Merged: Erebus site launched

[Dick N. Cider]

NZALPA has today launched a comprehensive (and excellent) website commemorating the 30th anniversary of the loss of TE901. It includes the video footage together with personal accounts and extensive resources surrounding the accident and the subsequent investigations and inquiries.

Erebus plane crash disaster story. Air New Zealand flight TE901 crashed at Mt Erebus Antarctica 28 November 1979 > Home (http://www.erebus.co.nz)

[AC Busted]

Thanks for the link, much appreciated.

[malcolmyoung90]

Thanks for the link. It looks like a well put together and comprehensive site.

NZAPLA were talking about setting this up last year, so it's great that it has finally been done.

[Fantome]

Thank you Dick. An impressive archive with files that appear to contain the complete published reports. Shouldn't be long before the speculators start posting in the forum section and debate the finer points of the numerous discrepancies that Gordon Vette, (and others), only started to uncover before his stroke. Big accolades for the Kiwi pilots' union.

[prospector]

It is an interesting site, as long as one keeps in mind who constructed it.

The opening photo really does show what a massive piece of real estate Mt Erebus is, and how not sighting this massive mountain whilst descending VMC, maintaining own terrain separation visually, beggars the imagination.

“captain’s decision to make a VMC descent below the specified minimum safety height while north of McMurdo.” from Ron Chippendales accident report, which is still the official report, is the belief of many.

[compressor stall]

I am not sure exactly what point you are trying to make prospector - particularly with the quotes - so I shan't respond directly in case I misunderstood your position.

Having personally 1. flown into McMurdo sound and 2. flown down south in VMC white outs, I can clearly see how the uneducated failed to see the "massive mountain" - (and yes, it's very big!).

[prospector]

compressor stall,
Much has been made of the change in track, sector white out, and other related points. My point is, from 16,000ft, Erebus should have stuck out like the proverbials, this would not have anything to do with whiteout, sector or otherwise at this altitude, when the decision to descend further, VMC maintaining own terrain separation visually, was made.

[Ozdork]

On a personal note, I met the Flight Engineers' (Brooks) widow, Wendy, when she was working for Hazeltons' in Sydney in the early 80's, and adding to the tragedy of it all she had been diagnosed with breast cancer. Does anyone know how she did, and of her daughter Fleur?

[27/09]

My point is, from 16,000ft, Erebus should have stuck out like the proverbials, this would not have anything to do with whiteout, sector or otherwise at this altitude,

Prospector,

Are you qualified to make this statement, have you flown in this enviroment? I haven't so I don't know what it is like but I do take note of comments like this

Having personally 1. flown into McMurdo sound and 2. flown down south in VMC white outs, I can clearly see how the uneducated failed to see the "massive mountain"

[Tarq57]

I've just spent a fair amount of the afternoon looking over the site and reading some of the accounts.

I'd like to thank very much the folk who worked to put it together. It's very readable indeed.::D

As well as a recognition to those that had to deal with the events at the time, it also seems to me a valuable catalogue and reminder of the personal dedication and integrity of those who put their beliefs first, at some personal sacrifice, so that a new paradigm of accident and incident investigation be moved toward. One that I believe to be correct.

Now if only it would "take", in a few more areas; geographically, politically, economically....

[prospector]

27/09

" Are you qualified to make this statement, have you flown in this enviroment? I haven't so I don't know what it is like but I do take note of comments like this"

No, I have not, but then neither had this crew, which is why the requirements to be met for descent below 16,000ft were spelt out in such detail.

[27/09]

Prospector

How can you say thisMy point is, from 16,000ft, Erebus should have stuck out like the proverbials,
when you have never been there in the same condtions that the crew of TE901 experienced. I'll bet the photo you refer to wasn't taken in the same conditions that existed on the day of the fateful flight.

I don't recall what the requirements were for descent below 16,0000 but if I recall correctly the crew believed that they had those requirements. As history now shows they didn't have those requirements, the conditions had deceived them, hence my reference to Having personally 1. flown into McMurdo sound and 2. flown down south in VMC white outs, I can clearly see how the uneducated failed to see the "massive mountain

One of the problem this crew faced was, they didn't know what they didn't know, when it came to operating in these conditions. The US military require at least one trip down there as an observer before flying down as an operating crew member, these guys had never been there before.

It's easy to be arm chair critics with the benefit of 20/20 hindsight.

[prospector]

27/09,
All this ground has been covered in previous threads, in particular if you do a search on thread "Erebus 25 years on" you will see there are many folk who do not agree with Mr Mahons findings as to the cause of the disaster, he did open up a new chapter in accident investigation perhaps, but his opinion, which is all he could deliver, could not be challenged, and the Official Report is still that issued by Ron Chippendale, the Air Accident Inspector. That report is available for perusal at the site mentioned in the original post.



"I don't recall what the requirements were for descent below 16,0000 but if I recall correctly the crew believed that they had those requirements"

These were the requirements, and a copy was found in the cockpit during the search.
" 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."

Which one of these requirements was met??

[Desert Dingo]

Prospector is still unable to accept the Royal Commission Report

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.

[Old Fella]

Having flown several resupply missions to McMurdo, as a C130 F/E, on Operation Deep Freeze in the summer of 1978 I do understand how the Air New Zealand crew got into trouble with such catastrophic consequences. No single factor caused the accident, as is almost always the case. What we should all be doing is feeling great sympathy for those whose lives have been shattered by the loss of loved ones and, importantly, learn from the accident. Given the limited rescue capability at McMurdo it is probable that even if the crash had been survivable many would have perished from exposure to the elements before a rescue could have been completed. Playing the blame game 30 years on from the accident does nobody any credit.

[Casper]

Desert Dingo,

I see that prospector needs a reminder on a previous post by you!

--------------------------------------------------------------------------
Privy Council

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:

[prospector]

Desert Dingo,

Prospector is still unable to accept the Royal Commission Report


Quote:
"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 "


As against a direct Company order for this flight

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."

When, according to your quote, an invitation from an Air Traffic Controller overides a Company Standing order, then yes, I have trouble accepting A Royal Commission Report.

[Jackson]

During the recovery I can remember seeing the bodies of the Captain and First Officer lying in the snow. I recognised who they both were. I couldn’t blot that out of my mind. They were two human beings with names known to me. That made it very difficult.

I found Captain Collins ring binder diary which I read. It contained what appeared to me to be handwritten briefing notes so I handed it to Sergeant Gilpin. It was later produced empty at the enquiry. It has never been adequately explained to me how this happened.
-----------------------------------------------------------------------
Above is an extract from the article by Inspector (then Constable) Leighton on the website. The second paragraph suggests a cover up at an early stage.

[skol]

I was on the DC10 at the time and flew Mahon from CHC-AKL so he could observe the radar shadow behind Mt. Egmont.
I was very impressed with this man and the work he had obviously done and have no doubt his report was spot on.

[crocodile redundee]

From my understanding , the Flight Engineer HAD been on a previous flight; & from the Flight Recorder transcript HAD expressed verbal concern as to where the Aircraft was at , geographically - something along the lines of "I dont like this" or "I dont like the look of this" or "This isnt right". Anyone have similar recollections????

[pisstin broke]

Prospector
Just as a matter of interest, what Air New Zealand management position do you hold (or held)?

[Steve Zissou]

crocodile redundee and prospector - if you haven't already (and I'm guessing by your comments you haven't), have a read of some of the articles on the website in particular Gary Parata's article on the CVR transcript.

Gary Parata's Article Page 1 (http://www.erebus.co.nz/Investigation/TheCVRTranscriptControversy/GaryParatasArticle.aspx)

Makes very interesting reading, expecially to learn of Ron Chippendale's deviation from accepted protocol at the time in producung a CVR tramscript. The comment "I don't like this" examined in it's context and the fact that it was during an exchange between the flight crew on the loss of VHF contact with McMurdo.

Quoted below from Gary Parata's article:

Good rules and protocols for CVR transcription and interpretation are essential for forming strong defences against flawed results. They facilitate the production of a true and authentic record, and promote an accurate understanding of the events in question. However even with these precautions in place, highly experienced air accident investigators are still not immune from hearing the things they want - or expect - to hear on a CVR. Nor are they immune from ascribing meaning to a phrase based only on supposition, or perhaps subtle pressures from vested interests.

[prospector]

Steve Zissou,

At no point was VHF contact established with any ground stations.
From official accident report compiled by the Chief Accident Investigator

" The co-pilot was devoting a significant proportion of his time in an endeavour to establish VHF
contact with the McMurdo ground stations and did not monitor the decisions of the pilot in
command adequately in that he did not offer any criticism of the intention to descend below
MSA in contravention of company restrictions and basic good airmanship."
3.21 The crew were distracted but not preoccupied by their failure to raise the Ice Tower or any local
ground station on VHF, the failure of the DME to lock on to the TACAN and the lack of any
identification of the aircraft on radar."


"The comment "I don't like this" examined in it's context and the fact that it was during an exchange between the flight crew on the loss of VHF contact with McMurdo."

From whence do you get "the fact" on loss of "VHF contact with McMurdo". ? VHF contact was never established, why?? because there was a massive mountain between them, the same reason DME lock on was never established.
Have a look again at the requirements for descent you will no doubt notice it had to be within 20 nautical miles of Tacan ch 29.


The reasons for these descent requirements are so glaringly obvious, Mt Erebus was well clear of them, any error in track, AINS nav, whiteout, sector whiteout or what have you would be irrelevant.

[fourholes]

Good grief!:rolleyes: Back to the thread. NZALPA have launched a new website dedicated to the tragedy that occurred 30 years ago this November. From what I have read, the website does not have "have ago" at any party. I think everyone can agree, a lot was learnt from the disaster. Banging on about perceived facts 30 years on from your little hole in NZPP isn't helpful.

[Steve Zissou]

I stand corrected prospector, it was based around the crew's inability to achieve VHF contact. Still my point remains the same. As fourholes says though there have been numerous threads and years to rehash this particular debate.

Congrats to NZALPA for putting together an interesting and informative site. Reading both the Mahon and Chippendale reports fully will provide me with ample excuse to further put off my remaining ATPL study :ugh:

[RadioSaigon]

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.

I think therein lies the truth, despite prospectors deperate, ongoing attempts to malign the crew involved and support the 'official investigators' original stance. That the investigators stance has been comprehensively proven to be wrong, there will always be some who (for reasons of their own) will be unable to accept the truth. The investigators proclivity towards managing the facts to fit his own preconceptions is made clearly obvious in the Mahon report, Capt. Vette's investigation and writings -and something I can personally attest to from peripheral involvement with the same investigator during the course of another widely publicised crash.

[ZK-NSJ]

reading thru the nz queens birthday honours list, one name sticks out
for services to aviation alwyn gordon vette, officer of the nz order of merit

[ampan]

I have just visited NZALPA's website.

It is a pathetic collection of non-information.

Where is the evidence from the Royal Commission, all of which is available at several public libraries?

Where are the exhibits, all of which are available from Archives NZ?

One such exhibit proves, beyond any doubt, that the crew was told that their nav track was direct to McMurdo Station.

Perhaps that explains the ommission?

[Fantome]

There is a lot may be learned on this website, actually.
If not enough to satisfy ampan ,then surely he can roam the NZ archives.

NZALPA have provided the following on their new Erebus website, which would seem to indicate ampan's sleuthing is not too Sherlocky. (I would not be so rude as to suggest 'Pull ya head in!')

The Erebus enquiry: a tragic miscarriage of justiceC.H.N. L'EstrangeAir Safety League of New Zealand1995http://www.erebus.co.nz/Portals/4/Navigation/navAmazonLogoFooter__V264586593_.gif (http://www.amazon.com/Erebus-enquiry-tragic-miscarriage-justice/dp/0473033852/ref=sr_1_1?ie=UTF8&s=books&qid=1241691381&sr=8-1)
http://www.erebus.co.nz/Portals/4/Images/Resources/The-Erebus-Papers.jpg
The Erebus papers: edited extracts from the Erebus proceedings with commentaryStuart MacfarlaneAvon Press1991http://www.erebus.co.nz/Portals/4/Navigation/navAmazonLogoFooter__V264586593_.gif (http://www.amazon.com/Erebus-papers-extracts-proceedings-commentary/dp/0473008440/ref=sr_1_1?ie=UTF8&s=books&qid=1241690766&sr=8-1)
http://www.erebus.co.nz/Portals/4/Images/Resources/flight901.jpgFlight 901 to Erebus
Ken HicksonWhitcoulls1980http://www.erebus.co.nz/Portals/4/Navigation/navAmazonLogoFooter__V264586593_.gif (http://www.amazon.com/Flight-901-Erebus-Ken-Hickson/dp/0723306419/ref=sr_1_1?ie=UTF8&s=books&qid=1241690847&sr=1-1)
http://www.erebus.co.nz/Portals/4/Images/Resources/Impact-Erebus.jpgImpact ErebusGordon Vette & John MacdonaldHodder and Stoughton1984http://www.erebus.co.nz/Portals/4/Navigation/navAmazonLogoFooter__V264586593_.gif (http://www.amazon.com/Impact-Erebus-Gordon-Vette/dp/0340320249/ref=sr_1_2?ie=UTF8&s=books&qid=1241690926&sr=8-2)
http://www.erebus.co.nz/Portals/4/Images/Resources/Mahon-Book.jpgVerdict on ErebusJustice Peter T MahonCollins1985http://www.erebus.co.nz/Portals/4/Navigation/h_bubbles.gif (http://www.fishpond.co.nz/Books/Business/Labour/product_info/7816208/?cf=3)Fishpond
White out!M. GuyMartinborough1980Public Libraries
http://www.erebus.co.nz/Portals/4/Images/Royal-cover.jpgReport of the Royal Commission to Inquire into the Crash on Mount Erebus, Antarctica of a DC10 Aircraft Operated by Air New Zealand Limited
Justice P.T MahonGovernment Printer1981http://www.erebus.co.nz/Portals/4/Images/PDF-logo.gif (http://www.erebus.co.nz/LinkClick.aspx?fileticket=PUWvCWDoUoE%3d&tabid=159)Digital Copy
http://www.erebus.co.nz/Portals/4/Images/Chippindale-Cover.jpgOffice of Air Accidents Investigation, Report No 79-139Mr Ronald ChippindaleGovernment Printer1980http://www.erebus.co.nz/Portals/4/Images/PDF-logo.gif (http://www.erebus.co.nz/LinkClick.aspx?fileticket=ZAI8kk7csZ8%3d&tabid=159)Digital Copy
Judgments of the Court of Appeal of New Zealand on Proceedings to Review Aspects of the Report of the Royal Commission of Inquiry Into the Mount ErebusOwen WoodhouseIndyPublish.com2007http://www.erebus.co.nz/Portals/4/Navigation/h_bubbles.gif (http://www.fishpond.co.nz/Books/Fiction_Literature/General/product_info/11340773/?cf=3&rid=19546314&i=3)Fishpond
Psychological sequelae of operation overdue following the DC10 aircrash in AntarcticaA.J.W. Taylor, A.G. Frazer.Dept. of Psychology, Victoria University of Wellington1981Public Libraries
Websites on Erebus
Title
Web Address
Aviation SafetyAviation Safety Network > Accident investigation > CVR / FDR > Transcripts > CVR transcript Air New Zealand Flight 901 - 28 NOV 1979 (http://aviation-safety.net/investigation/cvr/transcripts/cvr_nz901.php)Te AraAir crashes - The 1979 Erebus crash - Te Ara Encyclopedia of New Zealand (http://www.teara.govt.nz/EarthSeaAndSky/SeaAndAirTransport/AirCrashes/5/en)NZ HistoryThe Antarctic experience - Erebus disaster | NZHistory.net.nz, New Zealand history online (http://www.nzhistory.net.nz/culture/erebus-disaster/visiting-antarctica)NZ HeraldFeature (http://www.nzherald.co.nz/mt-erebus-crash/news/headlines.cfm?c_id=1500932)Christchurch LibrariesMaterial relating to the Erebus disaster and inquiry (http://www.christchurch.archives.govt.nz/v/christchurch/interesting+items+website/Erebus/?g2_page=3)Christchurch Librarieshttp://www.christchurchcitylibraries.com/kids/nzdisasters/erebus.asp (http://www.christchurchcitylibraries.com/kids/nzdisasters/erebus.asp)WikipediaAir New Zealand Flight 901 - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Air_New_Zealand_Flight_901)South Pole Stationwww.southpolestation.com/trivia/history/te901.html (http://www.southpolestation.com/trivia/history/te901.html)Aviation Safetywww.aviation-safety.net/database/record.php?id=19791128-0 (http://www.aviation-safety.net/database/record.php?id=19791128-0)NZ TerritoryErebus Disaster (http://www.nzterritory.com/disasters/erebus.html)Plane Crash Infocvr 791128 (http://www.planecrashinfo.com/cvr791128.htm)Nation MasterNationMaster - Encyclopedia: Mount Erebus disaster (http://www.nationmaster.com/encyclopedia/Mount-Erebus-disaster)Pokene BlogVale Ron Chippindale: Erebus investigator was one of the many victims of TE 901, the disaster that will not go away Poneke’s Weblog (http://poneke.wordpress.com/2008/02/13/te901/)

[ampan]

I have every single one of those publications - and a few more.

But where, amongst the advertised weblinks, is the long PPrune thread re Erebus "25 years ago"?

Prospector is right. This was a bad case of pilot error, which coincided with a very bad case of airline error.

To state the bleeding obvious: yes, the crew thought they were flying down McMurdo Sound, and not towards Mt.Erebus.

But why did they think that?

Because at the briefing there was a handout, which showed a final waypoint at the end of McMurdo Sound, not at McMurdo Station.

But, and there can be no argument about this, the crew, at the briefing were told that their nav track was direct to McMurdo Station.

They might not have been told that this track went over the summit of Mt Erebus, but they were, definitely, told that the track was direct to McMurdo Station.

So if you're plotting the route the night before, using the handout from the briefing, and see that the nav track shows a nav track down McMurdo Sound (ie, not direct to McMurdo Station), what do you do?

According to Mahon and NZALPA, you are entitled to assume that the handout is correct and then drop the aircraft through a hole in the cloud down to 1500 feet, within 20nm of a 13000 ft mountain.

Complete f*cking bullsh*t.

PS: The penny eventually dropped: Despite the F/O recommending a right turn, the Captain instigated a left turn using the autopilot. Can any of the "believers" out there explain that one?

[prospector]

There are a few more publications appertaining to Erebus that have not been mentioned on the ALPA website. Perhaps posting some of the content will explain why not.

The Erebus Enquiry; A Tragic Miscarriage of Justice. by Noel L'Estrange, who states:

" Across the world in the head office of ICAO at Montreal, the Royal Commissions report was closely studied by the Head of the Operations section, Duane Freer, who made this comment:

" What on earth is going on down there? It reads like something coming from a third world country"

History of New Zealand Antarctic Research Programme 1965-88. written by Bob Thomson;

" 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 therefore need to seek advice from elsewhere, such as the RNZAF,USAF.USN or the Division."

History of Civil Aviation in New Zealand, by Maurice E. McGreal.

"Bolt/Kennedy, L'Estrange and Mackley all challenge the judgement of the Royal Commissioner, Peter Mahon, and in those documents identify the Commissioners lack of understanding of Aviation."

New Zealand Aviation Tragedies by John King;

Chapter 1. The Place of Departed Spirits.

This is a very good precis of many of the findings, recollections,etc of many of the people who were involved in this catastrophe.

[ZQ146]

Hasnt anyone of those rattliing on remembered that some bright spark changed the ING track without telling the crew or have you all forgotten that..30 years on leave it ALONE

[aerostatic]

This is worth a watch:

YouTube - Flight 901 Erebus: 20 Years On (http://www.youtube.com/watch?v=h9is6ycqCb8)

[Fantome]

There are a few more publications appertaining to Erebus that have not been mentioned on the ALPA website. Perhaps posting some of the content will explain why not.

The Erebus Enquiry; A Tragic Miscarriage of Justice. by Noel L'Estrange, who states:

" Across the world in the head office of ICAO at Montreal, the Royal Commissions report was closely studied by the Head of the Operations section, Duane Freer, who made this comment:

" What on earth is going on down there? It reads like something coming from a third world country"

BUT, this source IS listed on the website -

The Erebus enquiry: a tragic miscarriage of justice. C.H.N. L'Estrange. Air Safety League of New Zealand1995

[prospector]

fantome,
Oops, sorry, missed that one, at the top above the cover of another publication.

But why does not the requirements for descent, that states absolutely nothing about invitations from Air Traffic Controllers, VMC maintaining own terrain separation, or any other debatable points, get so little traction in this thread.


"Delete all reference in briefing dated 23/10/79. 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."

Which one of these requirements was met??


It is very clear, it states exactly what the requirements for descent are, it states nothing about unless you find a hole in the cloud then you may design your own descent procedure, and there can be no debate that the crew were not aware of its existence, a copy was found in the wreckage of the cockpit.

[ampan]

ZQ146: "leave it ALONE" ? Shouldn't that comment be directed to NZALPA?

As to the changed waypoint, so what? That was a bad error by the navigation section, which was disclosed at the outset. No-one is suggesting that the airline was blameless.

The point is that waypoint issue was a live issue before the flight even took off. The oral presentation at the briefing said that the track went direct to McMurdo Station. The co-ordinates on the handout said otherwise. So there was a contradiction. Yet the captain and the F/O simply assumed that the handout was correct, and then descended to 1500 feet in reliance on it. That was a very bad error, by an allegedly blameless crew.

