comment in brackets)
836
The Royal Commission Report (Justice Mahon’s report) convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged. (The conclusion of the Privy Council) And
their Lordships have very reluctantly felt compelled to hold that, in the various respects to which their Lordships have referred, the judge failed to adhere to those rules of natural justice that are appropriate to an inquiry of the kind that he was conducting and that in consequence it was not open to him to make the finding that he did in paragraph 377 (the organized litany of lies bit) of his report. You may care to go back to #88 in the thread where I tried to explain this to you before in greater detail.

[13370khz]

malcolmyoung90
----------------

No luck on "Erebus-The Aftermath". TVNZ said not available due
copyright reasons! I saw it about 1988 when shown by one of the
U.K. stations.

[Desert Dingo]

deadhead,

Complying with the four points in the briefing paper is a "red herring".
Apart from the initial flights, they were consistently ignored by the airline, although they were left "on the books."

The main point here is that the pilots were specifically authorised in the company briefing that they could descend in VMC with the approval of McMurdo ATC.

I am waiting for Prospector to claim that this is invalid because it is "I was only following orders" Nuremburg defence. :)

[Front Pit]

I am waiting for Prospector to claim that this is invalid because it is "I was only following orders" Nuremburg defence.

Desert Dingo :D :D :ok:

Why were there no pages left in Captain Collins’ otherwise undamaged ring-binder notebook?


Found this very interesting item in an article written in 1984 by Maurice Shadbolt. "After the Royal Commission was over, Sergeant Greg Gilpin, a member of the police search team in Antarctica, but who was never called as a witness, watched a TV documentary of the inquiries. The camera closed in on Judge Mahon as he examined Captain Collins's empty ringbinder notebook. "I was puzzled", says Gilpin. "It looked just like the notebook I saw at the crash site, where it was handed to me by a colleague. On the cover was Collins's name. All the pages in it were intact and the first few full of technical writing that appeared to be flight data. My colleague and I considered it an important find, so I placed it carefully in a plastic bag and left it with other articles at the campsite." Why then was Collins's widow given only the cover of the notebook? Why was she told that the inner pages were damaged? Would these pages have helped to make it clear how Collins was misled and why 257 people died? These questions will still be asked, though the full answers will never be known"

How very very interesting.........no cover up huh??!

[prospector]

Front Pit,
Read post 86 this thread re Collins folder.

Certainly this is becoming a waste of time.

Desert Dingo,

You posted some of Mr Thomsons statements but you missed this one.

"Air New Zealand and NZALPA went to some lengths to ensure that their senior pilots and members were seen as professionals who knew it all and did not therefor need to seek advice from elsewhere, such as the RNZAF, USAF USN, or the Division.

Are you or were you ever a member of NZALPA???

This from New Zealand Aviation Tragedies by John King

"The NZALPA evidence was all clearly rehearsed, declares Ian Gemmel, who had visited all the other Antarctic pilots with Chief Accident Inspector Ron Chippendale when he was gathering evidence for his report. "Their evidence differed from the interviews with Chippendale. Their answers then were not the same as given to the Court of Inquiry under oath, but they all agreed with NZALPA's stance. NZALPA's plan was to get the pilot off the hook. They socialised with the judge during and after the case.

This aspect is described by Morrie Davis as "absolutely disgusting and unforgivable". He has a copy of a letter written by Mahon part way through the enquiry, on Royal Commission of Enquiry paper, to an American lawyer saying the pilot was blameless and the airline was at fault.

Why did High Court judge Mahon resign when asked by Mr Davis to do so?? Mr Davis resigned because Mahon found the airline at fault, when Mahons findings were overturned he was invited to resign, and he did.

Look at the very first post of the thread.

"The advisory group received a draft of the report reviewed by two pilots with polar and whiteout flying experience, working independently of each other.

"They came up with some very interesting conclusions that basically said that poor old Peter Mahon had got it wrong," he said.

Former head of the department Gerald Hensley said the advisers felt there were problems with Mahon\'s logic and told Muldoon who said they should have a closer look.

The consulted pilots argued that only one person flew the aircraft "and that\'s the pilot," he said.

"From all that we did have some differences with Justice Mahon\'s argument that the plane, in his phrase I think, \'was programmed to fly into the mountain from the moment it left [New Zealand"
--------------------------------------------------------------------------
How does one programm a plane to fly into a mountain?? surely that is what the crew are in the front for, to make sure it does not fly into a mountain.

[Front Pit]

Prospector,
Your post #86 refers to Captain Collins flight bag and not the ring binder folder allegedly found intact but with no pages. Need to get your facts right old chap. :rolleyes:

[prospector]

Front pit,

My apologies, of course I should not have made that error, the state of the ring binder is crucial to the cause of the accident.

[prospector]

Desert Dingo,
It is obvious, as it always has been, that there will be no agreement as to who compiled the more accurate report on this tragedy, how about a little exercise, I will compile a list of those who disagreed with Mahons report, and went public with their findings, their interest in the findings, and their qualifications and experience to back their views, and you compile a list of those who have gone public with their agreement on Mahons findings, the reasons why, their qualifications and experience, and any interest they have in the situation.

And anyone that has knowledge of publications we miss may add to the list.

[Front Pit]

Prospector, it's appalling that you can be so sarcastic about the deaths of 257 people. := It's what was in the folder which may have provided crucial evidence, but appears to have mysteriously vanished. How very convenient.

Your post #147
And if that is your supposition, there is no point in continuing this discussion.
On such a note it is time to rest logical discussion.

You've lost the plot prospector, time to move on.

[Casper]

My apologies, of course I should not have made that error, the state of the ring binder is crucial to the cause of the accident.
----------------------------------------------------------------
The lack of pages from the ring binder which were present when found and the illegal break-in of the pilots' homes certainly indicate that the company was out to hide something and that something just may have provided some clues as to some factors that may have contributed to the crash.

I agree with the others, Prospector, you seem to have lost it.

[Taildragger67]

The PC did not examine Mahon's findings as to cause as they were not put before it. The judgment makes that explicit in a section headed "The limits on the matters decided on the appeal to this Board" (at p.836).

That section contains the passage:

The Royal Commission Report convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged. The judge was able to displace Mr. Chippindale's attribution of the accident to pilot error, (my emphasis)

and also (at p.837):

The judge's report contains numerous examples and criticisms of A.N.Z.'s slipshod system of administration and absence of liaison both between sections and between individual members of sections in the branch of management that was concerned with flight operations. Grave deficiencies are exposed in the briefing for Antarctic flights; and the explanation advanced by witnesses for the airline as to how it came about that Cap-tain Collins and First Officer Cassin were briefed on a flight path that took the aircraft over the ice-covered waters of McMurdo Sound well to the west of Mt. Erebus but were issued, for use in the aircraft's computer, as the nav track a flight path which went directly over Mt. Erebus itself, without the aircrew being told of the change, involved admissions of a whole succession of inexcusable blunders by individual members of the executive staff. None of this was challenged before their Lordships. No attempt was made on behalf of A.N.Z. to advance excuses for it.

These appalling blunders and deficiencies, the existence of which emerged piecemeal in the course of the 75 days of hearings, had caused the loss of 257 lives (my emphasis)

It is clear from these passages that the PC in no way questioned, challenged or otherwise threw any doubt on Mahon's findings of fact as to the cause of the crash itself. Further, the PC makes it clear that no other party sought to do so (or indeed has ever sought to do so, except perhaps on PPRuNe... :hmm: ).

The appeal was simply over what Mahon said in his paras 376 and 377 about actions which were purported to have taken place well after the crash and which can be separated from it. He had no right to make such a finding. It was outside his terms of reference and, under NZ case law, he was not (could not) enquiring into a crime (Cock v A-G (1909) 28 NZLR 405). If someone called me a criminal when they had no right to do so and could not substantiate their claim (and the PC points out (at p.839) that the claims were investigated by police), then I would challenge that claim. That is all the PC looked at, because that is all that they were asked to look at.

Had any of the individuals fingered by Mahon have had an argument with his findings as to the cause of the crash, they had, and still have, plenty of opportunity to challenge them. They have never done so.

So can we please now move on and leave the Judicial Committee of the Privy Council out of it?

[jack red]

Captain Collins and First Officer Cassin were briefed on a flight path that took the aircraft over the ice-covered waters of McMurdo Sound well to the west of Mt. Erebus but were issued, for use in the aircraft's computer, as the nav track a flight path which went directly over Mt. Erebus itself, without the aircrew being told of the change, involved admissions of a whole succession of inexcusable blunders by individual members of the executive staff.

The absolute root of this disaster!

My seven year old son can comprehend this what else seems to be the problem?:ugh:

[Casper]

Taildragger and jack red,

Your posts SHOULD put to bed any debate over the PC's involvement with the case. No one from TE or anywhere else has seen fit to challenge the PC or Mahon's findings as to the root cause of the crash.

Prospector may yet try again but it would appear that he has dropped the Air NZ ball.