[ZQ146]

Sounds to me that Ampan and Prospector are on some sort of personal vendetta for whatever reason bearing in mind one of them was only 19 at the time...Maybe they are relatives of those Air NZ so called blamless ones in head office.Seems to me that Captain Collins and his crew should be left in peace the whys and wherefores have had a good airing the two above should dry up and give it a rest :=

[bushy]

The important point here is that this whole affair resulted in the old process of saying "pilot error" and sweeping the whole mess under the carpet to protect the government and the regulator, cannot ever happen again.
It has been thoroughly demonstrated that it is essential to look for underlying factors, and to consider the politics and financial factors.
Justice Mahon did this, and I admire him for that. But he found "inconvenient truths" which got him into trouble.
And we still have some dinosaurs who think that the old "pilot error" finding is good enough.

[prospector]

"The important point here is that this whole affair resulted in the old process of saying "pilot error" and sweeping the whole mess under the carpet to protect the government and the regulator, cannot ever happen again."

Are you telling us that "Pilot Error" has been the figment of somebody's imagination, and that pilots never make stuff ups??

And telling us that highly qualified Accident Investigators sweep facts under the carpet just to protect the Government and the Regulator? The Government and the regulator normally being one and the same.

"And we still have some dinosaurs who think that the old "pilot error" finding is good enough"

That statement is garbage, what I am saying, with the facts that are available, that it was a JOINT EFFORT, how can anyone who puts a perfectly serviceable aircraft into the side of a mountain, that everybody knows the exact location off, equipped with Nav equipment that can give you a Lat Long readout exceedingly accurately, takes maybe 60 seconds to read and plot on a chart, be held completely blameless??

[27/09]

Prospector

I think you missed Bushy's point.

I don't think he meant for one moment to suggest that pilot error was not a factor. His point was that for so long "pilot error" alone was a convenient way of explaining many accidents without looking at underlying causes and other factors. Events stemming from the Erebus acccident changed that.

In light of the rest of his post I understand his comment And we still have some dinosaurs who think that the old "pilot error" finding is good enough to mean that some people still think pilot error is good enough as a sole explanation for most accidents. This statement is not garbage.

Yes, it was a "joint effort" as you put it.

[kiwiandrew]

Ampan said

" The oral presentation at the briefing said that the track went direct to McMurdo Station. The co-ordinates on the handout said otherwise. So there was a contradiction"

and

"But, and there can be no argument about this, the crew, at the briefing were told that their nav track was direct to McMurdo Station."

I take it then Ampan that you were personally present at the oral briefing since you "know" this , after all an oral briefing leaves no permanent record - or are you relaying what others who were present have said happened , I believe in a court of law this is known as 'hearsay'?

We cannot ask the flightcrew what was said at the oral briefing , so who else was present whose recollection you are relying on ?

[prospector]

27/09,
This is what I posted on another thread on this subject,"Erebus 25 years on" that was running some months ago,

"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."

So I am in agreement with Bushys post on that point,

The word garbage was used as I believe it was an attack on anybody who disagrees with Mahons findings. as I obviously, and many others do. And one does not have to be a "dinosaur" to do that.

[ZQ146]

Prospector

Me thinks your brain is in a "WHITEOUT"You cant see the woods for the mountain..Do you Fly or are you a driver in a snow storm..I spose you will keep rattling on for some obscure reason

[Desert Dingo]

Ampan (#30)
But, and there can be no argument about this, the crew, at the briefing were told that their nav track was direct to McMurdo Station.

They might not have been told that this track went over the summit of Mt Erebus, but they were, definitely, told that the track was direct to McMurdo Station. To use your own words
Complete f*cking bullsh*t.

The evidence showed the following briefing documents
In the Antarctic pack

GNC21N a large topographic chart (105 x 145 cm) showing New Zealand, Tasmania and Antarctica. No flight plan track lines on it.
NZMC135 another large topographic chart showing Antarctic coastline (Victoria Land) and a McMurdo Station inset. No flight plan track lines on it.
Strip Chart (annex 1) Topographic chart showing military tracks, including the two down McMurdo Sound to Byrd waypoint and left turn to McMurdo Station.
(DOD Strip chart Exhibit 165) Shows military route down McMurdo Sound to Byrd waypoint then left turn to McMurdo Station. Similar to Strip Chart (annex 1) but without topographic detail, just some bits of the coastline more than 100 nm from McMurdo Station.
RNC4 Radionavigation chart showing (among others) direct track from New Zealand down McMurdo Sound to Byrd waypoint where the track ends. Flight plan track not shown.
The famous Exhibit 164. An ANZ Nav department chart with no topographic detail but showing the two military tracks down McMurdo Sound to Byrd waypoint ending at a common waypoint with the track from New Zealand via Cape Hallet.
A copy of a previous flight plan (flown 2 days previous to the briefing) which has the final leg from Cape Hallet down McMurdo Sound to McMurdo waypoint and return to Cape Hallet.In the passenger pack
Passenger map (exhibit 47) Clearly shows track down McMurdo Sound although not in great detail.Then the slides Map of proposed route (Exhibit 197/8) showing track down McMurdo Sound.
Slide showing Mt Erebus “to left of track”
Slide showing Erebus to the left “on approach from Cape Hallet” (They got this wrong. It was actually Mt Erebus viewed from the south)
The slides appear to be taken with the aircraft over a flat surface of ice or snow, with a mountain in the distance. ( i.e. as it would appear if taken from somewhere over McMurdo Sound.)
All of the maps at the briefing showed tracks down McMurdo Sound. Not one showed a track over Mt Erebus or to the NDB.
All the briefing slides appeared to be taken from over McMurdo Sound or flat terrain.

Then there is the evidence given by the pilots on the previous flights as to the position of the final waypoint given at their own briefing.
Date of flight-- Pilot’s Name-- Evidence showed he believed track went to:
07.11.78 -- McWilliams-- McMurdo Sound
14.11.78 -- Calder -- Uncertain
21.11.78 -- Griffiths -- No evidence
28.11.78 -- Ruffell -- Ambiguous McMurdo
07.11.79 -- Dalziel --McMurdo Sound
14.11.79 -- Simpson -- McMurdo Sound
14.11.79 -- Gabriel -- McMurdo Sound
21.11.79 -- White -- McMurdo Sound
21.11.79 -- Irvine --McMurdo Sound And we have
Captain Simpson’s testimony: “I certainly did not get the impression from the audio-visual that our approach would be over Ross Island or Mt Erebus.” (M.p236) and about the McMurdo waypoint on the flight plan “I did not record this position but only noted it mentally. It seemed to be a logical position in that it was at the head of the sound clear of high terrain and a good position to start sightseeing….” (M.p237)
Captain Gabriel’s testimony: “ …. noting the heading of the aircraft was to the right of the high ground depicted in the slide. I consequently expected the aircraft to approach the McMurdo area on a track which would take the aircraft to the west of Mt Erebus. Nothing that I saw or heard during the audio visual presentation gave me the impression that the aircraft would overfly Mt Erebus during its approach to the McMurdo area.”
F/O Irvine’s testimony: “I am certain that at no stage during the briefing conducted by Captain Wilson was anything said to the effect that our flight plan track would go over Ross Island or Mt Erebus".Even the AirNZ board knew that Collin’s track went down the middle of McMurdo sound.
Board meeting minutes 5 December 1979
Quote;
“Strictly confid. Not to be used.”
Wreckage was “off track (considerably)...Aeroplane ...was left of centre.”

I think that Captain Collins and F/O Cassin demonstrated pretty conclusively that they did not believe the track was direct to McMurdo Station (or the now out of service NDB) when they engaged NAV and flew straight into Mt Erebus. I'll write that again: they engaged NAV and flew straight into Mt Erebus!

To argue that the briefing told them that the track was direct McMurdo Station is to ignore all the evidence above. It would also mean that each one of the flight crew had individually forgotten the briefing (or they were all suicidal).
I don't buy that.

[stillalbatross]

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."

If the 4 requirements were met when they descended they would have seen the Mountain, that's why the 4 requirements were there in the first place. If they hadn't descended in the first place, they wouldn't have hit anything.

So who elected to descend the aircraft below MSA? Air NZ management? Flight planning? Mc Murdo station? Wasn't it the case of a crew who thought they knew better than the company SOPs. Gordon Vette added a huge amount to what we have learned but can anyone of you out there slagging Chippendale honestly say that that aircraft wasn't taken VFR to a place that a widebody jet shouldn't have gone.

The accident has more similarities with a PPL in a 185 pushing his luck in dodgy weather somewhere near Mount Cook than any widebody accident I can think of.

I don't see how the crew can be utterly blameless, if the weather had met the requirements then it would have been obvious that the track had been changed. Isn't making correct decisions what we are paid for?

[slackie]

StillAlb...you need to read the evidence more closely...or if you have a couple of hours spare, what the dramatisation on the website (4 part TVNZ docu-drama). Sure it's pretty cheezy but it follows the main points of the evidence and both enquiries without having to read!

[ampan]

Kiwiandrew #41: How do I know what was said at the briefing?

(1) It was an audiovisual briefing, using photographs and a tape-recorded commentary – and I have a copy of the script used to make the commentary (as you would if NZALPA had done a half-decent job). It contains the following: “A standard route definition will be used employing the From-Via-To format. Enter NZAA then 78S/176E, this being the approximate co-ordinates of McMurdo Station.”

(2) The person who conducted the briefing was adamant that the pilots were told that their nav track from Cape Hallett was direct to McMurdo Station.

(3) Numerous pilots were called by the union to give evidence about their briefing. Not a single one of them said that that they were told that the nav track went to somewhere other than McMurdo Station.

(4) And if you still have doubts, Mahon himself accepted that the pilots were told that the nav track went direct from Cape Hallett to McMurdo Station (p60, para 164(b)).


The conflict in the evidence was about the track in relation to Erebus, not where the track went.

[compressor stall]

But it is entirely possible to fly into the side of a massive 13000' snow covered mountain with the first two of those four criteria met. :ugh:

Was there any mention of surface definition in the descent criteria? As recently as last January, a transport cat aircraft had a CFIT in Antarctica in level flight in VMC.... Luckily everyone survived.

I do not think that there is a single poster on here that believe the crew to be entirely blameless. On the contrary, the crew did make a mistake (or misjudgment - call it what you will). But the company culture, expectation and operations of the time let them make that mistake - with the tragic consequences. It should shoulder some of the blame too.

Oh what a difference 25 years of technology makes...
http://i663.photobucket.com/albums/uu353/stallie001/aviation/Picture6.jpg

[stillalbatross]

Slackie, I read most of what has been published. In fact I reread the CVR transcript again today. They were repeatedly told the wx was worse than their company SOPs so having 2 of the 4 requirements still isn't enough when 4 of the 4 were required.

Corporate culture? The aircrew were all a part of that. Much was made by Mahon of the company wanting the aircraft to descend or the punters weren't getting their money's worth, but would any good skipper override SOPs and safety to do that? If over the course of this and the next dozen trips the weather was never good enough to safely descend then the flights would have been axed because the public wouldn't have wanted to travel on them.

As said before, you basically had a 190 ton aircraft poking about in dodgy VFR. Who put it there? What about the 6 seconds the GPWS went off for before anyone did anything? Is that managements fault?

Nothing wrong with Chippendales report, the crew put the aircraft somewhere it shouldn't have been. The buck stops there.

All that Mahon and Vette did was show what the crew were dealing with after they descended. They shouldn't have.

[prospector]

compressor stall,

"I do not think that there is a single poster on here that believe the crew to be entirely blameless."

Hard to reconcile that with some of the previous posts, that is what the debate is about.

" 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. "

[Desert Dingo]

ampan (#47)
How do I know what was said at the briefing?
(1) It was an audiovisual briefing, using photographs and a tape-recorded commentary – and I have a copy of the script used to make the commentary (as you would if NZALPA had done a half-decent job). It contains the following: “A standard route definition will be used employing the From-Via-To format. Enter NZAA then 78S/176E, this being the approximate co-ordinates of McMurdo Station.” So what? That by itself doesn’t define the final waypoint. It is “the approximate co-ordinates of McMurdo Station” It is also the approximate co-ordinates of the McMurdo waypoint at the head of McMurdo sound which was on all the briefing charts. “Enter NZAA then 78S/176E” I would take as a computer entry that specifies a general area to pull up the briefing material for that area. It is in no way defining waypoints for the flight.
(2) The person who conducted the briefing was adamant that the pilots were told that their nav track from Cape Hallett was direct to McMurdo Station.As the call-girl said during the Profumo affair “He would say that –wouldn’t he”.
The evidence given by Captain Wilson and by Captain Johnson as to the verbal content of the RCU briefing was not accepted by the majority of the pilots who attended the briefings. Indeed there was one pilot who said that upon listening to the evidence given before the Commision in relation to the briefing which he had attended, he was led to wonder if he had been at the same briefing’.
(3) Numerous pilots were called by the union to give evidence about their briefing. Not a single one of them said that that they were told that the nav track went to somewhere other than McMurdo Station. So you don’t count
McWilliams
Roud
Woodhams
Dalziel
Eaton
Pullins
Simpson
Gabriel
Woollaston
White
Irvine
Sheppard who all testified that their briefing was for a track down McMurdo Sound.
(OK. I’ve included the flight engineers here as well, but you get the idea.To suggest that nobody was told the track was anywhere else but to McMurdo Station is plainly ludicrous).
(4) And if you still have doubts, Mahon himself accepted that the pilots were told that the nav track went direct from Cape Hallett to McMurdo Station (p60, para 164(b)). No he did not accept that at all.
Taken in context he is talking about the inadequacy of the briefing where all the maps showing the track down McMurdo Sound would take precedence over a verbal statement that the track was to McMurdo Station.

In fact, he came to the conclusion that Wilson may have been telling some fibs in his evidence about his briefing, and this led to the famous “organised litany of lies” statement that caused so much trouble.

Is there a prize for the most errors in a single post? :E

[compressor stall]

Prospector,

I missed that post on page 1 so my generalisation was in error. I had felt the thread was not so much about the blamelessness of the crew - rather the blameless of the company as championed by the likes of StillAlbatross.

The comments of StillAlbatross that, The crew put the aircraft somewhere it shouldn't have been. The buck stops there.

Show a complete lack of understanding of any sort of modern corporate safety management and accountability. Although those terms were probably not coined yet, the principles still existed - because there would be little other reason that the company went to so much documented trouble to cover up various issues.

Hopefully this (and the other threads) will be of education to others, here's a pic - better res that I have seen elsewhere. Impact was pretty much on the slopes under the saddle, and MuMurdo Sound to the right of shot.

http://i663.photobucket.com/albums/uu353/stallie001/aviation/erebuspano-2.jpg

[prospector]

With wx like that a VMC descent, after being identified on radar, would certainly be a possibility. Certainly shows Beaufort Island clearly, and its relative position to the impact point.

[ampan]

Mahon Report, page 60, para 164(b):

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

[ampan]

Desert Dingo -Toss the following thought around in your head: The pilots left the briefing thinking that they would fly down McMurdo Sound direct to McMurdo Station.

[Dark Knight]

Erebus is depicted as a material region, the lower half of Hades, the underworld. It was where the dead had to pass immediately after dying Charon ferried the souls of the dead across the river Styx, upon which they entered the land of the dead, where they remained for the rest of time. Erebus is synonymous for Hades, the Greek god of the underworld. Erebus has also been compared to darkness in general without personification.

Let it Lie.

"Not Chaos, not
The darkest pit of lowest Erebus,
Nor aught of blinder vacancy, scooped out
By help of dreams—can breed such fear and awe
As fall upon us often when we look
Into our Minds, into the Mind of Man—
My Haunt, and the main region of my song."

[Desert Dingo]

Desert Dingo -Toss the following thought around in your head: The pilots left the briefing thinking that they would fly down McMurdo Sound direct to McMurdo StationThey could have thought down McMurdo Sound was direct to McMurdo Station?

Rubbish.

Go and review all the testimony about pilots at the briefing estimating how far to the West of McMurdo station the track down McMurdo Sound was going to take them. For more than a year the briefed flight plan had the destination waypoint in McMurdo Sound then returning back to Cape Hallet. The pilots were trying to work out the track and distance for the left turn and visual leg for sightseeing over McMurdo Station.
This was a fundamental factor in the accident. This waypoint was changed and the crew were not told.

[prospector]

What is so hard to understand about this statement, it matters not what who said what to who, who remembers what from when. It is concise, to the point, it is indisputable that the crew were aware of the requirements of this order, it was the latest directive, it was in the cockpit with them.

"Delete all reference in briefing dated 23/10/79. Note that the only let-down procedure available is VMC below FL160(16000ft) to 6000ft as follows:

[ampan]

D. Dingo -You mean this sort of evidence? (from Capt. Gabriel, transcript p1712 - and not to be found in McFarlane's book):


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

Roughly I had a look at the topo map we were given at the briefing. The inset Exh. 4 I just roughly established where we were going. I thought it would be near enough to the 50 miles east of McMurdo Station.

Did you do that by roughly plotting the co-ordinates on that topo map?

Really just by roughly establishing in my own mind where the position was. I can’t say that I actually recorded the co-ordinates from the flight plan because we had to give the copy back at the end of the briefing, but looking at the map and from what I remember of the co-ordinates and looking at the topo map I thought in a rough sort of way we were going to about that position there so it wasn’t specifically plotted.

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

No. It was after the briefing.

How long after?

I first started looking at the map when I got home that night and it was about a day before I went down we actually looked at the map and thought we were going to that position. 4 or 5 days after.”

[Toshirozero]

ampan: quoting Gabriels esoteric excercise in obstrification hardly bolsters your argument; infact I'm at a loss to figure out what you're trying to substantiate actually.

By the way, Mahons' report was not over turned, and the privy councils findings and the criminal charges that eventually dropped against various ANZ personel all hung on technicalities, evidentially and semantically, based on due process and not on the actualities as they applied to all aspects of the accident, particularly evidence which was not produced to the commission.

If the Chipindale report was rubber stamped by the Royal Commission, to this day the accepted wisdom would be 'they where lost in cloud, off track and it's pilot error' as opposed to waypoint being changed and the crew were not told.

The consequence of this and the spatial aspects have been covered - anyone seriously proposing that Collins or any of the other crew would have selected navtrk after the last orbit if they were actually fully cognisant of their position is presupposing that they deliberatly flew straight at mt erebus..clearly, this is where the argument falls down: no-one would do that, ipso facto.

Mahon and Vette paid a high price for having the integrity to back up what they fundimenatlly knew was right:something else trapped that flight, and it wasn't a simple question of VFR reqiremets, radar let downs, lost in clouds, or ANZ's SOP's. Vette knew from experience there was a more valid supposition and Mahon with a keen objective intellect,who had to sit through day of day of clearly preplanned and deliberate attempts - bordering on perjury to mislead the commission - smelt a king sized rat early on.

This is also part of the problem. Apologists for ANZ, Muldon, CAA et el tacitly condone the sidelining and contempt that ANZ/Govt had for the commision. Would Mahon have reached the same conclusion if the evidence had been produced in accordance with the requirements of fact and evidence? Unlikely.

Mahons' crime, if it can be called that, was to show by the commissions' report that Kiwis aren't some back slapping, bunch of good old blokes,beer swilling "she'll be right mate jokers", but infact, when cornered are just as devious, sneaky, self centered, willing to break any law that suits the purpose and willing to sell anyone down the line to cover their own arses as any people in any other country..and a dead crew can't argue their case..which is what Mahon and Vette did for them, and paid a high price for their courage.

[ampan]

Toshirozero: The point of the extract is to demonstrate that the “eyeballing” evidence relied on by D. Dingo was not convincing, to say the least.

As to the decision to lock the aircraft back onto the nav track, that doesn’t dispose of anything.

Assume that at the briefing on 9 Nov the pilots were told that the track was direct to McMurdo Station but were not told that this track went over Erebus (which is, basically, what Mahon found).

Assume that the Capt. Collins retained one of the flightplans, or else noted down the co-ordinates.

Three weeks later, the night before the flight, he gets out his charts. He would have noted that a direct track from Cape Hallett to McMurdo Station went over Erebus. On plotting the track using the co-ordinates, he would have noted that the track went down McMurdo Sound, with the high ground of Ross Island (including Erebus) to the left. Assuming that he remembered what was said at the briefing, he would have noted the contradiction re the track. He resolved the contradiction by assuming that the track shown by the co-ordinates would be the track that the aircraft would fly, without conducting any further check. That was an error, and a reasonably bad one. He had received contradictory information re the final waypoint, so he should have checked that waypoint as it was entered the following morning. Instead, he simply assumed that the final waypoint was the same as the one he had plotted the night before. It doesn’t mean he was suicidal or insane. It just means that he made an error.

After completing the descending orbits, he locked the aircraft back on the nav track, obviously, as you say, under the assumption that the track was down McMurdo Sound, with the high ground of Ross Island to the left.

Then F/E Brooks says “I don’t like this” and a few seconds later, the Captain decides to climb out. F/O Cassin, in the right-hand seat, says that its clear to the right for a 180 degree turn. The Captain says “No negative”, then pulls out the Heading Select knob and initiates a left-hand turn using the autopilot (refer page 99 in the Chippindale report). Then the impact.