[Desert Dingo]

Prospector:
…. how about a little exercise, I will compile a list of those who disagreed with Mahons report, and went public with their findings, their interest in the findings, and their qualifications and experience to back their views, and you compile a list of those who have gone public with their agreement on Mahons findings,Do you think that will prove anything? Counting heads does not show if something is true or false.
A majority of people once believed the sun revolves around the earth, or that the earth is flat. They probably wrote lots of books about it too. It did not make either belief into a fact.
I prefer to look at just the facts, so I will decline your kind offer to make lists.

Are you or were you ever a member of NZALPA???No, sorry. Your “guilt by association” argument will fail to get off the ground.
However, I did meet Captain Gemmel.
Once. Briefly. I was being cleared to operate an Air New Zealand simulator to train NZ pilots for another airline and he turned up as part of the approval process. Thought he was a nice chap, although I was surprised to find him now working for the department upholding truth, justice and the New Zealand way. :)

[Desert Dingo]

Taildragger,
Please forgive me for mentioning the Privy Council again, but I think there is value in reading this pretty concise summary of the aftermath of the Royal Commission report as it explains why things turned out the way they did:
Andrew McGregor “Accidents, Failures, Mistakes and Leaky Buildings. (my emphasis)
Mahon also blamed the airline for deliberately conspiring to lie, reflected in his famous ‘litany of lies’ quote. Air New Zealand objected to the Court of Appeal (CA) on the basis of costs. According to historical clauses in the TAIC Act, the CA judged that Mahon overstepped his brief in judging that the Air New Zealand witnesses committed perjury, because it was a crime and could only be judged so in a court of law, not a Royal Commission of Inquiry (Beck 1987). However the Court of Appeal stopped short of faulting Mahon’s technical determinations including the predominant cause of the crash.
Mahon appealed to the Privy Council as a private citizen but the Privy Council not only supported the Court of Appeal, it also cleared the airline of blame without the corresponding rigour of Mahon’s enquiry. This effectively undid much of Mahon’s work and to a layperson, confused the findings. The logic of the Privy Council in clearing the airline of blame remains unclear. The judgement of the Court of Appeal and Privy Council is criticised by Stuart MacFarlane, a retired senior law lecturer, in his book titled The Erebus Papers (1991). According to MacFarlane (1991) and Beck (1987), in order for Mahon to judge between conflicting witnesses, he had to judge that several of them had lied and could not fulfill his mandate without judging so. In their view, this would have been obvious to the alleged liars and the warning that the Court of Appeal and the Privy Council judged should have been given, was unnecessary.
Beck (1987) cites that the main reason to go to appeal was in order to vindicate Air New Zealand of its reputation. Therefore without Mahon’s mandate to apportion blame, Air New Zealand may not have appealed and the investigation process may have concluded with a clearer outcome. It is interesting to note that during the course of Air New Zealand’s final submissions, when it was convenient for them to do so, counsel for the airline invited Mahon to stop short of attributing blame and merely identify the contributing factors. In response, Mahon acknowledged that “the prime purpose of aircraft accident investigation is to secure avoidance of similar accidents in the future, not to identify and apportion culpability or blame for what occurred” and that citing the ten factors was sufficient to achieve this (Mahon, 1981, p. 158). However he advised that his mandate also included the need to “answer the question whether this disaster was caused or contributed to by blameworthy acts or omissions by any person or persons” (Mahon, 1981, p. 158).
The cost of a clouded inquiry and the need to apportion blame was enormous. Following the inquiry, Captain Gordon Vette and Peter Mahon, both leaders and highly respected professionals in their respective fields resigned from their jobs, thus ending their careers. Although Captain Vette continued to implement improvements in international air safety, regrettably Mahon died a few years later. In the minds of many professionals, the judgement of the Privy Council confused the conclusions that Mahon so painstakingly derived and made it difficult for safety professionals to openly promulgate the lessons learnt from the Erebus crash, which ICAO later admitted carried a profound message in preventing organisational accidents in the future.
This is from a well written analysis of how the incremental results of the actions well-meaning people doing what they thought was the right thing at the time, can eventually result in a disaster. Well worth reading
http://www.prosolve.co.nz/accidents.pdf

[prospector]

"A majority of people once believed the sun revolves around the earth, or that the earth is flat. They probably wrote lots of books about it too. It did not make either belief into a fact"

And by the same token it does not make Mahons beliefs fact.

"although I was surprised to find him now working for the department upholding truth, justice and the New Zealand way."

Which Dept would that be, or has it completely gone along with the dinosaurs??

[Brian Abraham]

the contents of the notebook were not relevent to the event.

Big call. Bloody big call CI300. Tell us more. What did it contain - no one else knows. :ugh: The very fact that the airline (who else pray tell) saw fit to destroy the evidence says something about what the pages contained.

[SR71]

I've been lurking...

Those who espouse that, because Collins was PIC, he should bear ultimate responsibility for the tragedy, have surely failed to appreciate the most crucial tenant of the New View of Human Error which Dekker's books/papers so thoroughly elucidate.

Was the PIC of JL 123, who fought valiantly with his a/c for 32 mins, ultimately responsible for the loss of 520 lives because he failed to appreciate a pressure bulkhead was repaired incorrectly?

Was the PIC of AA 191 reponsible for the loss of 271 lives because AA mechanics had invented their own procedure for replacing self-aligning bearings on the pylon in compliance with a Douglas service bulletin?

Surely, the safe conclusion of a commercial flight is, quite literally, the end result of hundreds of people doing the jobs expected of them with due diligence?

How is this situation different?

I fly an EFIS FMC equipped aircraft and have no knowledge of how the DC-10 nav system works....

Every time I go flying I upload a company route designator into my FMC. It may change from day to day but as long as the waypoints agree with my flight plan, I'm happy. Because we fly to less than 30 destinations, my familiarity with the various routes will probably allow me to pick up any outrageous changes that might likely kill me.

But name me a single commercial pilot of this/my generation who will then cross check an unfamiliar route against his enroute chart(s) to see if all the previous safety nets have failed, and he has now uploaded a route which will take him straight into a mountain...

I've yet to come across such a pilot...

Surely as PIC I have a right to expect to expect the route is not going to kill me just like I have a right to expect a pressure bulkhead's integrity?

It is a question that puzzles me regards this incident, but how/who changed the route? Who changed the coordinates and why was the route changed?

Yeah, but what about the VMC let down....

I have to say that my reading of the CVR transcripts don't suggest a cavalier crew to me...

Let me ask another rhetorical question...

Is there a commercial pilot out there, who hasn't at some time, been temporarily unsure of his position?

Happened to me a few weeks ago, 4000 ft below MSA, nav-aids disagreeing with each other, false FMA indications, suspect radar control coverage, and, therefore, only FMC filtered IRS information to rely on....temporarily. I was able to resolve the situation within seconds.

Seems to me the crew of ZK-NZP (PIC and others) resolved their course of action within seconds. It just wasn't quite enough.

[prospector]

SR71,

I am, for one, not suggesting that the blame is entirely with the crew.

Neither do I believe they are completely blameless, as Justice Mahon found, and so many believe.

This from Ron Chippendale, the Air Accidents Inspector.

"The errors in the briefing were serious but not an absolute excuse for the accident when the means were readily available for the pilot in command to make certain he knew where he was."

This covers what many experienced aviation people believe, and is a fair statement of events.

[Desert Dingo]

SR71,
It is a question that puzzles me regards this incident, but how/who changed the route? Who changed the coordinates and why was the route changed? The initial route approval was directly over Mt Erebus and required severe limitations on descent.
The military route down the middle of McMurdo Sound was a far better idea, so the track was altered to conform with the military route.
Then in September 1978 steps were taken to print a flight plan for each Antarctic journey from a record stored in the Air New Zealand ground based planning computer. And it is at this stage that the longitude co-ordinate for the southernmost waypoint was fed into the ground computer as 164° 48' E. "So as I say, I think it likely that the change of the McMurdo destination point was intended and was designed by the Navigation Section to give aircraft a nav track for the final leg of the journey which would keep the aircraft well clear of high ground." Then the next revision of charts became due, but official approval for the change had never been sought from CAD, although it would have been granted.
... the next edition of the Ross Sea chart NZ-RNC4 would contain the official Air New Zealand flight path to McMurdo, and that the safest course would be to put the destination point back to the approximate location at which Civil Aviation Division had thought it had always been." Small problem, though. The flight plans were now being transmitted to McMurdo ATC and showed the lat/long of the waypoints, and the changed waypoint would be obvious and they might not be happy with the change. Easily fixed. By typing in a special character the lat/long is replaced by just the waypoint name.
As usual a signal was sent to the United States base at McMurdo with advice that the aircraft was to fly to the Antarctic on 28th November and the flight plan for the journey. And in the list of waypoints appears the word "McMurdo" in lieu of the geographical co-ordinates which had appeared in the equivalent signal for the flight three weeks earlier "In my opinion, the introduction of the word 'McMurdo' into the Air Traffic Control flight plan for the fatal flight was deliberately designed to conceal from the United States authorities that the flight path had been changed, and probably because it was known that the United States Air Traffic Control would lodge an objection to the new flight path." So the waypoint was changed, and you know the rest.
The subsequent Court of Appeal after Mahon’s report came out successfully quashed Mahon’s attributing blame to the company, although his findings on the cause of the disaster were never challenged. The minority report of CA totally exonerated the company of any blame.
This kinda pissed off Justice Mahon, so he took his marbles and left the game.
His Way: A Biography of Robert Muldoon by Barry Gustafson p292

Mahon was shattered by the decision of the Court of Appeal and decided to retire immediately because he took the Court's finding to mean his credibility as a judge had been destroyed and that he was 'incapable of distinguishing truth from falsehood’. A few weeks later he wrote a longer, more formal letter again noting that 'my judicial position has been compromised bythe way in which the Court of Appeal handled this case’

He requested that the Government exercise its discretion and pay him a pension which be would supplement by part-time; university teaching because a convention prevented him returning to the bar. He also asked if the Government would appeal the decision to the Privy Council on the grounds that the Court of Appeal as a whole had 'misconceived the true nature of a Royal. Commission', and that Justices Woodhouse and McMullin should not, because of their family and other connections, have taken part in the appeal.