Why did he decide to turn left? If he was certain that he was in McMurdo Sound, with the high ground of Ross Island to the left, then he would have turned right, as the F/O had recommended. One explanation is that he recalled what he was told about the track at the briefing and the pennies started to drop. The fact is that in his actual position (at 1500 feet in Lewis Bay with Erebus dead ahead and Cape Bird to the right and behind), the only way out was to the left.

[prospector]

Refer to the photo posted by compressor stall, note the position of Beaufort Island, if the VMC conditions were as good as some are trying to convince us, why was it that they did not click they were on the wrong side of the Island, if they were on the track they thought they were on. Beaufort Island is a very very conspicuous object, and not many of them down there to get confused with.

'they where lost in cloud, off track and it's pilot error'

That is not the case at all, to my way of thinking, the argument is that they commenced descent without meeting any of the requirements laid down by either CAA or the Company. As has been stated in this thread and others, all Mahon and Capt Vette were trying to justify is the sequence of events after the descent was commenced.

[ampan]

Prospector: See page 154 of the Mahon Report, which contains two photographs of Beaufort Island taken by the passengers. It was, as you say, very conspicuous.

Mahon gives at least three explanations, two of which contradict eachother. Vette comes up with an elaborate theory to explain why Peter Mulgrew said "There's land ahead" right when Beaufort Island was dead ahead, suggesting that he was referring to other land.

The most likely explanation is that on the three occasions they flew past Beaufort Island, they assumed that they were in the middle of McMurdo Sound and simply disregarded the island (even though there is no such island in the middle of McMurdo Sound).

[Desert Dingo]

ampan
How can you possibly persist in assuming that the track was from Cape Hallet to McMurdo Station when all the evidence shows that it was not?
How can you ignore:
All the documentary evidence showing the track was down McMurdo Sound.
For more than a year the flight plan was to the McMurdo waypoint at 7753.0S16448.0E and this was the example shown at the briefings.
The testimony of at least 12 people saying that they were briefed that the track was down McMurdo Sound.
The testimony of the pilots about a left turn to get to McMurdo Station.(By the way, contrary to what you wrote, Captan Gabriel’s testimony is in McFarlane’s book – on page 351).
The point of the extract is to demonstrate that the “eyeballing” evidence relied on by D. Dingo was not convincing, to say the least. The point being made is that if pilots are discussing making a left turn and estimating a distance to McMurdo Station, then they cannot possibly be coming from a final waypoint at McMurdo Station. If that doesn’t convince you that the final waypoint was not McMurdo Station, then you have a serious comprehension problem.
Assume that at the briefing on 9 Nov the pilots were told that the track was direct to McMurdo Station but were not told that this track went over Erebus (which is, basically, what Mahon found). Bullsh!t – for all the above reasons.
Three weeks later, the night before the flight, he gets out his charts. He would have noted that a direct track from Cape Hallett to McMurdo Station went over Erebus. That is quite possible
On plotting the track using the co-ordinates, he would have noted that the track went down McMurdo Sound, with the high ground of Ross Island (including Erebus) to the left. The coordinates obtained from the flight plan shown at the briefing - yes. Highly likely given the testimony about him plotting the track on his atlas.
Assuming that he remembered what was said at the briefing, he would have noted the contradiction re the track. No. Here your argument is based on the premise that he was briefed that the track was direct to McMurdo Station. There is overwhelming evidence that this did not happen. Mahon came reluctantly to the conclusion that this was part of the “organised litany of lies” he was fed from the company.
He resolved the contradiction by assuming that the track shown by the co-ordinates would be the track that the aircraft would fly, without conducting any further check. That was an error, and a reasonably bad one. He had received contradictory information re the final waypoint, so he should have checked that waypoint as it was entered the following morning. Instead, he simply assumed that the final waypoint was the same as the one he had plotted the night before. It doesn’t mean he was suicidal or insane. It just means that he made an error. These are invalid conclusions based on the incorrect premise above.
Why did he decide to turn left? Seems pretty logical to me. If you are flying from the left seat it is the natural way to turn. You can better see what you are turning into in a left turn. Also his last two turns had been left.
One explanation is that he recalled what he was told about the track at the briefing and the pennies started to drop. The fact is that in his actual position (at 1500 feet in Lewis Bay with Erebus dead ahead and Cape Bird to the right and behind), the only way out was to the left. How many times does it need repeating? THE BRIEFED TRACK WAS NOT DIRECT TO McMURDO STATION.

[prospector]

ampan,
Perhaps this from Bob Thomson explains that situation, Bob Thomson has made over 50 flights to the AntArctic, most of them on the flight deck, he had in fact been the guide on prior ANZ flights.

"The captain didn't give attention to problems that 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. Most of the times Mulgrew had been there he'd gone by sea, and all his travel from Scott Base was to the South. Hardly anybody ever went into Lewis Bay.

Had they orbited Ross Island they would have seen the cloud. If a pilot is unsure he always goes up, never down. The co-pilot on Flight 901 never opened his flight bag to look up the co-ordinates. I always had a chart in the cockpit and checked the latitude and longtitude readout, but the crew of the fatal flight never referred to it.''


"How many times does it need repeating? THE BRIEFED TRACK WAS NOT DIRECT TO McMURDO STATION."

So what? if the descent requirements had been complied with it is of no relevance.

[ampan]

OK, Dingo: Let’s go through it bit by bit – again.

“All the documentary evidence showing that the track was down McMurdo Sound”

“All”? There is only one document showing a track from Cape Hallett to a point in the middle of McMurdo Sound (ie the Byrd Reporting Point): Exhibit 164 (McFarlane p102). But the topography is barely discernable.

The RNC4 chart (McFarlane p81 ) shows a track from the west of Cape Hallett to the Byrd Reporting Point. Why would any navigator rely on that, given that you are coming from Cape Hallett, not from the west of it?

Ditto the strip chart (McFarlane p101).



“The testimony of at least 12 people … ”

All they said was that they did not know that the track went over Erebus. Not a single solitary one of them said that Capt. Wilson told them that the final waypoint was anywhere other than McMurdo Station.

If you disgagree, post the evidence. You won’t find any.



“The testimony of the pilots about a left turn.”

Where’s that bit?



"Capt. Gabriel’s testimony"

No, it’s not all in McFarlane’s book. The bit that is missing is the bit where he admits that he didn’t, actually, do any “eyeballing” at the briefing. He did it, he said, after – relying on what he remembered of the co-ordinates. Mr McFarlane decided to leave out that bit, because it didn’t suit his cause.


“Pilots discussing a left turn”?

What are you talking about? The briefing, or what happened on the Simpson / Gabriel flight?


The rest of it is just your opinion, with which I disagree.

I understand why the capitalised red type appears at the end - because you know it means an obvious case of pilot error (probably having attended several half-baked briefings in your time).

[stillalbatross]

So without any ground based Navaids, using an Inertial Ref system that was only accurate to 1.99 NM per hour, there is absolutely nothing wrong with making up a descent based on that IRS accuracy? A descent that puts you IMC below MSA in the hope that you will get a good look at everything VMC when you get down there. And most aviators on here siding with the crew completely agree that from an airmanship point of view they would happily do the same?

There would never have been a single comment on the CVR regarding the weather conditions if they had remained within the company SOPs.

[slackie]

As far as they knew they were VMC (see Vette's sector whiteout material)...and had possibly confirmed their position visually (if mistakenly). And in order to confirm this they elected to re-establish on the briefed track up McMurdo Sound after each orbit. When they (possibly) became uneasy with the situation they elected to climb out, again straight up McMurdo Sound.

It appears to me that those that a few here have their minds irrevicably set on either side of the fence (for whatever reason)...and we could bang on here forever.

The stated purpose of the website is to be the definitive location for all information pertaining to the accident. If I had any further evidence that didn't appear on the site then I'd submit it to be included.

[prospector]

"I had any further evidence that didn't appear on the site then I'd submit it to be included."

It is the interpretation of the evidence, already presented, that is what is creating the animated discussion.

[ampan]

slackie: NZALPA could have easily included the evidence and the exhibits on the website. They chose not to - and I can understand why, because I've seen it all.

The fact is that the whole Erebus saga was a war between the union and the airline, which was started by union, and for which the airline was not prepared.

As for the allegedly "even-handed" presentation on the website, I do no more than point to the "Jim Collins Memorial Award". If NZALPA were going to be even-handed, it would be the "Gordon Brooks Memorial Award".

[stillalbatross]

As far as they knew they were VMC (see Vette's sector whiteout material)...and had possibly confirmed their position visually (if mistakenly). And in order to confirm this they elected to re-establish on the briefed track up McMurdo Sound after each orbit. When they (possibly) became uneasy with the situation they elected to climb out, again straight up McMurdo Sound.



Disagree. As Vette showed you needed a cloud layer above you to get the whiteout conditions that lead them to believe that they didn't have terrain in front of them. They were uneasy before descent, in descent and for some time at the lower level. They shouldn't have commenced descent in the first place. There is no point in blaming the company, the crew elected to descend themselves. They were slow to react to a worsening situation and slow to react to the GPWS. Having blind faith in the INS, below MSA in a completely unfamiliar environment?

Vette further highlighted what a completely unfamiliar environment it was so what were they doing there? LA three times a month isn't going to give you preparation for VFR around Antartica.

Lets say the company didn't give them the changed co-ordinates but the INS developed a xtrack error instead, without tacan they still would have hit the mountain. Whose fault then? Chippendale would still have come to the same conclusion.

What would Mahon have said then?

[Toshirozero]

'Lets say the company didn't give them the changed co-ordinates but the INS developed a xtrack error instead, without tacan they still would have hit the mountain. Whose fault then? Chippendale would still have come to the same conclusion'.

No, the outcome in all probability may have been the same, but the cause would have been different which would have changed the IIC's reasoning on how it ended up where it did; If the INS had gone pear shaped, it would have been a clue, and clues visual or otherwise were the problem.

What would Mahon have said then?

He would have said nothing, as the Chippendale report would have found the cause was a systems error, there wouldn't have been a public furore and no requirement for a subsequent Royal Commission - Mahon would have lived out his days in relative obscurity, Vette, retired a capt with ANZ and Chippendale would have got deserved praise for a complex investigation in difficult and trying circumstances; however, the 'malevolent trick of the polar light' put paid to that, ably assisted by the chicanery of the airline and govt

http://pixel.quantserve.com/pixel/p-e4m3Yko6bFYVc.gif?labels=NewsAndReference,EducationAndEmploy ment One other thing I noticed, some of these comments are disingenuous at best, and at worse, deliberately misleading, for example:

" Across the world in the head office of ICAO at Montreal, the Royal Commissions report was closely studied by the Head of the Operations section, Duane Freer, who made this comment:
" What on earth is going on down there? It reads like something coming from a third world country"
http://pixel.quantserve.com/pixel/p-e4m3Yko6bFYVc.gif?labels=NewsAndReference,EducationAndEmploy ment


But Freer wasn't referring to the content of the report,he wasn't referring to the commissions report at all, he was referring to the chaotic operating environment, lack of effective CAA oversight, poor flight planning and obvious conflicts of interest having a govt owned airline, under investigation by a govt dept...or as Sir Walter Scott put it - 'Oh what a tangled web we weave,When first we practice to deceive'

[prospector]

Once again, a question of interpretation, who was trying to deceive who???

'Oh what a tangled web we weave,When first we practice to deceive'

What interpretation would you take from Judge Harold H. Greene's ruling stating " 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 terrain, and he was on his own".

He also stated "The operational crew of Flt TE901 acted unreasonably in several respects, including not plotting their actual position from the AINS and descending below 16,000ft contrary to both prudent airmanship and Air New Zealand policy, without first ascertaining what was there or following the other requirenments for such descent. The crew also missed the obvious landmark of Beaumont Island being on the wrong side of the flight path and pressed on in the face of deteriorating weather, with five or six extra [eople milling around the cockpit causing some distraction during the critical period."

Toshirozero,
Perhaps you would like to give us your take on how Justice Greene of the US District Court in Washington was influenced by either the NZ Government NZ CAA, or the fact that the Airline was Govt owned?

Who was it who took the case to the US court, and for what reason?
It was not the decision that was expected, This judge obviously agreed with the Chief Accident Inspector's findings, and the published beliefs of many past and present aircrew, totalling many hundreds of thousands of hours of air time, as against a judge who had none.

[Toshirozero]

Your good at obscuring the point and it's evident you have little or no knowledge of how litigation works - the US Navy was implicated directly in the accident as part of the ATS system in the Antarctic.

Judge Harold H. Greene's ruling is pure legal jargon, implicit in removing the USN from any culpability.

'deteriorating weather?' the stated vis and photo evidence shows it was 8/8th clear, 40 nm plus.

'against a judge who had none'...For a judge with no aviation experience he did a good job of pin pointing why and how a fully experienced and capable crew flew a serviceable aeroplane into a mountain they did not see was there. That they weren't fully cognisant of their actual position is well documented- the question was why, that's been explained. It's an interesting fact about air accident investigation, that very experienced pilots crash servicable aeroplanes relatively regularly - experience isn't a guarantee of infallibility, and is therefore not a proof.

the 16000' ceiling argument has been thrashed out before. it was a fallacy disproved by Chippendale as well in subsequent arguments, and was a corner stone of ANZ's defence that it was a crew error - A point that you are more than ready to reinforce at every opportunity. The crew are not blameless, but more importantly, they are not culpable

De ton cotè mec, I'm getting bored

[fourholes]

:zzz: So am I:zzz:

[prospector]

Toshirozero,
"the US Navy was implicated directly in the accident as part of the ATS system in the Antarctic."

Are you sure????

"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 US Navy Air Traffic Controllers at McMurdo to warn Flt 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".

fourholes,
Does your computer direct you to this thread? why not utilise one of those items in your nom de plume and dissappear into it.l

[Toshirozero]

Pretty sure - the reason litigation is held in the US is that there is no statutory limit to maximum payouts - it's why all accident litigation is US based. It applies to pax, crew and every man and his dog.

Anyway, you answered your own question: '... sued the United States Government for alleged failure of the US Navy Air Traffic Controllers at McMurdo to warn Flt TE901'..it's legal jargonese but you get the point.

apportioning blame is part of the game or as Einstein said ' If the facts get in the way of a good theory, that's too bad for the facts'

That's me, I'm done with this pointless ping pong exchange, constantly recycling the same point isn't resolving the argument, a point substantiated by D Dingo et el

[prospector]

No, don't get the point. the crew members legal eagles alleged, the judge said CRAP. and agreed with Chippendales report.

[ampan]

Prospector: Who really cares about what Judge Greene thought? His opinions are about as relevant as those of McFarlane. In any event, Judge Greene was not called upon to determine who was to blame within AirNZ. He was called upon to determine whether the US Navy was partly to blame.

Toshirozero: The reason why a lot of accident cases are heard in the USA is because there are a lot of Boeing aircraft in service around the world. But there is no automatic right to sue in the American courts. For example, take the recent Airbus accident off Brazil. There would be no basis for a US court to hear litigation concerning that accident (unless, perhaps, one of the components was faulty and was manufactured by a US company.)

[prospector]

ampan,

I do, he was presented with the same scenario as other legal people and took a completely opposing view. I find this interesting because he was not directly involved with any of the people affected prior to making his decision.

[ampan]

Prospector: This whole 30 year long saga might not have occurred had it not been for the involvement of the "legal people".

Question: What was the 1970s procedure after passing a waypoint? Was it to check the next programmed waypoint against the flightplan, or against the chart - or both?

[prospector]

ampan,
Making "assumptions" was just as bad in 1970's as it is now.

Your suggestion as to the naming of the memorial is to me the only thing of any value out of this thread. We know it will never happen, but that does not reduce the thought behind the suggestion.

[ampan]

This is where Gordon Vette ruins his own argument. His whole career was based on huge legs across the Pacific in a DC8, with nothing to guide him except for a couple of NDBs, the stars, and the navigator seated behind him.

[Brian Abraham]

ampan & prospector, why don't the two of you just email each other. The audience has heard it all before. All parties, pro and con, have their beliefs and never the twain shall meet.

[slackie]

Here...here!!

[fourholes]

Now now Prospector, be nice. I can't decide if you are a "has been" or a "never was", the point I was trying to make is that you have had your say, this thread is going nowhere and the only person that cares anything for your ponderous diatribe seems to be ampan, so why don't you take Brian's advice:zzz: BTW. I kept reading this thread because I was hoping something interesting would emerge. I don't think I'll bother anymore:ugh:

[prospector]

Perhaps so, but maybe some of the younger generation will have cause to look a little deeper than what NZALPA feeds them.

slackie,
Hear, hear, I believe would be the words you meant to say.

Brian Abraham,

"I do not think that there is a single poster on here that believe the crew to be entirely blameless". as posted by compressor stall earlier, is a view obviously not shared by all, but maybe a few more now.

[ampan]

I would be very happy to bury the whole issue.

But is was NZALPA that dug it up, again.

Here's a question for Gordon Vette: If you had been in command of TE901, would the aircraft had collided with Mount Erebus at 1500 feet?

[Dark Knight]

Here's a question for Gordon Vette: If you had been in command of TE901, would the aircraft had collided with Mount Erebus at 1500 feet?This statement shows how stupid this subject has become - a stated previously - just email each other!!

The audience has heard it all before. All parties, pro and con, have their beliefs and never the twain shall meet. DK

[ampan]

Fine, as long as I get the last word: A bad case of pilot error.

[prospector]

Hear, Hear.

[fourholes]

I don't think so boys!

Good try though. They were in the long chain of human error, granted. But to lay the blame at their feet exclusively is wrong. Perhaps because you two live in the industrial wasteland after crapping on your colleagues in the past makes you feel better about trying to discredit NZALPA and 3 of its members who perished 30 years ago.

[prospector]

"But to lay the blame at their feet exclusively is wrong."

Granted, but who is doing that? All I am arguing is that they were not blameless as has been quoted on this thread by many.

" live in the industrial wasteland after crapping on your colleagues"

Really, from whence do you get that sort of information from?? Remember it was the president of NZALPA that took it upon himself to publicly state state that all pilots were in agreement with Justice Mahons findings, That is patently garbage, I have quoted statements from Aviators with many thousands of hours of aviating who do not agree with those findings. Why do you lot not do a bit of research instead of slavishly following the dictates of the disciples of Mahon????.

[FGD135]

To me, an interesting, absorbing thread. I was 15 at the time of this crash and are only now just forming my opinions on it.

To start with, my belief was that the fault was 90% by the pilots and 10% by the airline, but the more I read about it, the more that ratio changed.

At the moment, the company is somewhere around the 80% (at fault) mark.

prospector, I would like to thank you for the effort you have put into this argument. I appreciate it and believe you are making a positive contribution to air safety.

Your argument seems to be based solely on that descent SOP.

But, there are times when SOPs are not really SOPs. I will go into this a little more in my next post, but for now, be aware that SOPs can be:

1. Wrong (erroneously worded);
2. In direct contradiction to some other SOP;
3. Invalid (no longer applicable and awaiting a forthcoming amendment to remove it from the manuals);

Time prevents me from posting more right now, but I would like your opinion on the degree of certainty of position that was held by the crew in the minutes leading up to the crash.

[fourholes]

Why do you lot not do a bit of research instead of slavishly following the dictates of the disciples of Mahon????.

Thanks for your concern prospector, I don't. I have done the research. If you read my last post again you will see that I have conceded that the crew were in the chain of error. Why do you dogmatically accept Ron's report as flawless? I think, like everything in this world, the truth lies somewhere in the middle.

[skol]

Ampan,
Gordon Vette flew the DC10 and the 747-200, I flew them with him so get your facts right.

[prospector]

Ron Chippendale's job was to determine the cause of the accident, he did that, obviously, if the aircraft had not descended when it did it would not have impacted Erebus.

Justice Mahons brief was to determine why they went down when they did, and he did, and opened the can of worms that he did.

But there was much more to the can of worms he opened, and ALPA had a lot to do with that, they were the ones that insisted that these were perk flights to be distributed among senior pilots.

" 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 therefore need to seek advice from elsewhere, such as the RNZAF,USAF.USN or the Division." This from a very experienced AntArctic operator, as quoted earlier in the thread.

I have been criticised for offering an opinion after not having been down to the ice.

This crew had not been down to the ice, which was why the requirements for descent were so explicitly spelt out. They had no briefing about white out, so we are told, but any person of high intelligence such as these people obviously were would no doubt have heard of this peculiarity of operating in this environment. Yet they did what they did and with the results of which we are still all disagreeing about.

It is good to see some are now conceding that the crew were in the chain of error. My argument has always been against the finding that the crew were blameless.

[FGD135]

prospector,

What fault ratio would you assign between the crew and airline?

For me, the ratio is now 70% to the airline and 30% fault to the pilots. This ratio has moved a little since my last post as I have now read the CVR transcript.

My purpose for reading that was to ascertain how much uncertainty there was on the flight deck as to their position. From reading the transcript, it can be seen there was significant uncertainty and apprehension.

At no time did anybody on the flight deck actually lay eyes on Mt Erebus. That would have been a disconcerting and niggling thought in the back of all of their minds as they completed that final orbit and reengaged the NAV track.

At one point, about 3 minutes before impact, the flight engineer asks "where's Erebus in relation to us at the moment?". The responses he gets over the next 15 seconds seem to indicate that nobody is sure where it is.

Finally, the flight engineer says "I'm just thinking of any high ground in the area, that's all".

[Hempy]

I was 10 when it happened, and really had no idea about the Erebus crash until I saw a doco with original footage from the enquiry (that is now, thanks to the miracle of the internet, on youtube). I don't pretend to know any of the answers, but there was something fishy going on at ANZ with ring binders and staff stand-downs etc

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[Toshirozero]

'Changez le disque, putain con de merde'.

ampan - I can't let this waffle pass by - it's one thing to be ignorant, it another altogether to advertise it, you and that other blinkered, vindictive muppet should knock it off; and another thing, it's a good idea to know what you're talking about before writing the patronising crap in your previous comment.

The reason all accident cases are heard in the USA on behalf of plaintiffs looking for damages/compensation is because there are no max' limits to the payouts in the US judiciary. It has nothing to do with the airplanes state of manufacture or state of occurrence as determined by ICAO Annex 13, and the stated case of the airbus accident has already started litigation in the US looking for damages-it's standard practice - there are US legal companies, US based that specialise in this, and they arrive at accident sites about 10 minutes after the emergency vehicles - everywhere in the world.

And, sad as it is, if the ANZ family members from the 320 accident off the French coast last year want to seek damages, it will be in a US court, for the above mentioned reasons.

I am extremely tempted to run through all of you previous posts on this Erebus subject and pick out every misquote, quote out context, repetition, maligning statements and deliberate 'liguistic slight of hand' that you have employed to show how biased your point of view has been...and don't mention 'educating people' as a motive, as that's plainly an extension of your excuse to carry on regardless of the facts.

Arrêt maintenant mec. Je suis fatigué d'écouter votre bateau des imbéciles

[27/09]

To accept that either Ron Chippendale's or Justice Mahons reports as being 100% correct is unrealistic. Both contributed in a major way in determining what happened and to prevent a similar accident from happening again. Both reports are one mans expert opinon based on the evidence presented to them. Different experts can arrive at different conclusions using the same information.

There were many contributing factors to this accident, it is a classic example of the Reason theory. The crew as in many accidents are the final defence/barrier to the accident so their errors are easy to see and write off as the cause.

There were a whole series of events that preceded the crews actions leading up to this accident. Some events, as it became evident, somebody wished to cover up, the missing pages from a diary, a house break in etc.

Some of these events are:
Anecdotal evidence as to what had occurred on previous flights,
The lack of Antarctic aviation experience on the flight deck,
The weather/light conditions at the time,
The briefing as to where they were to fly,
Their expected route as opposed to their actual route
The change of co-ordinates.


ampan et al

Do you honestly believe pilot error was the sole cause of this crash? Your posts would indicate this is what you believe.

Here's a question for you.

Can you honestly say, given the events that preceded this crash, you might not have ended up in the same situation?

[Jackson]

Just a question.

Why would any operator planning a flight with expectations of sight seeing in VMC actually plan a route directly over the highest terrain (and highest LSALT) in the region?

[prospector]

FGD135,

There are two other entities that have to share the blame for this disaster. NZCAA, for not pursuing their regulatory role with more vigour, although it must be noted that there was an Airline Inspector scheduled to travel on TE901 but due to family commitments he had to cancel. It is a matter for individuals to decide if the flight would have been carried out the way it was if an Airline Inspector had of been on board.

NZALPA, For insisting that these flights be "perk flights" for their senior members, notwithstanding all the accumulated knowledge of other operators that had been amassed over the years,ie must have been down to the ice previously before going down in command.

And of course the Crew and the Company, one has to draw one's own conclusions as to the share of blame to be apportioned to each using the facts that are public knowledge.

Toshirozero.

"you and that other blinkered, vindictive muppet" .

It would be so easy to type what I think of your contribution, but what would that achieve??

Everything I have printed has been in the public arena for years, All I have done is present what is in many different publications, mainly because I now have the time to peruse all this material.

Are you saying anybody that does not agree with Mahons findings in there entirety is a "Vindictive Muppet"? If so it does the veracity of your posts no good at all.

"The reason all accident cases are heard in the USA on behalf of plaintiffs looking for damages"

Get your facts right. They did not go to the US for the amount of money, they went to sue the US Government for the alledged failure of the US navy controllers at McMurdo. If they had of won that case then they could have tried to collect. But they lost the case.

[ampan]

Jackson: Why not?

You're on nav track, in blue skies, with Erebus dead ahead.

Wouldn't you, like the rest, pull out the knob and fly "Heading Select?

[ampan]

27/09: I can't comment on your hypothetical. But Vette can comment, because he flew that same route.

skol: Vette was an AirNZ/Teal employee from the late 1940s. He spent 4-5 years in the RNZAF in the 1950s, and then rejoined the airline. In the late 1960s, he established many of AirNZs huge legs across the Pacific - in a DC8.

After the DC10 was introduced in the early 1970s, he managed to persuade AirNZ to give him some slots on DC8 flights so that he could maintain his navigators licence.

No-one can dispute Vette's credentials. But has he ever, anywhere, said that he himself would have parked that aircraft on Mt Erebus?

[27/09]

Ampan

You overlooked my first question. Here it is again.

Do you honestly believe pilot error was the sole cause of this crash?

I am at a loss to know why you can't answer the second question.

[ampan]

I overlooked the question, 27/09.

100% AirNZ, given that there was nothing wrong with the aircraft.

As for apportioning blame between the various AirNZ employees:

AirNZ Flight Ops and Nav sections: 60%
Capt Collins: 30%
F/O Cassin: 8%
F/O Lucas: 2%
F/Es Brooks and Maloney: 0%

[27/09]

:hmm:

Having stated this 100% AirNZ, given that there was nothing wrong with the aircraft.

As for apportioning blame between the various AirNZ employees:

AirNZ Flight Ops and Nav sections: 60%
Capt Collins: 30%
F/O Cassin: 8%
F/O Lucas: 2%
F/Es Brooks and Maloney: 0%

How can you say A bad case of pilot error which inferred to me you thought the pilots were 100% to blame. However I now understand that you think the pilots were only partially to blame which is a concept that most might agree with.

Now why wont you answer my other question? Can you honestly say, given the events that preceded this crash, you might not have ended up in the same situation?

[ampan]

27/09: No-one, including myself, has ever said that the pilots were 100% to blame. The only reason why this accident is still argued about is because Mahon said that the pilots were 0% to blame.

As for the "there but for the grace of God" point: What if TE901 was a simulation? Wouldn't Collins get a D? And would he argue with that grade? In fact, he would probably have been harder on himself than anyone else.

[Brian Abraham]

Given that we are treading old ground it may be timely to reproduce the following in order to gain some understanding of how accidents occur.

Sidney Dekker
Associate Professor
Centre for Human Factors in Aviation, IKP
Linköping Institute of Technology
SE - 581 83 Linköping
Sweden

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."

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.

[27/09]

ampan

There is only two maybe three answers to my queston, "Yes" "No" or "Maybe"

Your refusal to answer the question in a round-a-bout way answers the question don't you think?

[ampan]

It's a definite "maybe".

But there is more than enough evidence to establish that the pilots were briefed for a track direct from Cape Hallett to McMurdo Station. Apart from the script used for the audio commentary, note that the pilots then went on to the simulator. The did the pre-flight checks, including the manual entry of the waypoints. The instructor then positioned the simulator at 60 degrees south to practice the change to grid navigation, and then positioned the simulator over McMurdo Station to practice the cloud-break procedure. How did the instructor do that? By using the nav track that had been previously entered into the simulator. So what track must have been entered? One that went to McMurdo Station.

[Desert Dingo]

But there is more than enough evidence to establish that the pilots were briefed for a track direct from Cape Hallett to McMurdo StationI call Bullsh!t on that one.
The flight plans prior to the last flight were down McMurdo sound.
Great simulator training there.
Real life will be "A"; lets do a simulator session for "B".

I think most of us have worked out by now that a major factor in the accident was the company changing the final waypoint and not telling the crew.

[ampan]

No-one actually said that "real life will be A". I've seen the transcript of the audio, where it says that "real life will be B" - which was supported by the subsequent simulator session. And not one single pilot ever testified to being told that "real life will be A".

So when, the night before the flight, you see the contradiction, you have to sort it out, properly. That wasn't done.

[Desert Dingo]

And not one single pilot ever testified to being told that "real life will be A".You are joking. Right?

So when, the night before the flight, you see the contradiction, you have to sort it out, properly.The whole point is that you cannot be expected to see any contradiction.
There were only four digits changed of some thousand or so digits on the flight plan. The standard waypoint entry check is to compare the flight plan data with the data in the navigation system. It is not to check the flight plan data with co-ordinates on a map.

The flight plan data matched the data in the aircraft's nav system, so the crew had done everything expected of them. The problem was that the final waypoint had been changed and the crew were not told about the change.

Do you start to get the idea? The company changed the flight plan that the crew were relying on, and did not tell them about the change.

[ampan]

Not joking: Not a single solitary pilot said "Capt. Wilson told us that the nav track went to X", X being a position other than at McMurdo Station.

The point re the contradiction is that it was one that was brought to the captain's notice the night before (assuming that he was told that the nav track was to McMurdo Station).

So it all depends on what was presented at the briefing. If it was "the nav track is to McMurdo Station", then it must be an error. If it was "the nav track is to some penguin colony by the Dailey Islands", then it's not an error.

But there is no evidence to support the proposition that the pilots were told that the track went to a point near the Dailey Islands. Nothing at all - from either side.

[Steve Zissou]

Fine, as long as I get the last word: A bad case of pilot error.

What a c#@k

[ZQ146]

Please please...Ampan And Prospector cant someone shut these two pricks down...the last word will never come with them repeating themselves on and on obviously a couple of donkey drivers

[Desert Dingo]

Not a single solitary pilot said "Capt. Wilson told us that the nav track went to X", X being a position other than at McMurdo Station.Sorry ampan, you don't get away with such crap. Not a single solitary pilot? I'll give you 3 for starters.

F/O Irvine's evidence (B.552)
I am certain that at no stage during the briefing conducted by Captain Wilson was anything said to the effect that our flight plan track would go over Ross Island or Mt Erebus. When I left the briefing I had a clear understanding that we were flying into the McMurdo area up the McMurdo Sound with Ross Island and Mt Erebus well out to our left. If mention had been made that our track passed over Ross Island and Mt Erebus, I would most certainly have questioned Captain Wilson about it to clarify my own understanding.
One purpose in talking through briefing notes is to highlight important aspects of the briefing material. Mention of the fact that the planned track went directly over Erebus, the biggest obstruction in the area, would have been the most important factor in building up a mental orientation of the area in which the final approach and let -down to McMurdo were planned. For that reason, I would have expected direct and clear reference to have been made to it.Capt Gabriel’s evidence (B528)
The briefing session commenced with the audio-visual presentation. I remember when the slide came on together with the commentary "Erebus ahead" noting that the heading of the aircraft was to the right of the high ground depicted in the slide. I consequently expected the aircraft to approach the McMurdo area on a track which would take the aircraft to the west of Mt Erebus:
Nothing that I saw or heard during the audio-visual presentation gave me the impression that the aircraft would overfly Mt Erebus during its approach to the McMurdo area.
<snip>
In conclusion I wish to emphasise that early in my RCU briefing, from a comparison of the Byrd Reporting Point co-ordinates as shown on the RNC4 chart and the co-ordinates of the "McMurdo" waypoint on the computer flight plan shown to me, I calculated that the planned track for the aircraft was up the McMurdo Sound and clear of high ground.Nothing I saw or heard at either briefing before or after coming to this conclusion alerted me to the fact that the planned route was over Ross Island in the vicinity of Mt Erebus and terminated at Williams Field. Capt Simpson’s evidence (B422)
The briefing commenced with an audio-visual presentation. The impression I got from the audio-visual was that our approach to the McMurdo area would be up the McMurdo Sound. I certainly did not get the impression from the audio-visual that our approach would be over Ross Island or Mt Erebus.
<snip>

During the briefing Captain Wilson produced flight plans from a previous flight to the Antarctic for our perusal. These were available for inspection for some time and were retained by Captain Wilson at the conclusion of the briefing session. When I looked at one of these flight plans I noticed that the latitude and longitude of the McMurdo position were almost the same, but further south and west, as the Byrd Reporting Point. I did not record this position but only noted it mentally. It seemed to me to be a logical position in that it was at the head of the Sound clear of high terrain and a good position to start sightseeing from in the McMurdo area. I also noticed that the McMurdo waypoint on the flight plan was not described as the McMurdo TACAN or any other navigational aid as is the practice when waypoints are located with navigational aids. I took the McMurdo description of the waypoint to equate with McMurdo Sound being the area where the waypoint was located.
<snip>
... Captain Wilson describes running his pen down the HI-NDB-A chart and says that he mentioned to us that the track would come "from Cape Hallett over Erebus to McMurdo". I have absolutely no recollection of him saying this either with reference to the HI-NDB-A chart or at any other time during the briefing. If Captain Wilson had made such a comment to the effect that our track passed over Erebus or over Ross Island on route to McMurdo Station it would have been in conflict with my understanding that the NAV track proceeded from Cape Hallett to a position west and south of the Byrd Reporting Point. I am positive that in such circumstances I would have queried his remark. To overfly Mt Erebus and Ross Island would seem such an unwise manner of approaching McMurdo Station and in addition I would not have been happy overflying an active volcano only 3,500 feet above its summit especially if the conditions were IMC. In such circumstances turbulence would be likely and you would not know the extent to which the mountain was erupting. Pretty good trick if you say the track was direct McMurdo Station and everybody leaves the briefing thinking it was not.

[forget]

With both Tenerife and Erebus it’s sad that the pilots didn't give more credence to the doubts of the Flight Engineers.

KLM.
17.06:12 Captain. ‘We go …… check thrust’.
17.06:32 F/E. ‘Is he not clear then?’.
17.06:34 Captain. ‘What did you say?’
17.06:35 F/E. ‘Is he not clear … that Pan American’.
17.06:36 Captain. ‘Oh, yes.’
17.06:49 Impact.

ANZ.
12.49.08, Mulgrew. (Observer, Pax commentator.) ‘That looks like the edge of Ross Island there’.
12.49:24 F/E Brooks: ‘I don’t like this.’
12.49:25 Capt Collins: ‘Have you got anything from him?’ (McMurdo)
F/O Cassin: ‘No.’
12.49:30 Capt Collins: ‘We’re 26 miles north. We’ll have to climb out of it’.
12.49:35 Mulgrew: ‘You can see Ross Island? Fine.’
12.49:38 F/O Cassin: ‘You’re clear to turn right. There’s no high ground if you do a one eighty.’
(Collins was happier turning left.)
Capt Collins: ‘No.. . negative.’
GPWS.
12.49:48 F/E Brooks. ‘Five hundred feet’. (RadAlt)
GPWS.
F/E Brooks. ‘Four hundred feet’.
Capt Collins: ‘Go around power please’.
Impact.

[Desert Dingo]

Forget:
you make a good point, but I don't think your interpretation of the Erebus flight engineer's comment is valid.
Can I ask you to read Garry Parata's article at
Gary Parata's Article Page 1 (http://www.erebus.co.nz/Investigation/TheCVRTranscriptControversy/GaryParatasArticle.aspx)
where you will find (page 4)
Time
0048:55 ...have we got them on the tower?
No...I’ll try them again
0049:24 I don’t like this
0049:25 have you got anything from him?
no
The “I don’t like this” comment was voiced by the duty flight engineer, and Cooper says the tone and inflection indicated considerable concern.
It fell within the above exchange between the pilots regarding the lack of VHF communications with “Ice Tower.”
Again, the context must be examined in order to correctly interpret the meaning of this passage, rather than assuming theories of “mounting alarm” from the flight engineers being ignored by the pilots. If that had been the case the flight engineers would not have stopped issuing warnings until the pilots acted. As this did not occur it strongly suggests a less immediate reason for the comment.
It is likely that the duty flight engineer was referring to the exchange between the pilots and was simply expressing his unease that, contrary to expectation, no VHF communications were taking place. To put it another way perhaps, if the engineer had issued a warning the “crew loop” would have required that the flight engineer qualify the statement by clearly defining exactly what was bothering him, and then suggesting a course of action.
This second example serves as a further graphic reminder to leave CVR interpretation to the experts:

Same words, but a completely different meaning.

[forget]

Desert Dingo, I take your point, and we’ll never know one way or the other.

However, I do think that any ‘pilot in the street’ would question the ‘likely’ conclusion below on the FE’s ‘I don’t like this’.

If that had been the case the flight engineer would not have stopped issuing warnings until the pilots acted. As this did not occur it strongly suggests a less immediate reason for the comment. It is likely that the duty flight engineer was referring to the exchange between the pilots and was simply expressing his unease that, contrary to expectation, no VHF communications were taking place.

I can’t accept that lack of comms, alone, prompted the FE’s remark. Why would it? Is it not more likely to have been the trigger - the last straw - in the FE’s increasing discomfort.

As I say, we’ll never know one way or the other. But with 20/20 hindsight, and it’s reasonable to say that the FE wasn’t the only one feeling uneasy, all it would have taken was another crew member to agree, ‘I don’t like it either - lets go’.

Erebus, like the Kennedy assassination, leaves you in no doubt where you were when you heard about it.

[ZK-NSJ]

wasnt one of the crews houses broken into after the crash, and items removed from a planning folder?

[prospector]

When the Flight Engineers comment is aligned with the fact that they had no DME lockon, no radar contact, and no VHF contact, the scenario that forget suggests is a much more likely to be the correct one.

"I can’t accept that lack of comms, alone, prompted the FE’s remark."

After all, he only had 24 seconds from the I don't like it to calling 500ft of the RadAlt. Not a lot to suggest any different plan of action.

[ampan]

Desert Dingo #120: “I thought the track went down the middle of McMurdo Sound” is not necessarily inconsistent with “I thought the track went direct to McMurdo Station”. The statements would be inconsistent if the witness knows that a direct track from Cape Hallett to McMurdo Station goes over Ross Island (ie, does not go down the middle of McMurdo Sound). In order to know that a direct track from Cape Hallett to McMurdo Station goes over Ross Island, you need a map showing Cape Hallett, McMurdo Station and Ross Island.

The Radio Navigation Chart (McFarlane p81) is of small scale, does not identify Ross Island by name and, in any event, is what it says it is: a map for radio navigation purposes.

NZMS135 (McFarlane pp 90,91) is a topographical map showing all three positions, and containing an inset map of the area around McMurdo Station. But this map was not available at the briefing. The map used at the briefing was a photocopy of the inset (McFarlane p37). The inset does not show Cape Hallett, so the map can’t be used to picture the track from Cape Hallett to McMurdo Station in relation to Ross Island.

The point is that it was possible for a pilot attending the briefing to leave with the impression that the track was direct to McMurdo Station, and that this track would take the aircraft down the middle of McMurdo Sound, with Ross Island to the left.

[ampan]

I don't see the relevance of the "I don't like this" comment, because within 6 seconds of it being made, the captain had decided to climb out - via a left turn.

[prospector]

Perusing the Gary Parata article I find this quite suprising.

" Consider this exchange:
Time 0039:49 Having a bit of radio trouble at the moment
Have you got the squelch off?
Clearance to go down.
Say again?
Have you got the squelch off on that?
Time 0039:58 Yes, on both.
This exchange showed that the crew were actively troubleshooting the reasons why short-range VHF communications from “Ice Tower” 8 were not being received. The crew were utilising their wealth of knowledge and experience to resolve the anomaly. The words are clear and unambiguous, and were signed off unanimously by the CVR Group as having definitely been spoken."

Wealth of knowledge to ask if the squelch was off???

One would have thought that the wealth of knowledge would be trying to ascertain why there was no radar contact, no DME lock on, no VHF contact from a station that was, if they were where they thought they were, no more than, how many miles away???, over flat ice.

[ampan]

Forget about that stuff, prospector. It will be put down to "Monday Morning Quarterbacking".

It seems obvious - in hindsight.

[prospector]

Beg to differ there ampan, this new website was presumably constructed for the education of the layman. The passage I have quoted, to me, is pure spin. To any knowledgable, experienced person it may seem obvious, so why was it put on this website the way it is??. to influence people into agreeing with one interpretation of the facts perhaps???

[Steve Zissou]

This is like being at a tennis match: ampan, prospector, ampan, prospector ...:ugh:

[Desert Dingo]

ampanThe point is that it was possible for a pilot attending the briefing to leave with the impression that the track was direct to McMurdo Station, and that this track would take the aircraft down the middle of McMurdo Sound, with Ross Island to the left.Not so. That idea is flatly contradicted by the discussions about having to make a left turn from the waypoint in McMurdo Sound, then estimating the track and distance required to get to McMurdo Station.
The briefed track was not direct to McMurdo Station, regardless of how much you or the airline wish it were so.

[stillalbatross]

So all on here would have done the same and descended based on the company SOPs and the weather at the time. Apart from about 3 of us. Or are you all saying Collins and crew weren't at fault but nor would you have descended? I am confused.

I am still confused as to why you would all descend based on an INS that could have already been 10 or 20 miles out but still have been "in tolerance".

[ampan]

stillalbatross: Because you're in Brian Abraham's "VMC bubble": You'll see the high ground well before getting dangerously close to it.

Dingo: I'm not aware of any evidence about a left turn at the Byrd Reporting Point (or somewhere thereabouts).

PS: Here's the current version of the chart.

http://ortho.linz.govt.nz/antarctic/RossSeaRegions.jpg


If you look at both the main chart and the inset, it is clear that a track from Cape Hallett to McMurdo Station crosses Ross Island. But what if you only have the inset?