Woodhouse and McMullin had presented a minority report totally exonerating Air New Zealand of giving false evidence. Mahon had known in advance of the Court of Appeal hearing that Woodhouse and McMullin had children who were employed by Air New Zealand but when given the opportunity to object to their sitting had not done so.

Muldoon and Mclay diverged strongly over the Mahon report on the Erebus disaster and there wereheated exchanges between the two when Muldoon sided with Air New Zealand and Mclay defended Mahon. At one point. indeed. Mclay. who wanted to reject Mahon's offer to resign, nearly resigned himself when Muldoon favoured immediate acceptance. Mahon did resign and subsequently in 1983 the Privy Council also found that there was no evidence to substantiate Mahons charge that Air New Zealand's management had been guilty of a 'litany of lies' and a ‘conspiracy to deceive’. Nevertheless, there were many in the public who felt that Air New Zealand had been too quick to blame pilot error and to minimise other contributing factors to the tragedy and that Muldoon had been too partisan in defending the board and senior management of the airline. It seems to me that Justice Mahon’s big mistake was to expect the justice system to apply the same high ethical and analytical standards that he had set. Justices Woodhouse and McMullin TOTALLY EXONERATED the airline of giving false evidence, fercrissake! I could understand some quibbling over details, but to me that is just unbelievable! :confused:

[prospector]

"The subsequent Court of Appeal after Mahon’s report came out successfully quashed Mahon’s attributing blame to the company, although his findings on the cause of the disaster were never challenged. The minority report of CA totally exonerated the company of any blame.
This kinda pissed off Justice Mahon, so he took his marbles and left the game"
---------------------------------------------------------------------------
"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 Accident investigation report, which remains the sole official account---and has never been officially challenged."

It would appear "facts" depend upon where you find them.

"Successfully quashed Mahon's attributing blame to the company, although his findings on the cause of the disaster were never challenged".

Seeing as that he put all the blame of the company, and the Appeal Court said he was wrong, how do you reconcile that with the statement that

"His findings on the cause of the disaster were not challenged"

[Desert Dingo]

Seeing as that he put all the blame of the company, and the Appeal Court said he was wrong, how do you reconcile that with the statement that

"His findings on the cause of the disaster were not challenged"Quite easily:
When the squabble went to the Privy Council they said
The Royal Commission Report convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged. The judge was able to displace Mr. Chippindale's attribution of the accident to pilot error,What part of "unchallenged" do you not understand?
Are you able to discriminate between the cause of the disaster and the blame for the disaster?
I think not.

[nick charles]

Desert Dingo,

Thanks for that info re the changes to the flight plan. Although I've read Impact Erebus and Verdict on Erebus, I was unaware of the details leading up to the change of waypoints.

By the way, I've got the original "Today" program on the accident with live footage of the Royal Commission on DVD if any one is interested. It was taken from an old CVR tape so some of it is a wee bit strained but generally okay.

[prospector]

Desert Dingo

"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 Accident investigation report, which remains the sole official account---and has never been officially challenged."

Please read and inwardly digest.

Also look at the finding of Judge H Greene, District Court USA. when the blame was tried to be foisted on the Controllers at McMurdo.

" The Court concluded that the disaster was the fault of both Air New Zealand and the FLIGHT CREW, and that the US Navy controllers bore no responsibility. The case was dismissed and, being delivered entirely on facts was not appealed."

How many of Mahons peers have to disagree with his findings before it is accepted he stuffed up.

In some parts of his findings.

[Taildragger67]

1. Did ZK-NZP crash? - Yes

2. Was it CFIT or mech failure? - CFIT

3. Did the flight crew take an action which placed the aircraft in a situation where it suffered CFIT? - Yes

4. Did the flight crew recklessly take that action without due regard to any briefing, or were they operating in accordance with what they had been briefed on? - The latter

5. Were the crew aware of earlier flights which had descended to low level? - Yes

6. Did the carrier discipline any pilot who had descended to low level on earlier flights? - No

7. Did the carrier indeed seek to cover up the fact that earlier flights had descended to low level? - No, they used it in marketing the flights

8. Was it therefore reasonable for the flight crew to assume that it was ok to descend to low level? - Yes, in VMC conditions

9 - Are VMC conditions determined visually? - Yes - if you look out and see it's clear (or do not see that it is not clear), then usually (and in Jim Collins's long experience) chances are it's clear

10. Did some outside party do something to change the route from what the flight crew were led to expect? - Yes

11. Would it be reasonable to think that this outside party should tell the flight crew of such a change? - Yes

12. Did they so tell the flight crew? - No

13. Was the outside party therefore negligent in not informing the flight crew of that action? - Yes

14. Can we assume that, if the flight crew knew their actual position relative to Mt Erebus, they would have descended the aircraft to 1600'?

So... yes, the flight crew were responsible for descending the aircraft over the sea to the north of Ross Island. Aliens did not do it and the aircraft did not do it of its own accord or under radio control from Auckland; Collins and Cassin did it.

So Collins and Cassin must take responsibility for doing that. Indeed I don't think anyone has ever denied that fact.

However, they did so, as we know, based on briefings that made them believe that they would be taking such action 20-odd miles off Ross Island. That this reality changed is not their fault. It was a combination of their training, meticulous following of that training, and the change made to the nav inputs, which put them into the 'wrong' place at the wrong time.

It was also entirely reasonable for them to assume that conditions were VMC.

In summary:
IF THE WAYPOINT CHANGE HAD NOT BEEN MADE, OR IF THE FLIGHT CREW HAD BEEN INFORMED OF THE CHANGE, THE FLIGHT CREW WOULD NOT HAVE ASSUMED THAT THEY WERE SEVERAL MILES AWAY AND WOULD NOT HAVE DESCENDED THE AIRCRAFT WHERE THEY DID SO.

The flight crew's actions were the last links in the chain of causation, which started with the nav waypoint change. At any point, the chain could have been broken - eg. not making the change, telling the crew, crew not descending below 16,000', or even selecting G/A power and nose-up just a few seconds earlier. But it wasn't.

So the carrier is (at least vicariously) to a very large extent, liable.

To draw a parallel with VH-OJH at Bangkok - it was the hands-on actions of the flight crew, operating the aircraft's systems, which caused it to overshoot the runway; it didn't do so by itself. But the crew were 100% exonerated, as it could be proven that they were acting 100% as per their training for such conditions. It was the training which was at fault.

Let us consider the following scenario:
- I am in a foreign city, out for dinner and trying to get back to my hotel.
- I look on the map and see a street which runs directly from the restaurant, to my hotel front door.
- Unknown to me, a water-main has burst half-way down that road, not visible from the surface but undermining and weakening the road. Local authorities know about it - but I am unaware of it and there are no warning signs.
- I therefore assume I know where I am and head down the road.
- Halfway down, I fall through the tarmac and into a hole.

Prospector, according to your logic, I am mostly, if not totally, to blame. Yes, I put myself in danger by walking down the road. But is it my fault that the road was weakened, and no-one bothered to tell me?

Your logic would also support arguments that women who wear attractive clothes or go to pubs are to blame if they get raped; one hears of very few nuns getting so attacked.

One day, lying on their death-bed, someone will 'fess up and tell those assembled that it was they who changed a couple of digits on the printout of waypoints given to the crew of of ZK-NZP prior to its last trip. If they are still alive, they are living with a terrible burden.

As for Mahon's 'peers' agreeing or disagreeing with his findings of fact, the Judicial Committee of the Privy Council (sorry for dragging them back in here) - who were Mahon's judicial superiors (ie. better than peers) not only did not disagree with Mahon's findings of fact but went on to praise his meticulousness. So his direct superiors (NZ at the time having recourse to the Privy Council but not to any US court) did not, as you assert, disagree with his findings to do with the crash.