[crocodile redundee]

I wonder whether the recent Air France A330 disaster would have been averted by having that "3rd pair of eyes" on the Flight Deck?? (And many other incidents over the years) Progress?? Technological Redundancy?? Not always a positive step forward in Aviation.........
I did hear said that when Airbus were introducing their A320 (2 crew) concept that they were prepared to wear the "occasional" disaster on the type as an unfortunate "Statistic" when relating incidents precluded by having only 2 crew flight decks.
That 3rd pair of eyes is "Cheap Insurance" (had been calculated at $2 extra per pax ticket based on a 130 pax aircraft over a 4 hour sector.) The general public wouldn't bat an eyelid over paying that, knowing the asset it provided to a flight crew overall....

[Brian Abraham]

Because you're in Brian Abraham's "VMC bubble": You'll see the high ground well before getting dangerously close to it.
Not necessarily, due to the limitations of the Mk. 1 Mod 0, electromagnetic detector in the 790–400 terahertz range. In my one and only flight over the ice the limitation was made plain when at 18,000 in VMC conditions we could have flown into the proverbial brick wall without seeing it. The military practice the art of camouflage - seeing without seeing, if you get the drift. I don't know why you are so unwilling to accept evidence provided by very experienced ice people such as compressor stall and P-B. All detectors, whether they be radar, sonar or the human eyeball, have limitations and can be spoofed one way or the other. Training in the detectors limitations can surmount many of the problems, but not all - eg specialist photo interpreters searching for camouflaged equipment.

[Desert Dingo]

ampan Dingo: I'm not aware of any evidence about a left turn at the Byrd Reporting Point (or somewhere thereabouts).Well you would be if you looked at the evidence about what was shown at the briefings.

PS: Here's the current version of the chart.

http://ortho.linz.govt.nz/antarctic/RossSeaRegions.jpg


If you look at both the main chart and the inset, it is clear that a track from Cape Hallett to McMurdo Station crosses Ross Island. But what if you only have the inset? And why would you have only that chart or the inset?
Yep. That is a lovely chart, and you keep referring to it, and it does not have a track on it, which makes it hard to relate to the flight planned track.

However, the evidence shows that the other charts presented at the briefing were:

Strip Chart (annex 1) Topographic chart showing military tracks, including the two down McMurdo Sound to Byrd waypoint and left turn to McMurdo Station.
http://www.members.optusnet.com.au/d.dingo/Annex-1%20detail.jpg

and
(DOD Strip chart Exhibit 165) Shows military route down McMurdo Sound to Byrd waypoint then left turn to McMurdo Station. Similar to Strip Chart (annex 1) but without topographic detail.
http://www.members.optusnet.com.au/d.dingo/exhibit%20165%20detail.jpg

and RNC4 Radionavigation chart showing (among others) direct track from New Zealand down McMurdo Sound to Byrd waypoint where the track ends. McMurdo Station is off to the left of ith inbound track
http://www.members.optusnet.com.au/d.dingo/RNC4-A.jpg


and Exhibit 164. An ANZ Nav department chart with no topographic detail but showing the two military tracks down McMurdo Sound to Byrd waypoint ending at a common waypoint with the track from New Zealand via Cape Hallet.
http://www.members.optusnet.com.au/d.dingo/Exhibit%20164%20detail.jpg

Even the map for the passengers showed a track down McMurdo Sound and a left turn.
http://www.members.optusnet.com.au/d.dingo/Pax_map_detail.jpg (http://www.members.optusnet.com.au/d.dingo/pax)

For you to be convinced that the briefed track was direct to McMurdo Station is contrary to the evidence. For you to believe that any crew member, after being shown these charts, would leave the briefing thinking the track was direct to McMurdo Station defies logic.

Please don’t try to refer us to the Annex J chart which does show a track direct to McMurdo Station and over Erebus. That is the obsolete chart the airline fed to Mr. Chippindale in their initially successful attempt to make it all look like pilot error.
I'll try to make the point once more.
THE BRIEFED TRACK WAS NOT DIRECT TO McMURDO STATION.

[ampan]

Desert Dingo #137: Thanks D. Dingo. Great post. (I wish I could figure out how to do that.)

Starting with the passenger map, I accept that this was available at the briefing, but doubt that it was given any attention. It was obviously not intended to represent the nav track down McMurdo Sound from Cape Hallett and back, because the nav track going back was the same as the nav track going down.

As for the other four maps, they all show a route that turns left at the Byrd Reporting Point. But as you note, that’s the military route, for aircraft landing at McMurdo Station. Obviously, none of the AirNZ flights intended landing at McMurdo Station – which is why none of the flights made any left turn at Byrd. They usually went to the right of track to get a closer view of the coast of Victoria Land, and then turned left towards McMurdo Station, passing the general Byrd location on the way.

But the real point is that the pilots at the briefing were expressly told that they would not be flying the military route. Even Capt. Gabriel accepted that this was said.

Another point: Although the strip chart is obviously a topographical map, it was not available at the briefing. Rather, it was one of the maps provided on the morning of the flight.

As for Ex. 164, I don’t understand the controversy. AirNZ said it was a working document prepared by the nav section and that it made yet another error by including it in the briefing materials for the 1978 flights. Is that explanation not plausible? All anyone needs to do is look at the document. Would anyone draw any conclusions about the nav track from a “chart” like that?

When you refer, in red capitals, to the “briefed track”, what do you mean? Do you mean the track shown on a couple of handouts? So does a briefing consist of the receipt of handouts? So why not simply mail the handouts to the pilots and let that constitute the briefing? You have to consider the whole briefing exercise: Slides with accompanying audio, plus the verbal information from Capt. Wilson, plus the subsequent simulator session conducted by Capt. Johnson.

For the sake of argument, let it be assumed that Capts. Wilson and Johnson are the liars that they are alleged to be, and that both were prepared to risk several months in prison (for … and I’m struggling here … in Wilson’s case, to keep his post-retirement briefing job at half the salary that he received before? As for Johnson, to keep on getting that extra 4k per annum, minus lost expenses, that he got for being an executive pilot?) So let’s ignore any evidence from Capts. Wilson and Johnson. Let’s only use the union’s evidence.

Start with Exhibit 12, which was the script that Wilson used to make the audio commentary. This is what the script says, and this is what the audio said:

“A standard route definition will be used employing the From-Via-To format. Enter NZAA then 78S/167E this being the approximate co-ordinates of McMurdo Station.”


Desert Dingo suggests that the above co-ordinates are also the approximate co-ordinates of a point 20nm to the west of McMurdo Station, by the Dailey Islands. Really? The actual co-ordinates of the final waypoint for TE901 were “7752.7S/1665.80E”. If you round those ordinates off to the nearest degree, the result is 78S/167E. The co-ordinates for the Dailey Islands waypoint were “7753.0S/16448.0E”. If you round those co-ordinates off to the nearest degree the result is 78S/165E.

Further, I have the whole of the script in front of me, and there is absolutely nothing to suggest that the waypoint was anywhere other than at McMurdo Station.

Moving on to the pilots who attending briefings in 1978 and 1979, not a single solitary one of them said that “Wilson told us that the nav track went to a point by the Dailey Islands”. The only evidence they gave was either in the negative: “”He didn’t say the track went over Erebus” or it was “We did some rough eyeballing etc.” Not a single one gave any evidence about what Wilson said about the location of the final waypoint. Desert Dingo has done the search, and has come up with nothing. There is no evidence from any pilot to the effect that “Wilson said that the nav track went to a point by the Dailey Islands [or somewhere similar].”

[FGD135]

About this "briefed track":

Nobody seems to be addressing the fact that there were two, fundamentally different tracks in play.

One track was the track that ANZ wanted the crew, for optimum sightseeing, to follow. This track was the "sightseeing track". It was only around Antarctica and would be flown visually (with the AINS disengaged).

The other track was the one that would be programmed into the AINS. This track was the "AINS track" and was purely to get the aircraft from New Zealand to a position from where the sightseeing track could commence.

It would be folly to assume that these two tracks were intended to be one and the same. Mahon seems to have made that assumption and you, Desert Dingo, seem to be doing the same - or have I just misread your posts?

All the discussion I see in this thread about "the briefed track" fails to differentiate between the two.

Of course the passenger handout will show the sightseeing track. Of course the briefing will include detail as to where the sightseeing track should go.

The briefing should also have included some detail on the AINS track - given how fundamentally and conceptually different it was/is to the sightseeing track. Whether the briefing did or did not include this information seems to be in hot dispute.

I find it difficult to believe that the briefing would not have made references to the AINS track. The transition from the AINS track to the sightseeing phase - thence back to the AINS track was surely a significant aspect of how the flight would be conducted.

If I had been at the briefing and been told that the AINS track terminated at a point 27 miles west of McMurdo Station, I would have been asking "why does it terminate there? That makes no sense. It should terminate at the McMurdo Station TACAN".

Collins seems to have realised that the two tracks may have been different - hence his plotting the AINS track for himself the night before the flight.

[Brian Abraham]

But as you note, that’s the military route, for aircraft landing at McMurdo Station. Obviously, none of the AirNZ flights intended landing at McMurdo Station – which is why none of the flights made any left turn at Byrd. They usually went to the right of track to get a closer view of the coast of Victoria Land, and then turned left towards McMurdo Station, passing the general Byrd location on the way.
But they would need to make the left turn in order to carry out the NDB approach should the weather dictate. What each crew actually did was make a judgement that they were in VMC and descended accordingly, just as the fateful flight.

[prospector]

"But they would need to make the left turn in order to carry out the NDB approach should the weather dictate."

But!!!! the WX was below minimums for the only instrument approach approved, basically a cloud break approach to 6,000ft, and the NDB had passed its use by date, not to be used for Apps. It was on but not being monitored.

"just as the fateful flight"

I think you will find that all prior flights had been identified by radar before these VMC descents were commenced.

[ampan]

Brian Abraham: The NDB cloud-break procedure was ‘out and back’, starting from a position overhead the NDB at FL200. It wasn’t a straight-line descent.


FGD135: I agree. Something must have been said by the briefing officers about the nav track. If what was said was inconsistent with the charts or the slides, and if any of the pilots had noted the inconsistency during the briefing, then something would have been said. The fact that nothing was said indicates that that no inconsistency was noted - during the briefing.

The material used during the briefing was inconsistent. The audio commentary indicated that the final waypoint was at McMurdo Station, as did the positioning of the simulator overhead the NDB. On the other hand, some of the slides suggested that Erebus would be to the left of track, and a couple of the charts showed the military track, with Erebus to the left of it.

Why didn’t any of the pilots note the inconsistency? My explanation is that there is no inconsistency unless you know that a track to McMurdo Station goes over Erebus. If you don’t know that fact, then you leave the briefing under the assumption that the track goes direct to McMurdo Station and that Erebus will be well to the left of track. It should also be noted that this is not, actually, my own explanation. I only got the idea after reading the evidence of Capt. Ruffell (McFarlane pp 203-206). Of all the pilots who gave evidence about the briefing, his made the most sense and was consistent in all respects (despite McFarlane’s stupid criticisms of it.)

If it is assumed that Capt. Collins left the briefing under the assumption that the track was direct to McMurdo Station and that Erebus would be well to the left of that track, then things fall into place. The night before the flight, he got out his charts and would have noted within a couple of minutes that Erebus was on the track to McMurdo Station. But when he plotted the track using the ‘Dailey Islands’ flightplan he would have noted that this track had Erebus well to the left – which was consistent with some of the material used at the briefing. So he made an understandable error: He assumed that the indications at the briefing of a track to McMurdo Station were wrong, which caused him to not check the McMurdo waypoint before going below MSA.

The other matter to consider is what happened just before the impact, when Capt. Collins decided to turn left. This decision, to me, is not that of a pilot who is certain that he is in the middle of McMurdo Sound. It is much more consistent with that of a pilot who has been given contradictory information.

Although I’m not a member of the Vette fanclub, his work on sector whiteout can’t be argued with. When TE901 levelled out at 2000, then 1500, feet, they must have seen what they expected to see. But that initial impression would have soon given way to a different impression. For example, the false horizon produced by the sector whiteout would not be behaving like a normal horizon. And once the black reference points on either side were out of sight, the false horizon would disappear (which might explain why F/E Brooks was the first to raise the alarm, given his seat position).

Within a few seconds of F/E Brooks expressing concern, Capt. Collins decided to climb out. Some have asked why he decided to turn if he was certain that he was in the middle of McMurdo Sound: Why not just continue straight ahead on the nav track back up to MSA? My answer would be that both Collins and Cassin knew the standard ‘get out’ drill, which is to go back up through the same airspace in which you came down, because you know that the route will be clear of terrain. In other words, a 180 degree turn, once made, gets you back to where you were.


But why did Capt. Collins decide to turn left?

http://www.erebus.co.nz/Background/TheFlightPathControversy.asp (http://www.erebus.co.nz/Background/TheFlightPathControversy.asp)

[stillalbatross]

My answer would be that both Collins and Cassin knew the standard ‘get out’ drill, which is to go back up through the same airspace in which you came down, because you know that the route will be clear of terrain. In other words, a 180 degree turn, once made, gets you back to where you were.



That makes no sense at all. Was he VFR below with a single mountain, Erebus, to worry about or was he flying around the Antartic Alps when he found himself flying up a Fjord in his C180 and thought I better nip it around in a 180 and get out of here?

You make it sound like he was completely out of his elements in that environment which is why AirNZ made such strict requirements for descent which is why his decision to descend was the wrong one.

That simple. If you handed this accident to someone not familiar with it and substituted DC10 with C180 it would make a lot more sense. How much mountain/alps C180/DC10 flying did he have?

His decision to press on in poor VFR conditions and the CFIT that resulted isn't any different from dozens of accidents that inexperienced pilots find themselves in. As Vette showed he was inexperienced for the conditions he took the aircraft into.

[ampan]

(1) He was out of his elements: Although Capt. Collins obviously knew about sector whiteout ("bit hard to tell the difference between the cloud and the ice") he had no proper training.

(2) The "strict requirements" argument can't succeed, in my opinion. This is where I disagree with Prospector, based on the evidence from the Royal Commission.

(3) There are several matters that fall into the "could have done better" category. But Capt. Collins made a bad error the night before, when he assumed that his nav track would not go to McMurdo Station, after receiving information at the briefing that it did. Part of his job was to be the 'last line of defence' re briefing cock-ups. I accept that he did not have to check everything, but he had to check that McMurdo waypoint, given that the issue had been been raised. Alternatively, he could have stayed at MSA.

[prospector]

ampan,

What would be your belief as to how the flight would have been conducted if the Airline Inspector was onboard??? This bearing in mind that the strict requirements to be met for any descent below 16,000ft, and the requirement for no descent below 6,000ft, were arrived at in consultation between ANZ and CAA. The following from John King's New Zealand Tragedies: Aviation.

"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 only let-down procedure available " and the remainder as has been printed on this thread many times.

These requirements are not subject to any misinterpretation, and there is no doubt the crew were aware of them, which part of the evidence overides these requirements, in your opinion???

[ampan]

Prospector: I can't see anything in the two memos expressly prohibiting going below FL160 before getting to the "let-down" area (ie, behind Erebus). You will say that it's implicit, and it probably is - but what about the previous flights and Capt. Wilson's concession? It's just not clear enough, I reckon, to make it a simple 'breach of a rule' case of pilot error.

[prospector]

ampan,
We will have to differ on that point. I cannot see anything implicit about "Note the only let down procedure available" , reads very much like a definitive order expressly prohibiting any descent below FL160 unless the stipulated requirements were met.

[ampan]

And the transcript of the audio is exactly as you suggest, Prospector.

"We are almost 77 degrees south proceeding from Cape Hallett towards Ross Island at FL330. Mount Erebus almost 13,000 feet ahead. McMurdo Station and Scott Base lie 20 miles beyond the mountain in the direction of grid north.

[new slide]

Now approaching Erebus at 16,000 feet, the minimum sector altitude. In VMC a descent to this minimum altitude up to 50 miles before McMurdo will be found advantageous for viewing."

[trashie]

Air New Zealand to apologise for tragic Antarctica crash

(Reuters/Airbus) Thirty years after an Air New Zealand plane crashed into Mt Erebus in Antarctica during a sightseeing flight killing all 257 on board, the airline will finally apologise to the victims' families.

The apology will be the first to relatives of the victims since the Erebus disaster devastated New Zealand on November 28, 1979. Chief Executive Rob Fyfe is to use the 30th anniversary of the tragedy next Friday to apologise for the way the families were treated after the accident. But he will not apologise for the accident itself or the controversial subsequent investigations, which at first attempted to blame pilot error for the crash.



In a statement released this week, the airline said Mr Fyfe would "speak directly about the lessons learned from the Erebus tragedy and the way in which the airline interacted with the families in the aftermath of the accident".

Jackie Nankervis, who was 15 when she lost her father and uncle in the accident, said an apology would be "a step in the right direction". She said the only gesture from Air New Zealand to her family at the time was a bunch of flowers. All other contact was with the police.



The Erebus disaster, which also killed six Britons, was New Zealand's biggest single tragedy. Sightseeing flights from Auckland to Antarctica were popular day trips at the time, with DC-10s taking passengers on a low-flying sweep over McMurdo Sound before returning to New Zealand.

At 8:20 am on 28 November, 1979, when Flight 901 left Auckland Airport there was nothing to suggest this would be anything other than yet another uneventful flight. The two pilots, Captain Jim Collins and his co-pilot Greg Cassin had not made the trip before but both were competent pilots and the flight was considered straightforward.



The men entered a series of latitude and longitude co-ordinates into the aircraft computer but unknown to them two of the coordinates had been changed earlier that morning. When these were entered into the computer the changed the flight path of the aircraft 45 kilometres to the east which put the plane on a collision course with Mt Erebus.

The navigational error combined with a white out that made it impossible for the pilots to see the 3,794m-high active volcano, Mount Erebus looming in front of them to create the setting for a tragedy it would be impossible to escape.



By the time the plane's altitude device began blaring out a warning the pilots had just six seconds to collision.

The plane hit Erebus with such force it disintegrated, leaving a 600m trail of wreckage.



A one-day Royal Commission of Inquiry 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.

However public opinion has remained divided over who was to blame for the crash. Experts said the new flight path would still have been safe if Captain Collins had not descended to 450m, although he had been authorised to drop to this height.



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 $NZ150,000 (£70,000). The chief executive of Air New Zealand resigned a week after the report was released to the public.

However the counselling systems that swing into place in the aftermath of disasters today did not exist at the time, and the victims' families were offered no help to cope with their personal grief..



Mr Fyfe has been widely praised for his handling of the Airbus A320 crash off the French coast last November when all seven on board died after the plane plunged into the Mediterranean during a test flight.

In a recent letter to the Erebus families, Mr Fyfe wrote: "It was the experience of that accident ... that caused me to reflect on many of the gaps and failings that occurred in the days, months and years after November 28, 1979."

[Lucky Six]

Air New Zealand to apologise for tragic Antarctica crash

(Reuters/Airbus) Thirty years after an Air New Zealand plane crashed into Mt Erebus in Antarctica during a sightseeing flight killing all 257 on board, the airline will finally apologise to the victims' families.
The apology will be the first to relatives of the victims since the Erebus disaster devastated New Zealand on November 28, 1979. Chief Executive Rob Fyfe is to use the 30th anniversary of the tragedy next Friday to apologise for the way the families were treated after the accident. But he will not apologise for the accident itself or the controversial subsequent investigations, which at first attempted to blame pilot error for the crash.

In a statement released this week, the airline said Mr Fyfe would "speak directly about the lessons learned from the Erebus tragedy and the way in which the airline interacted with the families in the aftermath of the accident".
Jackie Nankervis, who was 15 when she lost her father and uncle in the accident, said an apology would be "a step in the right direction". She said the only gesture from Air New Zealand to her family at the time was a bunch of flowers. All other contact was with the police.

The Erebus disaster, which also killed six Britons, was New Zealand's biggest single tragedy. Sightseeing flights from Auckland to Antarctica were popular day trips at the time, with DC-10s taking passengers on a low-flying sweep over McMurdo Sound before returning to New Zealand.
At 8:20 am on 28 November, 1979, when Flight 901 left Auckland Airport there was nothing to suggest this would be anything other than yet another uneventful flight. The two pilots, Captain Jim Collins and his co-pilot Greg Cassin had not made the trip before but both were competent pilots and the flight was considered straightforward.

The men entered a series of latitude and longitude co-ordinates into the aircraft computer but unknown to them two of the coordinates had been changed earlier that morning. When these were entered into the computer the changed the flight path of the aircraft 45 kilometres to the east which put the plane on a collision course with Mt Erebus.
The navigational error combined with a white out that made it impossible for the pilots to see the 3,794m-high active volcano, Mount Erebus looming in front of them to create the setting for a tragedy it would be impossible to escape.

By the time the plane's altitude device began blaring out a warning the pilots had just six seconds to collision.
[FONT='Arial','sans-serif']The plane hit Erebus with such force it disintegrated, leaving a 600m trail of wreckage.

A one-day Royal Commission of Inquiry 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.
However public opinion has remained divided over who was to blame for the crash. Experts said the new flight path would still have been safe if Captain Collins had not descended to 450m, although he had been authorised to drop to this height.

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 $NZ150,000 (£70,000). The chief executive of Air New Zealand resigned a week after the report was released to the public.
However the counselling systems that swing into place in the aftermath of disasters today did not exist at the time, and the victims' families were offered no help to cope with their personal grief..

Mr Fyfe has been widely praised for his handling of the Airbus A320 crash off the French coast last November when all seven on board died after the plane plunged into the Mediterranean during a test flight.
In a recent letter to the Erebus families, Mr Fyfe wrote: "It was the experience of that accident ... that caused me to reflect on many of the gaps and failings that occurred in the days, months and years after November 28, 1979."

He said the most important immediate response to the France crash was to support the families of the victims and learn from the flight safety lessons rather than laying blame.
Air New Zealand to apologise for tragic Antarctica crash - Times Online (http://www.timesonline.co.uk/tol/news/world/article6875627.ece)

[Tee Emm]

A one-day Royal Commission of Inquiry placed the blame for the accident

Mis-understanding somewhere. It should read "one-man Royal Commission".

[ampan]

Fyfe is an oily cock who hasn't even bothered doing any research. All he cares about is short-term PR and how his CV will look when he applies for his next position. As for his performance re the Airbus incident, it made me puke.

[aerostatic]

This is bound to wind a few people up:

Erebus milestone stirs up emotions - National - NZ Herald News (http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10603886&pnum=0)

I think this quote was extremely misleading: So does retired airline captain Ian Gemmell who this month described Mahon as "an idiot".
Gemmell isn't just a 'retired airline pilot' for crying out loud, he was the Air NZ DC10 Chief Pilot at the time of the Erebus accident and directly implicated in the 'cover up' by Mahon.

[FlyBoy737800]

Approaching the 30th anniversary (28 November) of this crash

I have just watched, “Erebus: The Aftermath”

I was schocked to see how the airline tried to blame the pilots and cover up.

Justice Mahon's, got to the truth but a bigger picture and forces were at work to silence and discredit him.

It makes me cynical, angry and I question what justice is.:mad:

[ampan]

Quite correct. Ian Gemmell was Air New Zealand's chief pilot at the time and he was directly implicated in the alleged cover-up, in that Mahon implied that Gemmell had recovered documents from the ice which then vanished.

If Gemmell recently said that Mahon was an idiot, I would tend to agree. It's also very good to note that "Marshal von Manstein" is still alive and still kicking bucketloads of **** out of lawyers:

"The answers which he gave were unhesitating and positive. When possible, his answers were monosyllabic and he seemed to treat the various counsel with thinly veiled contempt. His lean figure, standing upright with an almost military stance, reminded me of someone: but I could not for the moment remember who it was. I looked at his bronzed, immobile aquiline features, and his close-cut grey hair, and I surveyed his uncompromising demeanour. Then I remembered who it was that the Captain reminded me of. In his general appearance, he was very similar to photographs I had seen of the celebrated Field Marshshall von Manstein, probably the most brilliant commander of the present century. And as the hearing went on, I came to see that his similarity to the Field Marshall was not exclusively visual." ('Verdict On Erebus', p84)


[Here's one for the conspiracy theorists: Mahon fancied Gemmell and requested a "date". Gemmell told Mahon to **** off. Mahon responded with his famous report.]

[Dick N. Cider]

When I started this thread it was to let people know the Erebus site built by NZALPA was up. The debate here has been largely circular for some time now and people will believe what they want to believe.

If there is substantial material missing from the site by all means contact NZALPA and let them know. They were keen to have the information publicly available so that people could reflect on what happened, and make sure that lessons learnt were not forgotten. I don't think anyone can debate the importance of this accident and the subsequent investigations in shaping a vast range of standard operating, disaster recovery and investigation procedures.

The site will never be comprehensive in the true terms of the word but it does represent what is arguably the single best repository of available information available to Joe Public. Read it, draw your conclusions and move on.

DNC

[Remark810]

Out of interest anyone know who maintains aeronautical charts for Antarctica?

[compressor stall]

That depends where you fly.

USAP produces its own approach charts for McMurdo and Pole. These are not publicly available. AirServices Australia publish publicly the Casey / Wilkins GPS/NPA. I'm not sure of the current status of the approaches and aids at Marambio on the peninsula. There is a NDB at Rothera too.

There are a number of published VFR only approaches for some bases in Antarctica (eg Troll).

And that's about it for approach charts. As for large scale maps:

6 GNCs cover the continent - order here NACO Product Catalog - Antarctica (http://www.naco.faa.gov/ecomp/Catalog.aspx?a=AERO+NIM+MISCDOD+GNC+AY) (note the recent chart dates :p).

Additionally each national sector (may) publish its own maps in WAC format or similar. These vary significantly in age and in many cases have either never been published or once only back in the 60s...

There is recent highly accurate satellite digital elevation data around but this has not found its way into any published maps yet.

[slamer.]

Erebus crash remains a mystery


4:00 AM Saturday Nov 28, 2009

One of the mysteries of the Erebus crash not understood by many is how Captain Jim Collins and his crew could fly into the side of the mountain in broad daylight with good visibility.
Paul Davison, QC who represented the Collins family and the Pilot's Association at the Royal Commission describes what happened: "He had been insidiously tricked into believing everything was safe by all of the systems he was using and all the resources he was using including
his eyes."
The phenomenon Collins came up against is known as sector whiteout - a situation, says Davison, where you maybe operating in clear air, but your eyes are not able to provide surface and distance definition because the diffuse light can create a convincing ocular illusion.
When the decision was made to descend Davison says Collins, like any pilot, was concerned to use his vision to maintain terrain avoidance and keep the aircraft in a safe location.
This would involve him looking to identify features of landscape and topography of the area.
"Believing that his aircraft was in the centre of McMurdo Sound he would expect to see an expanse of flat sea ice to South."
Which is what he saw, but even so, in making his descent he was ultra cautious by adhering to his Nav track and turning the aircraft first to the right before proceeding back to the north where he had just come from.

In making his decent he undertook a descent pattern which ensured he kept the aircraft in clear air over the flat sea ice and only then did he recapture the Nav track to proceed south.
"What he is doing is covering territory he knows it is safe to descend into." As Davison points out, for aviators, one's eyes are one's protection and insurance in these circumstances. "That is the great irony because here his eyes deceived him. The intersection of the overcast with the mountain and the gradation of shade would have given an illusion of an horizon many miles away when he was actually looking at the slopes of Mt Erebus which would have been only several miles away." At that point he went under the overcast cloud, but remained in clear air.
It didn't help either that Air New Zealand pilots hadn't been briefed on what whiteout conditions were. "Had he been briefed to understand the risks of proceeding under overcast he wouldn't take that risk without the appreciating the danger." The insidious nature of these deceptions lead him to believe his understanding of his location was accurate.
His navigation system told him he was on course. "He believed it was flying him down McMurdo Sound - and if adhered to his Nav track he could ensure the aircraft was in a safe location."
Collins also used his eyes and those of the people on the flight deck - in particular Peter Mulgrew who had been to the Antarctic on a number of previous occasions and knew McMurdo approach route well.
Land forms left and right were identified from the flight deck which appeared to confirm their location of flying down the centre of McMurdo Sound.
What they didn't realise was the landforms they were seeing were actually located either side of Lewis Bay on the northern side of Ross Island and they were on a collision course for Mt Erebus.
The crew has previously been talking to McMurdo Station by high frequency radio and had been offered a radar directed flight in the vicinity of McMurdo, but as the aircraft gets closer, Collins finds he is not receiving line of sight radio communications and lock on to a navigational beacon as expected.
Increasingly concerned at this failure to make radio contact, Collins decides to climb away. Despite the mountain's proximity, even then it could not be seen and tragically he was too late.

[ampan]

Chippendale Report, p99:

"Eight seconds prior to impact and 2 seconds before the GPWS warning started, the roll mode FMA changed from NAV track to Heading Select, as the Heading Select knob was pulled out. This would be done to turn the aircraft through the autopilot and followed a discussion by the pilots on which way to turn to get out of their present position. The co-pilot said "it's clear to turn to the right" but the Captain contradicted him. Immediately the Heading Select knob was pulled out the aircraft commenced to roll to the right. This right roll was also evidenced by the movement of the ailerons and spoilers which reached a maximum of 11 degrees bank 3.5 seconds before impact. The roll was then reversed, as the pilot attempted to commence a left turn. This reverse role which was the result of control surface movement, results in the aircraft striking the ground while rolling left through a wings level attitude. These rolling manouvres had no effect on the aircraft heading which was last recorded as 358.95 degrees grid."

If the captain throught he was in the middle of the sound with Erebus to the left, and with his co-pilot telling him that it was clear to turn right, then why did he turn left? None of the 'believers', Capt. Davison QC included, has been able to explain that one.

Explanation: Various pennies started to drop, which included a recollection of the statement made at the briefing that the track was to McMurdo Station. If you're on that track 27 miles out, the only way out is to go left.

So he got that bit right, but he should never have gone below MSA without first checking that final waypoint, especially given the contradictory information he had received about it. If that wasn't an error, then I don't know what is.

One disadvantage of being dead is that you can't defend yourself. But there is also another disadvantage: You can't put your hand up and admit that you made a bad mistake.

[reubee]

When I started this thread it was to let people know the Erebus site built by NZALPA was up. The debate here has been largely circular for some time now and people will believe what they want to believe.

If there is substantial material missing from the site by all means contact NZALPA and let them know.


So what are the outstanding mysteries that 30 years on would require a deathbed confession.

what happend to the pages in Collins notebook?
why didn't the US Navy ATC personnel want to testify? were their tapes erased acidentally or on purpose?
if their was an 'orchestrated litany of lies', who was the puppetmaster. Morrie Davis, or was he the fall guy for Des Dalgety?
if the CVR was analyzed today, would new technology decipher it better?
were all the passengers camera films examined? were there any shots that showed the view to the south as they orbited that were disregarded because they were perceived not to show anything?
Was a passenger filming on a movie camera at point of impact?
if you put some cameras on a UAV and got it to fly the circuit over and over throughout the summer, would you get some footage of conditions as they were that day?

and having watched Erebus: The Aftermath on tv1 last 2 days and what was a whos-who of NZ Actors twenty years ago, Was that a youthful Jim Hickey playing one of the pilots with a 1 line speaking role?

[DozyWannabe]

I remember watching "Erebus : The Aftermath" as a kid when I was home sick from school in about 1989/90, and being fascinated by the subject. For years and years I did a lot of reading on the subject and had a nostalgic trip down memory lane when I found the YouTube upload and the NZALPA website.

While the fundamental argument that a pilot should be aware of where he is at all times is fair, the fact is that there is scant, if any evidence to believe that Captain Collins thought he was anywhere other than over McMurdo Sound.

Several things in the story proposed at the time by ANZ simply don't make sense, and Mahon was quite justified in believing it likely that someone was trying to pull the wool over his eyes. The only thing he was censured for was stating this belief as plainly as he did - his investigation and conclusions regarding the accident were never in doubt, though the full force of the New Zealand Government and Air New Zealand's PR operations did their best to claim that the censure for the former invalidated the latter - quite successfully it would seem, given some of the posts on this thread.

The meat of what Mahon was saying was that there was a fundamental organisational failure at ANZ, and in Civil Aviation, in the time leading up to the crash - to whit:

1. For whatever reason, the 1977 and 1978 requirement that any captain taking an Antarctic flight should first take a familiarisation flight down there was rescinded for 1979. By all accounts, ANZ simply said they weren't going to require it anymore, and Civil Aviation acquiesced.

2. While the initial, manually navigated flights did indeed have their final waypoint a route that took them over Mt. Erebus, in all cases the weather and visibility were good enough for the crew to take them off that track and fly the McMurdo Sound route. It should be noted that Mahon was of the opinion that the initial waypoint and route directly over Erebus could not be justified under any circumstances for a sightseeing flight and should never have been approved in the first place.

3. Chief Navigator Brian Hewitt of Navigation Section made a gross error when he miskeyed the waypoint - he simply did not perform the final re-check as required by the standards set by the company, and for 14 months the computerised track took every single ANZ Antarctic flight down McMurdo Sound, and because that route was very close to the military McMurdo Sound route that the line pilots had been flying visually prior to computerisation anyway - to the line pilots it seemed like a perfectly logical waypoint.

3. In any case, the only department of ANZ that continued to believe that the route went over Erebus was the Navigation Section themselves. Every single line pilot that flew the route testified to the fact that the route took them down McMurdo Sound, and at least some, if not most of the briefing materials given Captain Collins indicated that route, and not the route over Erebus. Now, here's where things get tricky - because all the hard copies of the briefing materials other than the few provided by Captain Gemmell (which could be argued supported ANZ's claims) were either lost on the mountain, lost in transit, or possibly destroyed (see the story about Captain Collins' ring binder, recovered at the site intact, yet reappearing at the commission with the pages missing). All briefing materials bar one indicated the McMurdo Sound route, or an approximation of that route - and upon cross-examination Chief Navigator Hewitt was "very surprised" that these documents indicating the McMurdo Sound route constituted part (in fact a majority) of the briefing materials.

4. Regardless of the reason - Navigation Section updated the computer track only hours before Captain Collins and his crew took TE901 off the ground and failed to tell them. Collins may have plotted the route on the maps at home using the numbers he had - but they were the old (incorrect) numbers. Now it could be argued here that he should have cross-checked the new numbers with the old - and logically this was an oversight. But the prevailing culture at ANZ at the time, as testified to by the line pilots, allowed pilots to safely assume that the co-ordinates given at the briefing would be the same ones they'd be flying. This right here is a major systems failure, and, Mahon (IMO rightly) considered, the fundamental cause of the accident.

5. Prior to this you had a situation whereby the national carrier and the Civil Aviation authority of New Zealand had a relationship that some would say was too cosy. And you also had Prime Minister Muldoon as the majority shareholder in the national carrier, and a personal friend of ANZ's then-CEO to boot. Had this not been the case, I suspect the reaction to Mahon's findings would have been very different.

In any case, it transpired that the minority decision by the Court Of Appeal censuring Mahon (for his language regarding the "litany of lies" remember - not his findings), was taken by two judges who had children working for ANZ at the time. After the report was published, ANZ also released the minutes of meetings taken directly after the accident which revealed that the board and senior pilots were well aware of the discrepancy in the nav track, and yet denied this publicly and to Mahon himself - proof they were indeed lying. But because this evidence was not entered in the original Commission (ANZ took the request for documents to include those up to the time of the accident - again pretty convenient), this could not be produced either during the Appeal, or to the Privy Council.

Finally, Chippindale himself said in 1989 that Civil Aviation was actively trying to avoid a large insurance payout, and while he stood by his report, it was relevant.

[stillalbatross]

So Dozywannabe, with the TACAN out on the day, can you find me another airline that descends below MSA based solely on what the IRS is telling them? Another airline, anywhere in the world? Can you find me a navigation systems maker who made a prelaser gyro system and claimed it never required updating?
On the day, with the correct co-ordinates, that aircraft still could have hit terrain if the IRS had wandered and there was no Tacan to do a position update.
Yes, the company panicked and did some stupid things subsequent to the disaster but it was very poor airmanship that put the aircraft at an altitude where CFIT could take place.
If an engine caught fire due to incorrect assembly, as a crew do we put the fire out and land somewhere safe or do we crash and say the engine shouldn't have been on fire?
Descending below MSA, under radar, does basic airmanship still dictate we check our position?

[burty]

So Dozywannabe, with the TACAN out on the day, can you find me another airline that descends below MSA based solely on what the IRS

If you're VMC why not?

[DozyWannabe]

What burty said - don't forget that ATC cleared them for descent under VMC, and they were not in bad weather at the time - as was proven by the photos and film taken in right up to the second the aircraft hit. Chippindale got that dead wrong.

In answer to your question, probably not nowadays. But the 1970s were a whole different kettle of fish, as you should well know.

[prospector]

"Chippindale got that dead wrong."

That statement is dead wrong. Before you make statements like that, get hold of the known, undisputable facts.

This is what the Company orders were for that flight, there is no doubt the crew were aware of these requirements, a copy was found in the cockpit after the crash.

" Delete all reference in Briefing dated 23/10/79. Note that the ONLY let-down procedure available in VMC below FL160 (16,000ft) 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 120degrees Grid through 360G to 270G, from McMurdo Field, within 20 nm of TACAN CH29.

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


You will note that this is the ONLY let down available.

Which of these requirements was complied with??

You should also be aware that the requirements as stated was to cover the fact that this crew were completely inexperienced in AntArctic operations, in fact the only one to have been down to the ice was one of the Flight Engineers.

You no doubt know, that all other operators required a minimum time as First Officer, observer etc before going down there in command.

The weather at McMurdo was below requirements for the only approved let down procedure. To go and invent your own let down procedure, especially when at no time Mt Erebus was ever sighted, is surely the hight of folly, and the end results were exactly what the approved descent procedure was designed to avoid.

[Graybeard]

I heard or read at one time that they didn't have a chart in the cockpit even as good as a National Geographic map of Antarctica. Not so?

GB

[DozyWannabe]

This is what the Company orders were for that flight, there is no doubt the crew were aware of these requirements, a copy was found in the cockpit after the crash.
No, the company said that's what was found in the cockpit after the crash. Certainly some things that were found in the cockpit after the crash disappeared or were destroyed, while the company was running every document that didn't support their position through the shredders.

The whole thing stunk like a boathouse at low tide and the company execs were trying to save their own skins at the expense of good men.

Graybeard - Captain Collins took an atlas with him with his intended route marked on it (having marked it out on a large-scale table map the previous evening) - his wife and daughters testified to this. The atlas was never found, or was disappeared because it would have been devastating to ANZ's case.

[prospector]

DozyWannabe,

I suppose Elvis told you all this, while you were on your way to take possession of the Sydney Harbour Bridge that you have just purchased for an unbelievably low sum.

[Fantome]

Anyone who has read all prospector's views and arguments on this subject knows that he has much detailed insight. But that does not make him a complete authority, and to be so sarcastic adds little to the standard of debate.

[prospector]

Fantome,

Perhaps you are correct in that the sarcasm was uncalled for BUT

"don't forget that ATC cleared them for descent under VMC,"

Did they?? when can a controller CLEAR anybody for descent below route MSA before they have been identified on radar??? the flight was never identified, and by definition requesting a VMC descent requires you, and tells the controller, you can maintain own separation from other traffic and TERRAIN.

"
"No, the company said that's what was found in the cockpit after the crash"

Really?? That is where Elvis comes in. Can he, or anyone, prove that this is only because the Company said it was?? It was in fact a Company memorandum to AntArctic crews dated 8 Nov 1979 OAA:14/13/28. and it was advising that the McMurdo NDB was not available, and it stated as has been posted in this thread many times, the ONLY let down procedure available.

The weather and belief as to position.
"
"the fact is that there is scant, if any evidence to believe that Captain Collins thought he was anywhere other than over McMurdo Sound."

If the crew had of noticed, in this good weather, as it was at the time and place, photo's are available showing Beaufort Island quite clearly, but if they were on the track they thought they were on, they were on the wrong side of the island, hard to mistake that Island, it is the only one there.


"as was proven by the photos and film taken in right up to the second the aircraft hit. Chippindale got that dead wrong."

Really? Less than 4 minutes before impact, Mulgrew told the pax "I still cant see very much at the moment, keep you informed as soon as I see something that gives me a clue as to where we are".

This was the positional awareness as the aircraft was in a descent at more than 265 kts, that descent going down to a little under 1500ft.


To be told that the Chief Aircraft Accident Inspector was "Dead wrong"
and that Mahon got it all correct I must admit makes me a little sarcastic.

[Casper]

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.

[Dark Knight]

Mods

This continually goes around and around over the same old ground proving little to any, satisfying nil.

Plus more than a little out of date; surely more than time for the Aviation History and Nostalgia Forum???

DK

[Fantome]

Cannot agree. There are still aspects of the flight/crash/investigation
that have not been thoroughly examined. Such as the anomalies between
the FDR and CVR that on circling and descent have unaligned time references. Also passenger photos and videos not as yet subjected to thorough forensic analysis. Some there are, largely working quietly on their own, striving to put together sufficient evidence to warrant a full reappraisal. Never close a case if there is any possibility of revealing hitherto unconsidered evidence.

[Dark Knight]

Not so.

There have been the investigations and inquires, the evidence has been re-examined there and here many, many times where some remain unconvinced and probably will forever.

The investigations, the inquires have been done, recommendations made and implemented to prevent further or similar accidents in the future. That is the nature of aviation and it is time to move on better using our energies and resources preventing other incidents in the future, not wasting them futilely rehashing, rehashing the past.

It becomes like roadside memorials; attempts to pass the grief and guilt to others whilst, within days, the flowers rot and putrefy leaving a blight on the landscape: continued spurious searching for `answers' achives little except extending the grief of those involved.

Time to let them rest in peace.

Move On!

DK

Mods; the lock or Aviation History and Nostalgia Forum?

[Fantome]

It's not about unresolved grief. It's not about rotting flowers or 'moving on'.
It's about questions based on the long and searching review of all published material that is still being undertaken by individuals who have no axes to grind, but can see with a forensic clarity not available to all who were involved in the official process. What transpires for this thread is neither here nor there.

[bushy]

Dark Knight
Some were saying that after the Chippendale investigation.
But subsequent information and events have proven that further investigation was indeed appropriate.