What they could not agree with, was his opinion as to whether there was a conspiracy to cover something up. Indeed they did not even say there was not a cover-up; they simply could not agree that there was an organised conspiracy to cover up. It's a fine point, but an important one.

It's not too long a judgment; if you read it from the point of view of the conspiracy aspect, rather than as to whether the Committee is assessing the findings as to the crash, you'll see the difference. I would agree that it's a difference which someone without legal training may easily miss, given the time apparently spent discussing the crash. The Committee's discussion is not actually as to the crash; it is as to whether or not there is evidence of a conspiracy.

The Committee went on to say that it was time to put it all to rest. I suggest we agree with that opinion.

[prospector]

" It was also entirely reasonable for them to assume that conditions were VMC."

IF THE WAYPOINT CHANGE HAD NOT BEEN MADE, OR IF THE FLIGHT CREW HAD BEEN INFORMED OF THE CHANGE, THE FLIGHT CREW WOULD NOT HAVE ASSUMED THAT THEY WERE SEVERAL MILES AWAY AND WOULD NOT HAVE DESCENDED THE AIRCRAFT WHERE THEY DID SO.

Lot of assumptions there, one of the first things I was taught when I was doing my training was not to make assumptions.you must know. Also a major no no was to go down sucker holes, especially when I had only an assumption of my position.


"So Collins and Cassin must take responsibility for doing that. Indeed I don't think anyone has ever denied that fact."

Yes indeed, and yet they are blameless???


"Your logic would also support arguments that women who wear attractive clothes or go to pubs are to blame if they get raped; one hears of very few nuns getting so attacked."

Garbage, another assumption.

"The errors in the briefing were serious but not an absolute excuse for the accident when the means were readily available for the pilot in command to make certain he knew where he was."

As has been stated before, that statement from Ron Chippendale holds more water that all the legal clap trap that has been printed.

The Committee went on to say that it was time to put it all to rest. I suggest we agree with that opinion.

Agreed.

[Desert Dingo]

Prospector
Also look at the finding of Judge H Greene, District Court USA. when the blame was tried to be foisted on the Controllers at McMurdo.

" The Court concluded that the disaster was the fault of both Air New Zealand and the FLIGHT CREW, and that the US Navy controllers bore no responsibility. The case was dismissed and, being delivered entirely on facts was not appealed." Can you give me some more details about this case? I have tracked down a Judge Harold H. Greene of the US District Court in Washington DC but can’t find the case you mention.
Can you give me any info on the case number, date plaintiffs/respondents etc.?
Did this judge conduct a separate accident investigation, or did he rely on Chippindale’s report?
He obviously was not referring to Mahon’s report, which did not blame the flight crew.
If he was relying on Chippindale’s report, then I give your argument no points at all.
Chippindale produced a good report, based on what was known at the time and using what are now outdated methods of investigation.
However, when you consider all the extra details brought to light in Mahon’s investigation, when Chippindale writes …
2.5 The flight plan was printed for each flight from a computer stored record which, until the night before the flight, had the longitude for the McMurdo destination point incorrectly entered ………….
……… In the case of this crew no evidence was found to suggest that they had been misled by this error in the flight plan shown to them at the briefing. ….. that is obviously absurd.
Similarly when you say
…….Office of Air Accident investigation report, which remains the sole official account---and has never been officially challenged."
… are you suggesting that Chippindale’s report is the definitive report on the accident?
It may not have been “officially challenged”, but you cannot deny that Mahon’s investigation showed Chippindale came to a lot of incorrect conclusions.
You can’t blame Chippindale too much; he was working with what was available at the time. However, if you are trying to argue that Chippindale’s report is the sole correct version then, once again, … that is obviously absurd.

[prospector]

Desert Dingo,

This from New Zealand Aviation Tragedies by John King.

"And then came to Court battles, spread over several years and resulting in judgements that went against the OPINION of the Royal Commissioner. The last of these came towards the end of 1987 when representatives of the families of the dead crew members sued the United States Government for alleged failure of the U.S. Navy air traffic controllers at McMurdo to warn flight TE901 that it was in danger. Relatives of the 237 passengers had received substantial compensation, but because the 20 crew members were working for a New Zealand company they were eligible for only the standard accident compensation, and proving negligence against an outside agency was their one opportunity to receive a higher payout.

Following the U.S. District Court hearing in Washington DC, Judge Harold H. Greene wrote in his ruling,

"It is clearly established that, when the pilot told Mac Centre he wished to descend VMC, he effectively informed the controllers that he could see where he was going. In so doing he took SOLE RESPONSIBILITY for separating THE AIRPLANE FROM OTHER AIRCRAFT and the TERRAIN and he was on his own,
There also was much credible testimony to the effect that, and the Court finds that, air traffic controllers are not in a position to challenge, or second guess, the representation of a pilot that he can see where he is going and. indeed, that controllers are trained not to question such a representation".
----------------------------------------------------------------------
To get away from all the legal jargon, the pilot asked for descent, he said he could see where he was going, even on the track that they thought they were on, at no time did they see a 12,000ft mountain, in an area that has brilliant visibility, over 100 miles at times, they would have been no more than 20 miles from Erebus, even on the so called wrong track, they did not see it at any time, even from 16,000ft, before they commenced the descent, and this in an area that they must have known can play some funny tricks weather/visibility wise. and this was their first time down there. one would think extreme caution would be the order of the day.
--------------------------------------------------------------------------
A bit more from Judge Greene,

" Judge Greene said the operational crew of Flight TE901 acted unreasonably in several respects, including not plotting their ACTUAL POSITION from the AINS and descending below "below 16,000ft, contrary to both prudent airmanship and Air New Zealand policy, without ascertaining what was there or following the other requirements for such descent. The crew also missed the obvious landmark of Beaufort Island being on the wrong side of the flightpath and pressed on in the face of deteriorating weather, with five or six extra people milling around the cockpit causing some distraction during the critical period."

Nowhere is Mahon's findings, or Chippendales accident report mentioned, it is not known to me if these in any way influenced Judge Greene, but I would guess not.

Just to get the facts straight on a previous statement you made,

Captain Hawkins (and others) may have been telling fibs.
In the Auckland Star of 22 October 1977 an article appears with “At the controls Captain Hawkins brings the DC10 down to 200m over Scott and McMurdo Bases – well below the towering volcano Erebus belching smoke only 40 km. away.”

The police tried to make a case of this, and as is reported in the same book by John King,

"My lawyer approached the police to ask why nothing had happened, why there was no talking to me, and they asked him what I had to hide. They didn't believe the evidence the other members of my crew, saying it was a bit like a wife giving evidence for her husband.

In the end the one piece of evidence "The DC10 was going to a lower altitude" which proved absolutely nothing when no mention of its previous height was made, and the case was quietly dropped.

… are you suggesting that Chippindale’s report is the definitive report on the accident?

Yes I am, because it is.

It may not have been “officially challenged”, but you cannot deny that Mahon’s investigation showed Chippindale came to a lot of incorrect conclusions.

Garbage, it did no such thing, Mahons report was an enquiry, and only his opinion came out at the end.

As you obviously believe that the Commissioners report is Gospel, I see nothing to be gained going over the same ground again and again, you obviously have chosen to only read any statement that support Mahons theories and nothing is to be gained from any further discussion.

Thank you,

[ampan]

A very interesting discussion. I suspect the main reason why this debate still rages is that Justice Mahon completely exonerated the crew. In apportioning blame, it wasn't "90% Airline / 10% Crew". It was "100% Airline / 0% Crew". And as has already been pointed out, that finding was not affected by the subsequent litigation, which focused on other unrelated issues. So history will record that the crew was completely blameless, and this is difficult to accept. The airline, obviously, must shoulder most of the responsibility. But Mahon's complete exoneration of the crew, and the methods he used to get there, are very difficult to understand.

It should be noted Mahon was a lawyer, not an aviator - and he was not above the twisting of a word or two. The end result sounds good on the first reading, but makes less sense on subsequent readings. The classic example is the way he dealt with Chippendale's finding that the crew descended below Minimum Safe Altitude when "unsure" of their position. Mahon seized on the word "unsure", and found that the crew were, in fact, sure of their position: they believed they were in McMurdo Sound. But how can this form any basis for exonerating the crew? If they believed they were in McMurdo Sound, they were wrong. And the surer they were, the wronger they were.

As to the crew's certainty of their position, there is one piece of evidence that is never referred to. Just before the Ground Proximity Warning System sounded, the captain said "We're 26 miles north. We'll have to climb out of this." The first officer, seated in the right-hand seat, says "It's clear to the right and ahead. You're clear to turn right. There's no high ground if you do a 180." The captain responds "No. Negative." At this point, the GPWS sounds, the captain calls for go-around power and there is a sudden manual application of LEFT rudder.