[jafa]

It was a long time ago and none of us were there but:

Failed to mark the waypoints off on the chart. (They MUST have had some sort of chart)

Didn't do a track check out of the last waypoint (Mt Hallet?)

Sent the spare pilot back and kept the spare engineer in the cockpit for the lo-level bit. (Big mistake. Gotta be.)

Relied on the INS which they knew at that stage could have been 15 miles out.

What was the weather radar picture?

Didn't ping on the no VHF, no radar contact, and where is this mountain which is supposed to be fifteen miles away on our left??

Feel free to pick me up on any of that if you feel like it, anyone. !!!!!!!!!!!

[nortwinds]

There is similar current debate on the South Asia and the Far East Forum on continuing to try and resolve the SilkAir MI 185 tragedy as more detail gradually comes into circulation. There are similarities in the two cases, or more correctly of their investigation, and until they are finally resolved then the full lessons are not learned and the circumstances not guarded against in future.

[Graybeard]

Jafa:Didn't do a track check out of the last waypoint (Mt Hallet?)

Relied on the INS which they knew at that stage could have been 15 miles out.

What was the weather radar picture?


It's been a long, long time since I looked at this. Isn't Hallet some 200 miles back? A 10 mile or whatever difference in next wpt would be on the order of 3 degrees. Is that enough to trigger concern? There might be that much error reading the HSI.

The AINS-70 did triple inertial mix before the term was invented by Litton in their later LTN-72. From the 5 hours or so since last AINS position update near Christchurch, the position error was about 1.5 miles. ANZ and other KSSU configuration DC-10 operators had always seen that kind of accuracy. The crew had little reason to question the Nav system, and they obviously never checked the lat/long in their flight release against a good chart. In fact, it was the over-reliance on the AINS by the pilots and the company that resulted in complacency.

Whose responsibility was it for the pilots to have good charts appropriate for the route? The QF 747s flying Antarctica at that time didn't have AINS-70, just triple INS. What charts did they have as backup?

The RDR-1F Wx radar in the ANZ DC-10 fleet would paint only a thin line when presented with a steep mountain from 1500 feet altitude. It would have been useful before they descended, however.

GB

[jafa]

Thanks Graybeard.

I actually looked it up. Cape Hallet to McMurdo is 337 n.miles, a track check 15 minutes into that leg would have shown a cross track error of 4 or 5 miles or thereabouts - enough to get your attention, I would've thought.

Tks for the heads-up on the INS - I was going on the Carousel figures, dimly remembered. Allowable drift three miles per hour plus three, I think it was.

Chz.,

Jafa.

[jafa]

Me again.

The radar should have shown a shadow of the mountain??

Radar returns from sea ice in my experience are generally excellent.

Jafa.

[Graybeard]

I don't remember the procedure at Hallett? Did they turn to a new track? At any rate, their flight plan gave the track direct to McMurdo Station, and not the reporting point over the Ross ice shelf. The track angle difference is only 1.7 degrees. What document did they have to compare the new, wrong track to the prior, correct track?

Radio altimeters are C band, and cannot reliably track the surface of the ice, so I'm told. Some of the 1979 generation of Wx radars were C band, also. ANZ had X band in their DC-10, which should detect ice better. In fact, they use two different frequency radars to measure the depth of ice.

I don't remember there being any evidence the WXR on this flight was even energized, nor any comments recorded on the CVR.

There are so many ways this accident could have been avoided, yet I believe this one is the first that could be at least partly attributed to "Stick to the automatics, son; hand flying is for the birds." I referenced this thread in that one.

I further believe the blind reliance on automation was largely overlooked in both investigations.

GB

[workingman303]

Still don't see how anyone can claim that descent down to 1500ft in an area that has a substantially higher MSA and doing it solely based on what the INS is telling you is normal practise.

Like to hear someone telling me about how they switch off the GPS updating and delete the VORs and fly non precision approaches on a regular basis.

A reliance on the aircraft's nav system that is unbelievable.

[jafa]

Thirty degree track change at Hallet. Document? The chart. I would've thought they would mark the position on the chart 10 or 15 minutes past Hallet as per normal ops for random track operation. To check for cross track error. However they clearly hadn't checked the flight plan waypoints against the chart to begin with, as you said. Big Error number One.

You are in front of me re the radar technicals. But I would most certainly have had it on. Amongst other things to check for the mountain. Situational awareness back-up.

Couldn't agree with you more re the automatics.

Chz., Jafa.

[J52]

Some personal recollections which adds nothing to who was right or wrong in this tragedy and makes no judgements either way.

I had just finished my first marathon and was at the after race function when the provosts turned up and ordered us all down to a hangar. A couple of C130's were backed up to the doors and piles of survival gear and body bags on the hangar floor. We were told to size ourselves up for a survival suit and standby but not told why. News came through that an ANZ DC-10 was overdue in Antartica and we were going down on a SAR flight leaving within an hour (which I was not looking forward to, I could hardly walk after the marathon and sitting in a C130 para seat would not have been an optimal recovery).

About 2 hours later word came through the DC-10 had been found and no survivors and that NZ Police SAR would take over. I had a friend who had recently joined the Police and he ended up down there doing the recovery (and which he suffered for years afterwards from).

30 years on and it remains as vivid now as it was then. I seem to recall that ANZ had not had a fatality up until this accident (although NAC was not so lucky) and that they had commissioned an advertisement with Allan Wicker stating this fact which aired a few weeks beforehand. The look on Morrie Davis face when the journalist asked him how felt in that evenings news bulleting remains etched in my memory as does his response.

It is right to discuss these matters as it honours the memories of those who perished and the families left behind. May they rest in peace.

[DozyWannabe]

Still don't see how anyone can claim that descent down to 1500ft in an area that has a substantially higher MSA and doing it solely based on what the INS is telling you is normal practise.
For a regular flight of course not - and probably not for sightseeing flights now, as a result of lessons learned. But every pilot that flew that route prior did just that, and they were allowed to as long as the visibility was good - which as far as the accident crew was concerned, it was.

Regarding the weather radar, I believe Mahon went to visit Bendix, where he discovered from the manufacturers concerned that the atmosphere in the region is too dry, weather radar being reliant on atmospheric moisture, to make it useful as a warning for terrain at that altitude. The radar return would, unfortunately, only have confirmed what they believed they were seeing - a flat expanse of sea ice to the horizon.

And as has been stated before many times, the captain did indeed check the waypoints against charts the night before - in fact he showed his daughters where he was going on the family atlas. Those waypoints were changed in the early hours of the morning they took off and the flight crew were not notified of the change.

Regardless of one's opinion of the responsibilities of an airline captain once the aircraft has left the ground, it is important to also bear in mind the responsibilities of the employer to allow their employees to operate safely, and while I'm sure ANZ in the late '70s was not alone in this, there was a staggering degree of corporate complacency going on. Firstly, the rescinding of the rule that every Antarctic flight should have at least one crew member on the flight deck who had been down there before. Secondly, the laissez-faire attitude to the enforcement of MSA on Antarctic sightseeing flights. Thirdly, the failure of the Nav Section to perform a re-check on the co-ordinates fed into the computer, which remained incorrect for over a year - giving line pilots the impression that the intended route was down McMurdo Sound and not over Erebus.

Given sector whiteout conditions, the only clue that the crew would have that something had changed would be the different co-ordinates for the McMurdo waypoint on the printout they were given at pre-flight compared to the materials they'd been given at the briefing - how many pilots check that on a regular basis?

[Graybeard]

The last I knew, Erebus was an active volcano. It wasn't just a mountain of ice.

The investigator was misguided by traveling to Bendix to learn if Erebus showed up on the Wx radar, where he would get only theoreticals and hedging. He would have had only to interview ANZ and QF pilots who had been there using that exact same radar.

GB

[prospector]

"But every pilot that flew that route prior did just that, and they were allowed to as long as the visibility was good - which as far as the accident crew was concerned, it was."

From John King's publication New Zealand Tragedies, Aviation, which has the luxury of hindsight.

From 1987 until the disaster all those pilots had cheerfully flown down McMurdo Sound more or less on the approach path used by the Military Pilots, instead of over Ross Island. The former may have seemed the more logical route, keeping clear of high ground, but the airline preferred its DC10's to stay well away from any conflicting local traffic. In any case it was largely acedemic as all but one flight had approached Antarctica in brilliantly clear conditions and the final letdown was entirely VFR with no need for instrument cloud break procedures.

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

So, we see that not all flights prior did not "do that", and we are also told that the accident crew were well aware that the weather conditions were below that allowed by the company for descent in that area.

- "which as far as the accident crew was concerned, it was."

That statement is quite obviously incorrect.

[Fantome]

. . .. seem to recall that ANZ . . . . commissioned an advertisement with Allan Wicker stating this fact,( that ANZ had not had a fatality up until this accident), which aired a few weeks beforehand.


If this is true it may well be the only time ever that an airline boasted of such a thing. Also seems a swag of bad karma followed Morrie Davis around.

[J52]

Wasn't aware of any bad karma following Morrie Davis around, care to elaborate? I don't think you were meaning Muldoon.

The Alan Wicker commercial might have been pulled before airing in NZ but I am 100% sure it was made. I recall Alan Wicker stating in a news article that this was the first time in his career where he had endorsed an airline (not that he did it for free of course). I saw the advert when in LA.

[DozyWannabe]

The investigator was misguided by traveling to Bendix to learn if Erebus showed up on the Wx radar, where he would get only theoreticals and hedging. He would have had only to interview ANZ and QF pilots who had been there using that exact same radar.
Really? As I understood it, QF took a different route entirely and from the computerisation of the route to the flight before the accident - which would have been for more than a year, remember - all ANZ flights would have followed the incorrect INS track down McMurdo Sound. How would a QF or ANZ pilot have been able to tell him what Erebus looked like on the weather radar when none of them had approached Erebus from that angle?

And prospector, while I haven't read John King's book in its entirety, it would appear from the extracts I have read that it appears a somewhat one-sided account of events.

Also, we'll never know exactly what went on in the cockpit that day due to the limitations of the CVR technology installed at the time, but it would appear that they went below the cloud cover to provide visual confirmation of where they were. The photos and film taken from inside the jet show there were no problems with visibility at all for some time prior to impact, contrary to the theories put forward by ANZ and Chippindale, which suggested they were lost in cloud until the point of impact. As such, King's assertion that

Its unpopularity with the passengers, however, was a likely factor in making Captain Collins more determined to press on to McMurdo when condition were marginal

is thoroughly speculative. And at any rate regardless of weather, the "hard floor" specified by ANZ was routinely flouted by previous flights, and prior to the accident the company was quite happy to distribute material that made that fact clear.

[Dark Knight]

The Holy Grail loosely follows the legend of King Arthur.

Arthur along with his squire Patsy recruits his Knights of the Round Table, including Sir Bedevere the Wise, Sir Lancelot the Brave, Sir Robin the Not-Quite-So-Brave-As-Sir-Lancelot and Sir Galahad the Pure.

The group is instructed by God to seek out the Holy Grail.

They are led to a castle controlled by the French where they believe the Grail is being held. After being insulted in mangled Franglais and failing to invade the castle in a Trojan Rabbit, Arthur decides that they must go their separate ways to seek out the Grail.

Concurrent to these events, in a manner of breaking the fourth wall, a modern-day historian, while describing the Arthurian legend as for a television program, is killed by a knight on horseback, triggering a police investigation.

Each of the Knights encounter various perils on their quest.

Arthur and Bedevere attempt to satisfy the strange requests of the dreaded Knights who say Ni. Sir Robin narrowly, but bravely, avoids a fight with the Three-Headed Giant. Sir Lancelot accidentally assaults a wedding party at Swamp Castle believing them to be hiding the Grail. Galahad is led by a Grail-shaped beacon to Castle Anthrax, populated by only comely women who wish to perform sexual favours for him, but is "rescued" by Lancelot.

The Knights regroup and travel to see Tim the Enchanter, who points them to caves where the location of the Grail is written on the walls. To enter the caves, the group is forced to defeat the Rabbit of Caerbannog using the Holy Hand Grenade of Antioch.

With their final destination known, the group travels to its last peril, the Bridge of Death, where each Knight is forced to answer three questions by the bridgekeeper before they can cross; Sirs Robin and Galahad fail and are thrown into the chasm below the bridge, before Arthur tricks the bridgekeeper. Lancelot becomes separated from Arthur and Bedevere, later shown arrested by modern-day police for the murder of the historian. Arthur and Bedevere travel to the Grail's castle, which they find is already occupied by the French who send them away with their insults.

They amass a large army to prepare to storm the castle, but just as they are ready to start the charge, the police arrive and stop it, arresting Arthur and Bedevere, and putting an end to the film; the search is never resolved nor are further inquiries ever held.

(Apologies to Monty Python however, there are many, many similarities where I shall leave it to readers to apply places and posters names to characters from the film as appropriate to this everlasting tale)

DK

[prospector]

DozyWannabe,

There can be no mistaking what the weather at McMurdo base was at the relevant time, it was well below the minimums required for the approved cloud break procedure.

If you want to use the phrase "one sided" try this for one eyed and one sided.
"From the point of view of both organisations they could obtain, so they believed, absolution from their own numerous errors by merely ascribing the disaster to a failure by Capt Collins to observe the minimum flight level of 16,000ft. This was the principal basis for the case for Civil Aviation Division and, as will be seen from what I have already written, it was in my view a basis without any justification whatever".

Here we have the learned judge, stating, in his opinion, that not complying with the Minimum Safe Altitude, had nothing to do with the "accident".

Most people who have any knowledge of this occurence readily accept that many errors were made by a number of parties, both errors of omission and commission, but the prime cause was the decision to go below MSA, without meeting any of the requirements as laid down by both the CAA and the Company.

The statement by Justice Mahon that the decision to go below the route MSA had nothing to do with the accident shows to me anyway, the folly of appointing someone who had never sat in the drivers seat of any aircraft, to enquire into, and criticize the findings of a highly qualified Aircraft Accident Inspector.


Dark Knight,

You have made your opinions abundantly clear, why then does your brousing bring you back to the thread????

[Graybeard]

Really? As I understood it, QF took a different route entirely and from the computerisation of the route to the flight before the accident - which would have been for more than a year, remember - all ANZ flights would have followed the incorrect INS track down McMurdo Sound. How would a QF or ANZ pilot have been able to tell him what Erebus looked like on the weather radar when none of them had approached Erebus from that angle?

Would you not grant that if Erebus were visible from 100 miles south, it would certainly be visible closer? I don't know what route QF took, but the book "Whiteout" reported QF SLF mooning the McMurdo residents, so they passed close enough to Erebus.

It matters not much from which angle Erebus is approached, it would be either visible under the ice on the radar, or not. Nothing but another transport aircraft with that radar, like ANZ and QF flights, would provide the answer. Still, I have seen or heard nothing suggesting they even had the radar energized.

GB

[Mr Seatback 2]

As an outside observer, and non-pilot, the Mahon report created an interesting perspective on the use of 'company culture' for the basis of determining the cause of the accident.

I've spent much of the day watching - and re-watching - numerous documentaries, research and interviews regarding the Erebus tragedy, as someone who wasn't born when it happened. I'm no expert - nor am I a pilot - so my comments aren't as informed as most on here. However, I have several questions I hope others can help me with:

Note: No judgement on anyone is cast in my post here!

1) While the Chippendale report certainly raised the fact that flying below MSA was the 'cause', it was Mahon's enlarged scope that brought the lack of checks and balances within Air NZ to the fore. It was raised in one of the documentaries (Flight 901 to Erebus) that there had been many documented instances in the media, and in Air NZ's own publicity material, where flights were conducted below MSA. Other pilots - prior to Erebus - had done this as well.

Is it not then feasible - given the circumstances - that 'company culture' played a role in shaping the actions of the crew, not just in the realm of this accident, but in prior Antarctic flights as well? Evidence and submissions showed many contradictions in terms of what expectations and rules crew were to follow.

2) The differences in scope of the investigation (Chippendale vs. Mahon's findings) - as have been noted on here - draw the distinction of a pilot vs. non-pilot making technical judgements in an aviation investigation. However, were it not for Mahon's findings, the many managerial and technical flaws that existed in Air NZ would never have come to light. Also, this breadth of investigation, from my own personal research, seems evident in other accident investigations around the world.

Pure conjecture, but it must be asked: If we relied on the findings of the Chippendale report, without questioning further, would we not be arguing instead about another accident occurring at Air NZ? Another incident involving a flightplan error - however, with the benefit of the lessons of Erebus - was caught on an AKL-RAR flight (termed the '4th December Incident' - had never heard of it before, in the sphere of the Erebus investigation).

I believe it occurred some 8-months after the RC ended?

3) Recently in this forum, much has been made of the Bendix weather radar, and its' ability to pick up ice, etc. The manual for the type of radar installed on the aircraft stated it should not be used for terrain avoidance. Aside from the GPWS (sadly), what other radar systems could the crew have used at the time? Just seems to be disagreement within the forum (not unusual, I know).

[DozyWannabe]

It was raised in one of the documentaries (Flight 901 to Erebus) that there had been many documented instances in the media, and in Air NZ's own publicity material, where flights were conducted below MSA. Other pilots - prior to Erebus - had done this as well.

Is it not then feasible - given the circumstances - that 'company culture' played a role in shaping the actions of the crew, not just in the realm of this accident, but in prior Antarctic flights as well? Evidence and submissions showed many contradictions in terms of what expectations and rules crew were to follow.
Put much better than I could.

The statement by Justice Mahon that the decision to go below the route MSA had nothing to do with the accident shows to me anyway, the folly of appointing someone who had never sat in the drivers seat of any aircraft, to enquire into, and criticize the findings of a highly qualified Aircraft Accident Inspector.
And conversely, had things been left with the Chippindale/ANZ report that focused on the MSA breach to the exclusion of all else, a whole plethora of lessons about company culture would not have been learnt.

The point I was trying to get at, that Mr Seatback 2 has explained so eloquently, is that while a descent in what could have been marginal conditions while relying on INS was a contributing factor to the crash, it was not the first such descent made, and in fact ANZ had been quietly removing layers of safety for two years prior to the accident, and had also been very lax about enforcing the MSA - which in today's world would and should be considered major contributing factors to the accident. That the holes in the cheese created by ANZ lined up on flight it did had more to do with bad luck than especially poor judgement (compared to their peers in ANZ) on the part of the crew in charge that day.

Remember - the only part of Mahon's report that was censured was the language referring to a cover-up. ANZ and Muldoon claimed that the whole thing was vacated, when in fact the report was considered painstaking and a model of its kind in every respect other than that.

[prospector]

DozyWannabe,

"In any case it was largely acedemic as all but one flight had approached Antarctica in brilliantly clear conditions and the final letdown was entirely VFR with no need for instrument cloud break procedures."

You say,

"it was not the first such descent made, and in fact ANZ had been quietly removing layers of safety for two years prior to the accident"

Which is where I disagree. It was the first descent made in marginal weather conditions, we have a record of flights descending below the laid down minima, but they were all carried out in "brilliantly clear conditions".

If you want to break the rules you must make sure everything is going for you, that was possible in Brilliantly Clear Conditions.

[DozyWannabe]

Prospector: "In any case it was largely acedemic as all but one flight had approached Antarctica in brilliantly clear conditions and the final letdown was entirely VFR with no need for instrument cloud break procedures."
The question there is where was King getting his information from? You're talking about a second-hand source with a hefty dollop of opinion thrown in for good measure. I'd be surprised if he personally interviewed every single pilot that went down there over the course of time that ANZ ran those flights - many of whom found ANZ and Chippindale's report hard to stomach, given what they knew was going on, and testified in support of Captain Collins at the inquiry.

If the book is the one I've seen, which is a 300-odd pager referring to all aviation mishaps in NZ over a time period, firstly one would need to look at the sources - was Chippindale himself one of them?

[prospector]

Dozy Wannabe,

This thread has been running for a long time. There have been many publications quoted from, from some very eminent people in the Aviation World, many have not agreed with the findings of Justice Mahon.
I would suggest you start from the beginning of the thread and absorb what has already been scribed.

The enquiry was as to the cause of the accident. All the other errors of omission and commission, of which there were many, would not have made one ioata of difference to the safety of the flight if it had remained above the required altitudes as laid down by the Company and CAA.

To state that it was a sight seeing flight therefor it was acceptable to bend the rules is ridiculous.

[DozyWannabe]

Your presumption that I would stick an oar in without reading the thread is quite depressing.

I don't understand, unless you were an ANZ management pilot of the era, why you're so vociferous in your condemnation of the pilots. ANZ and Morrie Davies were cowards hiding behind a rulebook that they knew was being routinely ignored. Chippindale was just a cat's paw for Davies and Muldoon, who didn't want his only national flag-carrier's reputation tarnished.

[Graybeard]

Mr. Seatback2:
3) Recently in this forum, much has been made of the Bendix weather radar, and its' ability to pick up ice, etc. The manual for the type of radar installed on the aircraft stated it should not be used for terrain avoidance. Aside from the GPWS (sadly), what other radar systems could the crew have used at the time? Just seems to be disagreement within the forum (not unusual, I know).

Well, gee, why does it have that mode named MAP? FYI, it was a very good mapping device. I don't believe the pilots were looking at it. There was a radar indicator mounted just outboard of each pilot's outboard knee, and difficult to observe by anybody else, unfortunately.