No-one, including Mahon (who never referred to this evidence), has explained why a pilot who is certain he is in the centre of McMurdo Sound would decide to turn left to climb out, because Erebus and Mount Bird would be to the left. The obvious manouvre was the right turn that had been expressly suggested by the first officer. The first officer, of course, was wrong. A right turn would have produced a collision with the cloud-covered Mount Bird - and the captain, in the final seconds of the flight, appeared to have some appreciation of there being danger to the right. And when the GPWS sounds, there is an immediate attempt to climb out, rather than any reference the possibility of a false alarm. None of this is consistent with the crew being certain that they were in McMurdo Sound.


Beaufort Island

Judge Harold Greene commented that the crew "missed the obvious landmark of Beaufort Island being on the wrong side of the flightpath."

Mahon attempted to explain that failure, but I did not find his explanation particularly convincing. Of more significance, in my mind, is a photograph of Beaufort Island that was included in Mahon's report. The photograph was taken by a passenger on the flight, and was included for the purpose of demonstrating that the aircraft was flying in clear air. But the photograph also demonstrates that Beaufort Island was almost impossible to miss. The photograph shows an island of significant size, with high cliffs. It is difficult to accept that the crew did not see the island, especially given that they flew past it on three occasions, two of which were below the cloud base. And it appears from the transcript that Beaufort Island was, in fact, sighted from the flightdeck. The Chippendale Report contains a diagram with the track plotted in 3D against the terrain. Also included are comments from the transcript, which are plotted on the track. As the aircraft is half-way through the second of its descending orbits, and just at the point when Beaufort Island is dead ahead, the flight commentatator says "There you go. There's some land ahead."

The flight commentator was not part of the crew, but given that he had just identified some land ahead, wouldn't the next question be "What land is that?" The aircraft had been relying on instruments alone since leaving Auckland, was approaching Antarctica, was flying VMC, below MSA, and the flight commentator had identified land ahead. I would have thought that at least one member of the crew would have attempted to cross-check the assumed poisition against this topographic feature. Had that been done, it would have been obvious that the assumed position was wrong. The map would have shown that there were no other islands in the vicinity. The island ahead could not have been any island other than Beaufort Island and the track allegedly plotted on the atlas would have showbn that the aircraft was on the wrong side of Beaufort Island, on a collision course with Erebus.


Change of the Waypoint

I note the explanation of "Desert Dingo" for the change to the waypoint. This appears to follow Mahon's theory, which was that the Navigation Section of the airline was attempting to conceal something from the US authorities or/and the Department of Civil Aviation. But what were they supposed to be trying to cover up? Mahon seemed to believe that the staff at the Navigation Section devoted large amounts of time towards some bizarre conspiracy, when all they had to do was simply change the route to what they wanted and then have it appoved by the US authorities and by Civil Aviation. I much prefer the evidence of the Navigation Section, who frankly admitted that they made a series of errors.

Putting the conspiracy theory to one side, it is not disputed that the nav track for the initial flights was over Erebus. It is not disputed that nav truck for later flights was down McMurdo Sound. And it is not disputed that on the morning of the fatal flight, the nav track was changed, back to one going over Erebus. Desert Dingo does not discuss the circumstances that led up to this final change. Mahon goes into the issue is some depth, but in doing so, he raises an important question which he never answers.

Approximately two weeks before the fatal flight, another flight had visited Antarctica. Shortly after this flight, the captain spoke with the airline executive pilot responsible for navigation on the Antartic flights. The discussion concerned the final waypoint. (It should be noted that on this flight, unlike the fatal flight, the final waypoint was in the centre of McMurdo Sound, which produced a nav track down the sound, rather than over Erebus.) Conflicting evidence was given about the discussion. The executive pilot said that the captain told him that the waypoint was in the wrong position. The executive pilot, assuming the correct track to be over Erebus, instructed the Navigation Section to correct the error, which they did on the morning of the fatal flight. The executive pilot's evidence was hotly contested. The captain said that he never told the executive pilot that the waypoint was in the wrong position. All that was said, according to the captain, was that when he overflew the waypoint in McMurdo Sound, he was about 20km from where he thought he would be and that he believed that future crews should be told of this.

Mahon accepted the captain's evidence, and rejected that of the executive pilot. In doing so, Mahon refused to accept that an airline would "program" an aircraft to fly over an active volcanoe. Again, this sounds good on the first reading, but makes less sense the more you think about it. The purpose of the nav track was to get the aircraft to the vicinity. It seems perfectly reasonable to align the nav track with the most conspicuous topographical feature, specifying a minimum safe altitude. Once in the vicinity, the aircraft was not committed to its nav track.

Even if the captain's evidence is accepted, it is very difficult to understand. The reason is that the captain attended the same briefing as Captain Collins. The briefing officer gave evidence and said that he told the pilots that the nav track went over Erebus. At that time, the nav track did not go over Erebus, but the significance of the briefing officer's evidence is that the pilots at the briefing were told that it did, and that one of those pilots was the captain on the fatal flight. The briefing officer's evidence was disputed by the captain, who was admanant that there was no reference to the nav track going over Erebus.

The important question that arises from that evidence is this: If the captain believed that the nav track was down McMurdo Sound, rather than over Erebus, why, when he overflew the waypoint in McMurdo Sound, did he note anything unusual? Why, in fact, did he note anything at all? If his evidence about the briefing was correct, the waypoint was exactly where it was supposed to be. If, on the other hand, the briefing officer had told the captain that the nav track went over Erebus, then there would be something unusual to note when the captain overflew the waypoint.

There may be an explanation for this, but Mahon never gave it. Instead, he labelled the executive pilot and the briefing officer as perjurers. This apparent contradiction goes right to the heart of the matter, because if the briefing officer told the pilots that the nav track went over Erebus, it is no answer to say that a sheet of paper was handed out with co-ordinates which, when plotted on a domestic atlas, showed a track down McMurdo Sound. In that situation, the pilots attending the briefing were obliged to clarify the situation.

[Taildragger67]

Ampan,

Good first post, which I will re-read and consider. Certainly some food for thought in there.

That said, taking things as they stand, I would like to make one small point by way of comparison to show that it is possible for pilots do do things which, had they acted differently, may have caused a different outcome; but fo rth epilots to be exonerated as they were acting reasonably with the information they had and the situation as they reasonably believed it to be.

That comparison is a DC10 crash in May 1979 (http://amelia.db.erau.edu/reports/ntsb/aar/AAR79-17.pdf) (AA191) at O'Hare. An engine separated, causing loss of power and assymmetry, but importantly, loss of systems and hydraulics. The crew had been trained to reduce to V2 (around 140kts) after an engine loss; however this crew did not know the engine had separated and certainly did not know they were losing hydraulic fluid, causing the left slats to retract (so raising that wing's stall speed to 160kts). Hence in reducing speed, the crew (by a very literal interpretation) made the aircraft uncontrollable.

However they could be exonerated as they were doing what they thought was reasonable, according to their training.

I will re-read Ampan's post and chew it over.

[prospector]

Taildragger67,
Don't think your comparison to the DC10 at O'Hare is really relevant in as much as TE901 was a perfectly serviceable aircraft, and there was no urgency to do anything when the decision to descend was made.

[ampan]

All agreed. The crew never gets the benefit of hindsight.

On reflection, my point about the captain's decision to turn left to climb out is not a good one. It seems reasonably obvious that he was not, at that time, certain that he was in McMurdo Sound. However, shortly beforehand, after completing two descending orbits that took the aircraft through a hole in the cloud cover, the nav mode was deliberately re-engaged, so that the aircraft would again lock onto the nav track. As Mahon points out, the captain, at that point, must have believed that he was in McMurdo Sound. It is possible that he became slightly less certain after he levelled out at 1500 feet and after the flight engineer said "I don't like this", and then rapidly reassessed the situation after the GPWS sounded. (Some criticism had been made of the slight delay in attempting to climb out after the GPWS sounded, but it should be noted that the first officer had just recommended climbing out to the right, which the captain was starting to have doubts about. The GPWS sounded and then the captain had to decide between the left and the right, which he does in a remarkably short time, and manages to get it right.)

So it's difficult to argue with Mahon's finding that the crew believed they were in McMurdo Sound. If that belief changed, it only changed during the final few seconds, by which time it was too late to recover.

Whether the crew were entitled to believe they were in McMurdo Sound is a different issue.

[ampan]

I think the point that Taildragger67 is making when referring to the O'Hare accident is that the crew can be completely exonerated (ie, 0% fault) even when there was something they could have done to avoid the accident. The fact that something could have been done does not necessarily mean that the crew must get "a little bit" of the blame. For example, the fact that the O'Hare accident would not have occurred if the crew had not throttled back does not make it "Airline 99.9% / Crew 0.01%".

(The O'Hare accident was the airline's fault, wasn't it? I'm aware that the manufacturer was blamed initially, for a defective bolt, with the result that all AirNZs DC10s were grounded for several weeks. But I seem to recall that the bolt was found to have nothing to with it.)

[grummanavenger]

http://www.stuff.co.nz/static/images/logo_bw.gif Tuesday, 12 February 2008200802121010
Erebus air investigator killed by car

LATEST: Retired chief air accident investigator Ronald Chippendale, who wrote a controversial report of the Erebus disaster, was hit and killed by a car this morning.
Mr Chippendale, 75, was struck by a car which went out of control in Porirua, north of Wellington, at 7.25am.
As chief inspector of air accidents, Mr Chippendale wrote a report on the 1979 Air New Zealand DC10 crash at Mt Erebus, Antarctica.
However Mr Chippendale's report, which blamed the crash on pilot error, was contested by a subsequent report by Justice Mahon.
In this morning's crash, an 18-year-old Porirua man allegedly lost control of his car while driving up Whitford Brown Avenue and ploughed into Mr Chippendale as he was walking on the footpath.
Mr Chippendale, who was returning to his Aotea home from his usual early morning walk, was killed instantly.
Air New Zealand Flight TE901 ploughed into the northern slopes of Mt Erebus on November 28, 1979. It killed all 237 passengers and a crew of 20, working under Captain Jim Collins.
Mr Chippendale, after a six-month inquiry as Chief Inspector of Air Accidents, blamed the aircrew.
He said Collins had erred by flying at low altitude in conditions which made it hard to define the ground and the horizon, and when the crew was not certain of their position.
However, a Royal Commission chaired by Justice Mahon, which reported a year later, fingered the airline.
On the night before the flight the flight track was changed in the plane's navigation system without the crew being told; the route went across Erebus and not over the flat sea ice of McMurdo Sound, the flight path for the earlier trips.
Mahon was also critical of the Civil Aviation Division. He caused a huge furore when he accused Air New Zealand of "a pre-determined plan of deception" and "an orchestrated litany of lies".
The Appeal Court later said these findings of Justice Mahon went beyond his jurisdiction and didn't comply with natural justice.
Almost 30 years later, debate over the primary cause of the crash continued.
Kapiti Mana Area police commander Inspector John Spence said today that the driver involved in the crash was shaken but uninjured.
He has been interviewed and it is likely that serious charges will follow once the investigation has been completed.
"Mr Chippendale was a keen walker and could be seen most days striding out in the Aotea and Papakowhai areas," Mr Spence said. "The circumstances of his death are a real tragedy."
Porirua Police are appealing for witnesses to the crash. Officers would also like to talk with a man and woman who stopped and helped the driver out of his car.
Y
http://www.pprune.org//secure-nz.imrworldwide.com/cgi-bin/m?ci=nz-stuff&cg=s-stuff-ttprinttt-4398100

[walschaert valve]

That's terrible news. I knew his brother Alan well, he died early from cancer.

Walking down the street, really sad.

[hoggsnortrupert]

And a sad day today:

RIP Ron Chippendale:

I still have the original Government copy of the accident findings by Ron Chippendale, together with, Impact Erebus, by Gordon Vette and Justice Peter Mahon.

To read them both collectively is "interesting".

If I could say that things where certainly different then, and with different values.
Ron Chippendale,Morrie Davis,& Sir Robert Muldoon, where of an OLD BOY era.

I mention this because of the political influence and I guess the some what “interferrence” by Morrie Davis & Sir Rob.

It is only my opinion that to some degree ,Ron was played by messer's Davis & Muldoon.

Yes the crew went below FL 160: but so had others.

This whole debate hinges around Captain Jim Collins and F/O Greg Casin "knowingly" operating VFR:

1/ They had not been trained in sector white out, Hence they thought they had clear air, and at some point something became apparent that they needed to get out of the position they were facing, I believe from reading both “reports” that from a totally “benign” & “ignorant” white out situation, that it was with some rapidness that conditions changed to the point that they wanted to get out of the conditions.

2/ They had no reason to doubt their INS system that was functioning perfectly.

3/ They had not operated the machine any different this day, to what other senior company pilots had previously.

4/ Jim Collins had drawn his intended track on a map the night before with his daughter, he had no reason to doubt the actual track, from track in his MINDS EYE from the night before:

5/ Jim Collins and Greg Casin did not know that FLt ops Dep had changed the Lat & long of a waypoint , with the result being a shift of the "MINDS EYE" route, to that of their actual flt path.

6/ The need for a topographical map in sector white out would have been pointless.

Tis indeed an interesting debate, and there has been an awful lot of good come out off this over the years, by way of "HUMAN FACTOR TRAINING".

As I said in a post last year, BRAVO GORDON VETTE!:ok::ok::ok::ok:

Chr's
H/Snort

[ampan]

A couple of points:

I agree with (1), concerning sector whiteout. It is interesting to note the despite the lack of any training, the captain was aware of the problem: At the beginning of the transcript (ie, about 30 minutes from impact), after getting the weather from McMurdo, he says "Clouds come down a bit ... May not be able to ... McMurdo. Very hard to tell the difference between the cloud and the ice."

Re (3) - I don't think it's completely accurate to say that the crew operated their flight to Antarctica in the same way as previous crews. In total, there were about 12 flights, over 3 years. They were timed to get the best weather, and they did. Of the previous flights, nearly all arrived to find perfect 'blue sky' conditions - so the crews did not pay a great deal of attention to the nav track or to the minimum safe altitude, because they didn't need to. I far as I am aware, there was only one previous flight where the McMurdo was covered in cloud, and that flight did not descend. It went to a different area.

Re (4) - I take your point about the atlas. Although the captain might have plotted the nav track on his atlas, it does not necessarily mean that he took the atlas with him - which would explain why the atlas was not found at the crash site. (But it wasn't found at the captain's house either.) If the atlas wasn't available on the flight deck, then the crew's failure to identify Beaufort Island is explained.

[Taildragger67]

Prospector,

I suggest Ampan has understood me. I am not drawing parallels between actual cause or type etc. but more that it is possible to exonerate people who actually have their hands on the tiller at the time of the incident, where they quite reasonably think one set of circumstances exist when, in fact, another does; the real fault then lies with what prevented them from being in possession of the full set of actual facts.

This is important because if, for instance, blame for the O'Hare DC10 had been laid with the pilots' mistaken reduction of power - "it was recoverable, if they had not reduced speed below 159KIAS, so the fact that they did so, makes them to blame" - then a host of other issues would not have been looked at - AA's maintenance, the fallibility of the DC10 engine attachment, FAA oversight, etc.

So to with Erebus - whilst it is undeniable that TE901's crew flew below 16000', to then say they are fully to blame would have meant other human and organisational factors would not have been fixed.

This is a learning process. Aviation learnt many things from TE901 and that is the legacy of Collins, Cassin and all the others who perished that day.

[hoggsnortrupert]

Re (4) - I take your point about the atlas. Although the captain might have plotted the nav track on his atlas, it does not necessarily mean that he took the atlas with him - which would explain why the atlas was not found at the crash site. (But it wasn't found at the captain's house either.) If the atlas wasn't available on the flight deck, then the crew's failure to identify Beaufort Island is explained.

Ampan: I think you perhaps miss my point!

In White out what you THINK YOU SEE, IS NOT WHAT YOU SHOULD BE SEEING, rather like a simulator, its all an ILLUSION OF NATURE! what good would have been an ATLAS or MAP:

Also: ONE of the Pilots, I can't remember which: their family home was broken into within days of the accident and records where taken!

There is indeed I feel some substance to the rumor over the years that ANZ and Morrie Davis, knew within a very short space of time, from the FLT not reporting in that they had flown into Erebus:

Why: The shift of the waypoints it is RUMORED to have been known about almost immediately:

I am willing to stand corrected here: but the chap that shifted the Lat & Long ( Waypoints) I heard committed suicide shortly afterwards.

I stand corrected if I am wrong:

Chr's
H/Snort:ok:

[prospector]

Taildragger67,
"So to with Erebus - whilst it is undeniable that TE901's crew flew below 16000', to then say they are fully to blame would have meant other human and organisational factors would not have been fixed."

My argument has been, and still is, that the Mahon enquiry was wrong in stating that no blame should be placed on the crew. No where have I stated that they were fully to blame.

As you say it is a learning process, but if the lessons learnt are not correct where is the value??

The following statement from Ron Chippendale would be what I find sums up the situation best, but it would appear I am in a minority with this belief, but hopefully it has made people rethink Mahons findings.

"The errors in the briefing were serious but not an absolute excuse for the accident when the means were readily available for the pilot in command to make certain he knew where he was."

[ampan]

I don't think I missed H'snort's point re a map. Yes, a map won't help if the sector whiteout prevents you seeing anything. But this wasn't the case. Although the crew couldn't see Erebus, they could see Beaufort Island. If you knew where you were in relation to Beaufort Island, then you would know where you were are in relation to Erebus - if you've got a decent map. If you haven't got a decent map, then that island down there in the sea is just an island down there in the sea.

Does anyone know what maps they had on the flightdeck?

[bushy]

I believe they had triple inertial nav systems, and one captain said he had never had an error in the inertial nav system in ten years of DC10 flying.
I have great respect for the head of the navigation section who stood up in court and explained that the co-ordinates had been changed.
The crew were, I believe navigating by reference to the inertial nav system. Not visually.
Of course they were discussing what they could see. That was the purpose of the flight.

[tinpis]

60's ANZ DC-10 had INS
DC8 had sun gun

[ampan]

And at night it would have been those star tables, wouldn't it?

So imagine what's going through the mind of a 1960s DC8 captain taking off from Auckland or Sydney, headed for Honolulu. If you miss Hawaii, you and all the passengers are dead, and the navigator seated behind you is using Captain Cook's methods to get you there. Wouldn't you be all over the first piece of land you saw?

[grummanavenger]

AirNZ's DC 8's also had dual doppler which permitted pilot navigation after an initial period where qualified flight navs were used.
Also in the initial stages of pilot navigation the aircraft also Loran equipped altho this had limited availability in the S pacific.

[tinpis]

I understand on the DC8 the Mk8 :ok: up the centre of the windscreen was a popular back up :hmm:

[ampan]

Someone should you guys a medal. Auckland/Sydney to Honolulu/Singapore/Hong Kong, for 7 years, without missing the target on any occasion (not to mention having to land at Kai Tak).

[SR71]

Hey Dingo,

Can you post another link to the Privy Council ruling?

That one doesn't work.

The case isn't even listed under the Judicial Committee of the Privy Council WWW page....http://www.privy-council.org.uk/output/Page171.asp

Anyone else know where I can read the document?

I've read the Court of Appeal ruling on Gutenberg.

Also, the actual Royal Commission report itself?

Is that online?

I've read Mahon's book.

"Impact Erebus" will set you back £95 on Amazon.co.uk!

"The Erebus Papers" will set you back £86 on Amazon.co.uk!

[ampan]

I haven't been able to find another link to the Privy Council decision. The easiest method might be to visit the library at the local law school. It's in a set of volumes called "Appeal Cases".

Mahon's report is probably out of print by now, but there are several copies available at the Auckland Public Library. They also have the transcript of the evidence given at the hearing (but not the documents).

There is also a useful book called "The Erebus Papers" (Stuart Macfarlane - Avon Press - 1991). It has decent photographic reproductions of many of the documents and also has extracts from the transcript of evidence. Unfortunately, the book also has the opinions of the lawyer who wrote it. Bit if those are ignored, it is very helpful.

Incidentally, if ALPA are going to do are proper job on the proposed website, why don't they dig up everything, scan it, and put it on the site so that everyone has all the information?

[hoggsnortrupert]

ampan Maps

--------------------------------------------------------------------------------
I don't think I missed H'snort's point re a map. Yes, a map won't help if the sector whiteout prevents you seeing anything. But this wasn't the case. Although the crew couldn't see Erebus, they could see Beaufort Island. If you knew where you were in relation to Beaufort Island, then you would know where you were are in relation to Erebus - if you've got a decent map. If you haven't got a decent map, then that island down there in the sea is just an island down there in the sea.

Does anyone know what maps they had on the flightdeck?

AND READING A TOPOGRAPHICAL "CHART" (not map)

Reading a "CHART" is an "ART" a skill, one that is taught the basics of, and to varying levels to encompass a VFR "TOPOGRAPHICAL CHART" reading exercise with PPL and CPL training:

What you do with it from here after depends upon ones skill attained, and evolved from more and more use: and is directly proportional to the level they have attained up to the point they switch to Scheduled IFR operations.

Now having a "TOPOGRAPHICAL CHART" for IFR operations is not of the normally accepted:

To read a TOPOGRAPHICAL CHART you can never ever ever rely on matching just one visual outside observation, with a feature on a "CHART".

You need to have enough outside visual definition to do this:

If you are in "PARTIAL" (SECTOR) white out, and you are not trained to recognise this, then how are you going to use a "CHART".

The degree to which they ( the crew) could actually identify visually is unsure.

What was recorded to be, (thought to be) Beaufort Island is a matter of, from my memory (as I do not have my reference material handy) a matter of conjecture.

To have a TOPOGRAPHICAL CHART in POOR weather conditions, you are usually low to the ground and in no position to have your heads down!

Now in this case suppose they would have had to transition to a Topographical chart, at what stage of the Flt would you do it:?

They would have expected to pick up a intended track on a chart from there INS lead in track! yes?

But there in lies your problem, in a white out and not knowing they are in a white out, and the difference in the INS track and a track on a Topographical chart would have been seperated by 40 odd kilometers:

The crew would have been from their previous backgrounds pretty good at reading a topographical chart, certainly way above average.

But even the best would not have picked this in these circumstances, 40 km's?

They did not understand the relevence of white out, they did not understand the illusion created by nature, even an experianced mountaineer of Peter Mulgrews experiance, was fooled by this cruel twist of nature:

Yes I agree with a previous post : that the crew has to have some portion of the blame: IE the S.O.P. & FL 160/ 060 restriction:

BUT BUT BUT: the culture then, the old boy club etc etc, indeed the company its self, had advertised photographs as part of their publicity campaign showing photos from previous Flts well well below this "Paper restriction" it would have been unconceivable for the company to put the punters in the seats and truck on down to the ICE and stay above FL 160, would have been another disaster,< excuse the pun!

So the Q: The greater portion of blame is what?

Only my opinion, but Prospector and Desert Dingo are both correct: I guess and I say I guess! the Q will remain for along time yet, The greater portion of blame belongs to who?

Chr's
H/Snort:ok:

( Sorry! I don't wish for it to be thought that the below is mine, I got it from wikipedia and the net)

Read on:

Beginning in February 1977, Air New Zealand offered tourist overflights from Auckland to the Antarctic. These flights were quite popular--in 1979 four were offered. They flew the route shown at left (from the information brochure). The last of these scheduled flights, Flight TE 901, a DC-10 with 237 passengers and 20 crew, took off from Auckland at 0820 on 28 November, on what was supposed to be an 11-hour turnaround flight. But it crashed into the side of Mt. Erebus at 1249, killing all aboard.
The loss of radio contact was noted at McMurdo, and Air NZ was soon notified that communications had been lost. Soon after 2130, the itme when the DC-10 would have run out of fuel, two VXE-6 LC-130 aircraft returning from Pole and Byrd were diverted to search. Both LC-130's spotted the crash site and the wreckage at about 0100 on 29 November. Helicpter search parties reached the crash site at about 0900, and they quickly confirmed that the wreckage was from the ANZ aircraft, and that there were no survivors.
The recovery efforts were quite extensive--in part because of pressure from Japan due to the number of Japanese citizens who had been on board. The operation lasted until 9 December; at one time there were as many as 60 recovery workers at the crash site. Recovered bodies and fragments were flown directly back to Auckland, and eventually all but 44 of the victims were identified.
Several inquiries were held--after mechanical failures were quickly ruled out, the focus switched to the flight crew, who had never made this particular trip before. Initially they were blamed for flying below an approved altitude, and staying there while being unsure of their location. But a second inquiry determined that the coordinates in the navigation computer had been changed without telling the crew or the flight followers at Mac Center. At the time of the crash, TE 901 was flying in local whiteout conditions (in clear air under cloud cover, but with no surface definition), but most of the flight had been in clear air--if commentator Peter Mulgrew had been in his seat a minute or two earlier he would have recognized that the aircraft was off course. As it was, the flight crew was confident of their position and flight path until the collision alarms sounded just before the crash.

Aircraft Accident: DC. 10 ZK-NZP Flight 901
When: 28 November, 1979
Where: Mount Erebus, Antarctica
What happened:
• At 8:20 am on 28 November, 1979, Flight 901 left Auckland Airport. On board were 237 passengers and 20 crew, looking forward to the 11-hour return flight to Antarctica.
• These sightseeing flights had been operating since February, 1977, and took the passengers on a low-flying sweep over McMurdo Sound, returning to New Zealand on the same day.
• Captain Jim Collins and his co-pilot Greg Cassin had not flown the Antarctic flight before, but the flight was considered to be straightforward and they were both experienced pilots.
• 19 days earlier the pilots had attended a briefing session where they were shown the printouts of a flight plan used by previous flights to the Antarctic.
• The plan gave co-ordinates for the trip to Antarctica and across McMurdo Sound which when entered into the computerised navigation system, would be flown automatically by the plane.
• On the morning of 28 November Collins and Cassin entered the series of latitude and longitude co-ordinates into the aircraft computer.
• Unknown to them two of the coordinates had been changed earlier that morning, and when entered into the computer, changed the flight path of the aircraft 45 kilometres to the east.
• At 12:30 pm Flight 901 was about 70 kilometres from McMurdo Station. Permission was given by the McMurdo radio communications centre to descend to 3050 metres and proceed “visually”.
• Air safety regulations were against dropping lower than a height of no less than 1830 metres even under good weather conditions, but Collins believed the plane was flying over low, flat ground. Other pilots regularly flew low over the area to give their passengers a better view.
• At 12.45 Collins advised McMurdo Centre he was dropping further to 610 metres. At this point he locked onto the computerised navigational system, but Flight 901 was not where either McMurdo Centre or the crew thought it was.
• The change in the two co-ordinates had put Flight 901 on a path not across the flat ground of McMurdo Sound, but across Lewis Sound and towards the 3794 metre-high active volcano, Mount Erebus.
• Because the air was clear and beneath the cloud layer, the white of the ice blended with the white of the mountain, with no contrast to show the sloping up of the land - a whiteout.
• At 12:49 pm the deck altitude device began to blare a warning but there was no time for Collins to save the situation from disaster. Six seconds later Flight 901 hit the side of Mount Erebus and disintegrated.
• From 12:50 pm McMurdo Centre kept trying to contact Flight 901, and finally informed Air New Zealand headquarters in Auckland that communication with the aircraft had been lost. US search and rescue aircraft were put on standby.
• At 10:00 pm (New Zealand time), about thirty minutes after the DC-10 would have used the last of its fuel, the airline told reporters that it had to be assumed that the aircraft was lost. Searches were made over the usual flight path, but nothing was found.
• Just before 1:00 am (New Zealand time) the crew of a United States Navy plane found some unidentified wreckage on the side of Mount Erebus. There were no signs of survivors.
• 20 hours after the crash, helicopter search parties were able to land at the site and confirm that the wreckage was the remains of Flight 901. All 257 people on board had died.
How many died: 257 (237 passengers and 20 crew)
Other events and outcomes:
• The wreckage made a 600-metre trail across the lower slopes of Mount Erebus. As the fuel tanks exploded a fireball ripped through what was left of the fuselage. The force of the impact would have knocked the passengers out or killed them immediately.
• The task of recovering and identifying the bodies of the passengers and crew (200 New Zealanders, 24 Japanese, 22 Americans, 6 British, 2 Canadians, 1 Australian, 1 French, 1 Swiss) was made more difficult because of the numbers involved.
• Over 60 people worked on the accident site, most in body recovery. 213 victims were eventually identified.
• On 22 February 1980 a burial service was held for the 44 unidentified victims.
• Early in the investigation into the causes of the disaster, it became clear that there was no mechanical reason for the crash.
• The information on the flight recorder tapes showed there had been no emergency in the cockpit of the aircraft.
• Attention was then focussed on the possibility of pilot error, pointing to the inexperience of the two pilots in flying in the Antarctic.
• A report by the chief inspector of aircraft accidents, Ron Chippindale, came out in May 1980. It stated that the decision of the captain in dropping to a height below the approved level, and continuing at that height when the crew was not sure of the plane's position, had been the main cause of the accident.
• Only weeks before Chippindale's report came out, the government announced a one-man Royal Commission of Inquiry. On 27 April, 1981, Justice Peter Mahon, released his report.
• This report placed the blame for the accident on the airline systems that had allowed the aircraft to be programmed to fly on the path which led directly to Mount Erebus.
• Mahon found that Captain Collins had been authorised by McMurdo to descend to 450 metres, and could not be said to have been guilty of unauthorised “low flying”.
• Air New Zealand and the Civil Aviation Division were ordered to pay the costs of the inquiry, and the airline had to pay an extra fee of $150,000.
• The chief executive of Air New Zealand resigned a week after the report was released to the public.
• Debate on where the blame for the crash should be placed continued. The changed flight path was in line with Mount Erebus but would have been safe if there had been no drop in height below the recommended level.
• Later court decisions questioned the way in which Mahon conducted his investigation.
• Public opinion has remained divided on where the blame for the disaster should rest.
• A wooden cross was erected above Scott Base to commemorate the disaster. It was replaced in 1986 with an aluminium cross after the original one was eroded by ice and snow.
• The Mount Erebus disaster was New Zealand's biggest single tragedy, with one more death than in the 1931 Napier Earthquake.

[prospector]

hogsnortrupert,
Following the U.S. District Court hearing in Washington DC, Judge Harold H. Greene wrote in his ruling,

"It is clearly established that, when the pilot told Mac Centre he wished to descend VMC, he effectively informed the controllers that he could see where he was going. In so doing he took SOLE RESPONSIBILITY for separating THE AIRPLANE FROM OTHER AIRCRAFT and the TERRAIN and he was on his own,
There also was much credible testimony to the effect that, and the Court finds that, air traffic controllers are not in a position to challenge, or second guess, the representation of a pilot that he can see where he is going and. indeed, that controllers are trained not to question such a representation".

'Mahon found that Captain Collins had been authorised by McMurdo to descend to 450 metres, and could not be said to have been guilty of unauthorised “low flying”."

Where exactly did Mahon find that that the flight had been authorised by McMurdo to descend to 450 metres?????

"• Captain Jim Collins and his co-pilot Greg Cassin had not flown the Antarctic flight before, but the flight was considered to be straightforward and they were both experienced pilots."

And herein lies the major problem, they were experienced pilots carrying out their usual duties of airline pilots, but were complete novices in the vagaries of Antarctic flying. the comments from Mr Bob Thomson, New Zealands most experienced Antarctic operator, printed earlier in this thread sums it up very well.

[Desert Dingo]

Prospector, it appears your favorite investigator screwed up Justice Green's investigation.

Stewart McFarlane, Senior lecturer in Law, University of Auckland (now retired)
http://www.investigatemagazine.com/archives/2006/03/investigate_nov_4.html
In 1987 during a claim for compensation by the dependents of the deceased Chippindale asserted that the engineers displayed their mounting alarm by the tone of their voices. Here again the evidence disproves his claim. He also claimed by implication that the voices marked by the Washington team as unidentified were in fact the voices of the engineers. He claimed this despite previously saying “At no time did I attribute any comment to any person. I relied totally upon the recognition of the voices made by the team in Washington.”
<snip>
So what did Chippindale actually do in order to create his theory of mounting concern? He took overlapping snatches of different conversations of passengers and cabin crew speaking in the galley area and flight deck and attributed them to the engineers when the Washington team agreed the voices were unidentifiable. He added words to the transcript which the Washington team agreed were unintelligible and suggested they suited his theory that the engineers were expressing their concern about flying conditions to the pilots. He latched onto a few remarks passing between Mulgrew and Moloney. After his theory was disproved by evidence given to the Royal Commission in 1980, he claimed seven years later, contrary to the opinions of seven to nine others, and supported only by Gemmell, that the engineers expressed mounting alarm by their tone of voice.
The conclusion must be that Chippindale’s claims are untrue. The engineers voiced no queries about the proposed descent, expressed no mounting alarm as the flight continued, and expressed no dissatisfaction. Those claims ought not to have been made by an inspector of air accidents. They brought no credit to the Office of Air Accidents Investigation. They were approved for release to the public by the Minister of Transport on 12 June 1980 and are still at the time of writing on the website of that Office’s successor. They have done lasting damage. They must have caused grief over the years to the flight crew’s families. They have created a fantasy scenario of events which supposedly led to the disaster that endures in the public mind to this day as media comments such as Cullen’s, Rudman’s, and Rankin’s bear witness and perpetuates this untrue scenario into history.
Chippindale’s evidence in the court case brought for compensation by the dependents of those killed by the crash against the US Government no doubt contributed to their case failing. He attended in person to give evidence “at the direction of the New Zealand Government”. The US Government paid for his transportation to and from the US.Ron Chippindale RIP

Obituary: Vale Ron Chippindale: Erebus investigator was one of the many victims of TE 901, the disaster that will not go away
In November 1989, 10 years after the crash of Air New Zealand flight TE 901, chief air accidents investigator Ron Chippindale admitted to me that he knew Air New Zealand had lied about sightseeing flights to Antarctica not being allowed lower than 16,000 feet. But he’d gone along with that fiction, during his own investigation of that terrible disaster, and all through the long royal commission that followed, at the end of which Justice Peter Mahon accused the airline of concocting “palpably false evidence” and “an orchestrated litany of lies.”
Because of that ringing phrase, Justice Mahon became another victim of Mt Erebus, driven from the Bench for it by his fellow judges and a furious prime minister, Rob Muldoon. But Ron Chippindale was an Erebus victim too, never forgiven by many pilots for obstinately supporting the airline’s lie that TE 901 had no right to be flying below 16,000 feet when he knew otherwise.
But even his 1989 admission did not stop Chippindale continuing to accuse the pilots of causing the crash by bad airmanship. Despite conclusive evidence to the contrary, he still held that they were flying at a low altitude knowingly uncertain where they were in the hostile, mountainous Antarctic environment. And he bizarrely told me that they could have saved the DC10 and its 237 passengers and 20 crew by sliding it across the icy slopes it hit to a standstill, rather than letting it smash to smithereens after the ground proximity warning system shrieked its awful “Whoop whoop! Pull up!” That would have been a feat of airmanship unparalleled in aviation history.
(more)
http://poneke.wordpress.com/2008/02/13/te901/
If this is true it demolishes Chippindale’s credibility for producing the definitive report of the disaster, as claimed by some on this thread.