While not guaranteed to be accurate in azimuth or altitude, that generation of Wx Radar is reliably accurate in display of distance to a target. It changes the pulse width in MAP mode to be more optimum for detecting terrain, which doesn't scintillate like rainfall. I have confidence Mount Erebus could have been seen on that radar in time to warn the pilots of their position error.

The GPWS primary sensor for terrain is the radio altimeter, whose antennas look straight down from the center of the belly, and whose beam width is only 60-70 degrees. The radio altimeter was designed and used as a landing aid. GPWS came along much later, and became required only four years before this accident, and nuisance warnings happened sometimes, usually by degraded radio altimeter installations, as seen by the Turk 737 at AMS.

The primitive nonvolatile memory of the GPW computer showed it had transmitted warnings to the best of its ability. As you know, they were level at 260 knots at 1500 feet, approaching a 300 foot cliff followed by a steep rise of terrain.

What radar of the day could have seen Erebus in time to prevent this accident? Installing more radio altimeters, with antennas just below the radome on the chin would have provided a forward look. It would require two, each mounted 30 degrees off the center line, to see terrain in a turn.

Then, of course, they would no longer be accurate height measuring devices, and they would be locked on to the closest target, the 1500 feet to the sea in this case. I'll let you do the math to decide if that would have provided more warning than they received from the GPWS.

GB

[prospector]

Dozy Wannabe,

You say " why you're so vociferous in your condemnation of the pilots".

Go through all of my posts on this thread and the previous one "Erebus 25 years on" and you will not find anything I have said that is in any way vociferous condemnation of the pilots.

My argument is, was, and will always be, that Justice Mahon was wrong with his summing up of the events.

It is a well known fact that all other operators going down to the Antarctic required a certain experience level prior to going down as P1. It was no skin off the management of Air NZ if only one or two pilots were given the Antarctic sight seeing flight. That would have satisfied common sense and the original requirements laid down by NZCAA.

Who was it that pressured Air NZ management into giving these flights to senior members of their association????

From Bob Thomson in his " History of New Zealand Antarctic Research Programme 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."

It has been stated previously in this thread, or the previous one, that 3 times a month Auckland to Los Angeles in the flight levels is no qualification for 1,500ft, bloodshot VFR, in Antarctica.

Nowhere in Justice Mahons summing up was any blame directed towards the people who created the situation where a Capt found himself in the position Capt Collins did.


If you wish to talk of vociferous condemnation have a reread of the garbage you printed.

"ANZ and Morrie Davies were cowards hiding behind a rulebook that they knew was being routinely ignored. Chippindale was just a cat's paw for Davies and Muldoon, who didn't want his only national flag-carrier's reputation tarnished."

[workingman303]

Dozy Wannabe,

You say " why you're so vociferous in your condemnation of the pilots".

Go through all of my posts on this thread and the previous one "Erebus 25 years on" and you will not find anything I have said that is in any way vociferous condemnation of the pilots.

My argument is, was, and will always be, that Justice Mahon was wrong with his summing up of the events.

It is a well known fact that all other operators going down to the Antarctic required a certain experience level prior to going down as P1. It was no skin off the management of Air NZ if only one or two pilots were given the Antarctic sight seeing flight. That would have satisfied common sense and the original requirements laid down by NZCAA.

Who was it that pressured Air NZ management into giving these flights to senior members of their association????

From Bob Thomson in his " History of New Zealand Antarctic Research Programme 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."

It has been stated previously in this thread, or the previous one, that 3 times a month Auckland to Los Angeles in the flight levels is no qualification for 1,500ft, bloodshot VFR, in Antarctica.

Nowhere in Justice Mahons summing up was any blame directed towards the people who created the situation where a Capt found himself in the position Capt Collins did.


If you wish to talk of vociferous condemnation have a reread of the garbage you printed.

"ANZ and Morrie Davies were cowards hiding behind a rulebook that they knew was being routinely ignored. Chippindale was just a cat's paw for Davies and Muldoon, who didn't want his only national flag-carrier's reputation tarnished."


+1

You only need to look at how reluctant the US military were to even acknowledge Air NZ going down there in the first place. Not to mention the fact that the DC 10 is one of numerous aircraft wrecks currently resting in peace in Antartica. It wasn't a place that they really should have been visiting. Hence the strict requirements for descent that unfortunately weren't followed.

The crew were hopelessly unqualified for the environment once they commenced descent.

[henry crun]

DozyWannabe: How dare you besmirch the memory and reputation of Ron Chippendale.
He was a honest true gentleman who was beholden to no one, and for you to state otherwise merely publicises your ignorance.

[Desert Dingo]

Henry Crun
DozyWannabe: How dare you besmirch the memory and reputation of Ron Chippendale.
He was a honest true gentleman who was beholden to no one, and for you to state otherwise merely publicises your ignorance. Enough of your righteous indignation.
I don't think DozyWannabe is the one displaying ignorance here.
Ron Chippindale did a pretty good job of demolishing his reputation all by himself.

Consider a few of Chippendale's errors just for starters:
He added words into the CVR transcription to suit his pre-conceived idea of what had happened. (The "Bit thick here Bert" conversation) See (1) below.
He accepted the misinterpreted Flight Data Recorder evidence to show a panic application of left rudder by the pilot immediately prior to impact. This rudder movement was the inertia effect on the rudder during impact as aircraft slewed to the left. In his report the synchronisation of CVR and FDR had been manually adjusted to give a result to fit with Chippindale's notion that the crew saw the terrain at the last moment. See (2) below.
He testified on oath that flight plan Annex 'J' (the old route proving plan that had the track direct to McMurdo and over Mt Erebus) had been recovered from the crash site. It was not recovered from the crash site. See (3) below.
He later admitted that he knew ANZ were lying to him. See (4) belowAlso:
The peak of Mt Erebus is about 20 nm from Mc Murdo. Collins locked the aircraft onto the NAV track after completing his orbits and descent. They were still engaged on the NAV track when Collins said “Were 26 miles north, we’ll have to climb out of this.”If Collins (or anyone else on the flight deck) believed the NAV track was taking them over Mt Erebus, and here they were at 1500 feet with less than 10 miles to run pointing straight at a 12,450 foot mountain they would have to be bloody suicidal.
When questions at the enquiry about why Collins put the aircraft in this position of danger, Chippindale replied that he had given the matter careful consideration, and Collins must have been suddenly afflicted by some medical or psychological malady which made him oblivious to the mortal danger looming in front of him. When it was pointed out that this must have simultaneously happened to everyone else present on the flight deck, and was patently an absurd proposition his credibility suffered badly.And:
In Chippindale's own report:
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.
This was another patently absurd conclusion for him to make.Ron Chippindale may have been 'a true gentleman' but he made many serious errors in his investigation of the Erebus tragedy.


************************************************************ ***********
(1) 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.

Stewart McFarlane, Senior lecturer in Law, University of Auckland (now retired)
http://www.investigatemagazine.com/a...ate_nov_4.html (http://www.investigatemagazine.com/archives/2006/03/investigate_nov_4.html)
************************************************************ ***********
(2) And so, in my opinion, the transcribers had made the mistake which investigators have often made in times gone by and in different circumstances. Many police inquiries have gone wrong for the same reason. The mistake they made was to first postulate what they thought had happened, and then treat all information which did not fit their theory as being not correct.
So here we had this investigatory defect revealed in startling form. The transcribers disregarded the simple facts which the 'black box' was telling them and substituted their own version of what it was trying to say.

Peter Mahon - 'Verdict on Erebus'
ChapterXXVII - How the 'Black Box' readout was misinterpreted
************************************************************ ***********
(3) Material Not Given on Despatch
Fig. 46. Annex.J
Annex J, when plotted onto a topographical map, indicates that the Air New Zealand flight path crosses Mt Erebus. It was distributed by Air New Zealand in the Antarctic envelope during 1977, when the flight path did, in fact, cross Mt Erebus, but was replaced by Exhibit 164 in 1978, when the flight path was shifted to McMurdo Sound.
Mr Chippindale stated on oath that Annex J had been recovered from the ice. This proved that it had been in Captain Collins' possession, and that it would have demonstrated to him the flight path crossed Mt Erebus, had he troubled to plot it against any of the charts he had. Much later it transpired that Mr Chippindale's evidence was untrue. It was never recovered from the ice at all. Instead, Mr Chippindale had evidently gone to Air New Zealand and asked them to supply him with copies of documents which they alleged they had given to the pilots, and Exhibit J was one of these documents. Mr Chippindale then, for reasons he has not explained, concluded that it would be in order for him to swear to the Royal Commission that his team had recovered it from the ice. Mr Chippindale subsequently defended his actions in a press release, in which he said that Mr LA. Johnson had given evidence on oath that he had handed Exhibil J to the pilots. But this claim of Mr Chippindale's is also untrue, as Mr Johnson did not say that at all.

Fig. 47. 1977 Flight Plan of 10. 10. 77 — NDB Waypoint. Mr Chippindale also said on oath that a flight plan was recovered from the ice which showed an Erebus route. Since this was an old 1977 flight plan, The implication was that the crew had it well in advance and had taken it with them to show the route, so that they must have known the flight path crossed Mt Erebus, even if they had not plotted the flight plan given to them on despatch. Since Flight Engineer Brooks had been to the ice in 1977, the implication was that he had given it to Captain Collins. However, research revealed that the waypoint on the flight plan said to have been recovered from the ice differed from the waypoint on Flight Engineer Brooks' 1977 flight. In view of that and of the dubious background to Mr Chippindale's claim that Exhibit J was recovered, it might be safer to conclude that, on the balance of probability, the 1977 Erebus flight plan was not recovered from the ice either.

Stewart McFarlane, Senior lecturer in Law, University of Auckland
'The Erebus Papers' p78
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(4) 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)

Poneke's Weblog
http://poneke.wordpress.com/2008/02/13/te901/ (http://poneke.wordpress.com/2008/02/13/te901/)
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[prospector]

henry crun,
A lot of verbiage from a number of people who obviously have no idea of the meaning of the request for a VMC descent below MSA.

"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".

That statement alone shows the value of the rest.

The minimum descent was 16,000ft, until after passing overhead McMurdo, then a descent to 6,000ft could be made, if the weather conditions were suitable.

[henry crun]

Desert Dingo: Mahon's investigation was not error free, so does that make him a cat's paw for the ALPA who wanted to protest the reputation of one of their own. ?

Your point (4). As prospector points out, Chippendale knew that ANZ rules did permit flight below 16,000ft, to suggest otherwise is absurd.
That shows how much reliance can be placed of the ramblings of a jounalist

[Graybeard]

I was acquainted with a Douglas FE who had spent time at ANZ working with their FEs, and was friends with the FE on that flight. Not long after, maybe as late as January, 1980, he told me he had heard the tape. He said his friend, the only one who had been on that trip before, said some 90 seconds before the collision, "I don't like (the look of) this. Let's get out of here."

Would he have recognized his friend's voice? Would the FE seat position, somewhat behind the pilots, have given him more sense of the white-out?

GB

[Brian Abraham]

it was well below the minimums required for the approved cloud break procedure
There was no cloud break procedure in place at the time prospector. Descent from 16,000 had to be made in VMC. The crew had been briefed the NDB was unavailable, although in fact it was on the air. Bearing in mind all the services provided by McMurdo were on a "your risk" basis, would a diligent crew have used the NDB despite being briefed it was unavailable.
request for a VMC descent below MSA
Chippendale makes the same mistake in sections of his report inferring that McMurdo had a controlling function. He does of course set out the reality. He notes the briefing did not contain information as to the extent of the controllers authority to control the flights. The USN had previously advised NZ Authorities "Air traffic control/flight following shall take the form of location advisory of Deep Freeze aircraft and position report relay only."
we have a record of flights descending below the laid down minima, but they were all carried out in "brilliantly clear conditions"
Chippendale - Whiteout: The condition may occur in a crystal clear atmosphere or under a cloud ceiling with ample comfortable light and in a visual field filled with trees, huts, oil drums and other small objects.

Would seem to give lie that "brilliantly clear conditions" would be a savior to an inexperienced crew.

[DozyWannabe]

Henry Crun :
For your benefit I'll repeat the situation regarding the Court Of Appeal and Privy Council findings, which was that Mahon's error, if it can be called that, was to state in his report that representatives of ANZ had lied to him without first putting that question to them while they were giving evidence. They found no fault with his other conclusions.

Graybeard :
The pilots responded immediately to the FE's comment of "I don't like this" and started a procedure to turn around and climb. While the comment certainly displayed anxiety, at no point did the FE exhort the pilots to expedite the maneouvre, so it's not like he was ignored.

I feel I should point out that I am not disputing Chippindale's qualities as a human being or as an aviator - simply that as a former military pilot and later as an investigator primarily dealing with light aircraft accidents, he drew some conclusions from the evidence that could be considered questionable - possibly because he had little experience of commercial airline operation.

[Graybeard]

I've never heard the tape, but I understood the Douglas FE to say the "I don't like this" was some 90 seconds prior to the GPWS warning, after which the Captain said, "Climb power, please." Not so?

[prospector]

Brian Abraham,

I believe you are cherry picking some of the requirements that had to be met prior to descent below 16,000ft.

Yes it had to be VMC, but only under the specified requirements.

These included
2. Avoid Mt Erebus area by operating in an arc from 120 Grid through 360 grid to 270 grid from McMurdo Field, within 20nm of TACAN Ch29.

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

When 901 said they would descend VMC they took on the responsibility of maintaining their own terrain separation, and separation from other traffic.

How could any controller separate them from other traffic if they had not been identified on his radar???

The VMC descent was only approved under the conditions stipulated, none of which was met.

The weather was reported at McMurdo to be completely overcast at 3,500ft with other cloud layers above, mountain tops in the area were covered in cloud.

Other aircraft in the area reported Ross Island as being completely obscured by cloud.

"Aircraft Accident Report No.79-139 is still the single official document as to the cause of the crash. Everything published subsequently, including the Royal Commission Report, is opinion".

That according to my references, is the state of play at this point in time,if you could disprove that statement then please do.

[Brian Abraham]

The VMC descent was only approved under the conditions stipulated, none of which was met.
Therein lies the rub. Perhaps with one exception (from memory - not checked), none of the flights complied with the requirement. The fact that they may have been in gin clear conditions is no defence, given Chippendales "Whiteout: The condition may occur in a crystal clear atmosphere".

It must be borne in mind when discussing Chippendales findings, that "Pilot Error" was par for the course in those days. Flight safety has moved on since then, with the realisation that pilot error is, more often than not, the end result of systemic failings within the organisation. And Air New Zealand proved to be replete with those, with its laissez-faire attitude to the operation.

It seems opportune to post the following.

Punishing People or Learning from Failure?
The choice is ours
Sidney Dekker
Associate Professor
Centre for Human Factors in Aviation, IKP
Linköping Institute of Technology

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.

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."

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.

[Brian Abraham]

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.

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 straight jacketing, 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 feed forward. 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 feed forward. In other words, there is insufficient evidence for breaking off the approach (as feed forward 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 feedforward, 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.

[workingman303]

And to add to Prospector's comments, I understood the TACAN was not working at the time so irrespective of what the crew thought they were doing, without TACAN they shouldn't have descended.

[werbil]

Brian - a very interesting paper.

IMHO people are losing sight of 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).

The results of the flight speak for themselves and to attempt to place the cause of the accident on one decision is extremely simplistic. At least give those that were tragically killed the respect of trying to learn as much as we can about how to prevent future accidents rather than playing the blame game.

[flatfootsam]

Prospector – Your comments and reliance on what you propose are the facts are disingenuous at best, but 10/10 for unrelenting opposition to what is a phenomenal amount of evidence and reasonable argument that has consistently contradicted just about everything you are relying on, short of the date : a remarkable stance considering how comprehensively your case has been undermined; your myopic approach to aviation safety analysis is a credit to the 1920’s where you obviously prefer to reside.

The let downdown procedure, VMC ,visibility, ANZs’ SOP’s ect is a Strawman argument that you propose like clockwork as the standard facet of your justification, negating the fact that a trained crew flew a functioning DC-10 in clear weather into the side of a mountain. The FL160 limit and descent procedure you rely on is inconsequential - ipso if the DC-10 had not descended below FL160 it would not have crashed is the same argument as if the DC-10 had not taken off it would not have crashed, ipso facto.

That is a fact as well: the selective representation of the passengers’ photographic evidence, which to put it politely, was more conspicuous by what it omitted, is also by coincidence how you have drummed on while selectively representing the facts in your case and very selectively omitting to include numerous other facts which I’m sure your uncomfortable with, but have been bought to your attention by numerous posters’.

For your supposition to hold water you have to complicity agree that the crew of TE901 deliberately flew at the mountain, not ‘into the mountain’ but by a deliberate wilful act they flew ‘at the mountain’. Prove that point and I’ll never comment again. Short of the crew being suicidal, that’s where your argument falls down, along with Aircraft Accident Report No.79-139, regardless of that fact that the NZ Govt maintains that this is the official record; well they would wouldn’t they, considering how much effort the put into the content.

Anyone with any background in accident investigation knows that the Mahon/Vette analysis was a world class piece of research and analysis, which along with the Mahon report presented the facts – not opinions as you suggest – and the conclusions, along with multiple examples of duplicity between the airline being investigated, the CAA and the Govt.

Furthermore, the Mahon and Vette investigations, subsequently went on to improve investigation techniques and more importantly aviation safety - Quite an achievement. The Chippendale report did what was politically expedient, short and simple. Anyone tarnished with that brush very probably spends a lot of their time attempting to justify themselves through posting on various web pages…ring any bells?

Also, very convenient that the FDR has gone missing as well. Prospector old chap, if you’re not smelling a rat by now, perhaps a visit to an otorhinolaryngologist is required.

Justice Mahon and Gordon Vettes’ subsequent investigations, analysis and systematic approach solved the riddle of this tragedy, in the process opening the management of ANZ, the collusion of the NZ Govt and the CAA at the time to the oft repeated accusation of complicity and illegality, obstrufication, deliberate destruction of evidence, perjury ect, ect…in the process Mahon and Vette , in a monument to pettiness and NZ governmental vindictiveness, were well and truly shafted for demonstrating the truth when it was deemed inconvenient. A shameful result for NZ and anyone with an ounce of professional scruples or sense of justice, which by extension excludes yourself based on your postings; in addition, you constant harping on does a disservice to the aviation safety advances that resulted in Justice Mahon and Gordon Vettes’ research.

So, here is a proposal. I will approach TVNZ, or one of the production companies they use, and propose a top to tail thorough review of the evidence and analysis in a modern aviation safety investigation environment: you can use the Aircraft Accident Report No.79-139 as a basis for investigation - subject to peer review – which I’ll call team A in this context, while simultaneously an independent review by current, modern investigators, which I’ll call team B in this context, schooled in modern analysis and techniques will work on the available evidence and produce a report based on known empirical data, Human Factors, Cognitive and Behavioural Science, Cockpit Resource Management , Threat and Error Management ect, ect, and we’ll see what the result is…my two bob’s on team B.

Let me know if you’re keen, I think it’s an interesting idea and has some value, at the very least, it will put the dampers on your constant whining.

I await with the fatalism of the convicted for your very predictable, knee jerk response

[Tarq57]

Sorry, flatfootsam, that's too hard for me to read.

Could you format it into paragraphs, maybe increase the font size a smidgeon?

Sort of like I've done here.

[flatfootsam]

I just did...bit of a problem on the editing button; it all went a bit haywire, but it's back in a normative format

[Tarq57]

Tks. My eyes can handle that. :ok:

[prospector]

flatfootsam,

You say

"negating the fact that a trained crew flew a functioning DC-10 in clear weather into the side of a mountain."

But in fact

" The weather was reported at McMurdo to be completely overcast at 3,500ft with other cloud layers above, mountain tops in the area were covered in cloud.

Other aircraft in the area reported Ross Island as being completely obscured by cloud".

Mt Erebus is a very significant feature of Ross Island.

Try and stick to fact, was the weather reporting station at McMurdo, and all the other reports from aircraft in the area also all part Of Justice Mahons Conspiracy???
"The FL160 limit and descent procedure you rely on is inconsequential - ipso if the DC-10 had not descended below FL160 it would not have crashed is the same argument as if the DC-10 had not taken off it would not have crashed, ipso facto."

Really?? what is the reason that every airline route has a published MSA, why do they do that if it is inconsequential??

[DozyWannabe]

Regarding the weather, McMurdo was reporting overcast in their vicinity and clear air to the northwest, which the crew worked out would be roughly around Cape Bird according to the CVR. The exact conditions at the time we can only speculate upon, because by the very nature of the location, there was no-one else in the McMurdo Sound/Lewis Bay area (McMurdo Station is, if I recall correctly, positioned to the south of Erebus).

Regarding the rulebook we're banging our heads against here - we need to take into account the fact that the majority of ANZ flights to the Antarctic descended to levels between 3,000 and 1,500 feet. There is no definitive proof of the weather conditions on those flights either, and if your position is such that the regulation should have been followed to the letter, then you should at least concede that ANZ were remiss in not identifying this as a problem and disciplining the pilots concerned. The fact is that they did not - these flights were sold in the company's own literature as "low-level" sightseeing flights, and actively promoted them as such when times were good. The line pilots shared their experiences with each other, and it became a de facto standard to disregard the 6,000ft limit - I wouldn't be surprised if many of the pilots weren't even aware such a limit existed before the accident.

The limit itself was drawn up by Civil Aviation with ANZ's help - it was a special case in the first place, specific to the route, because the route was unique on ANZ's roster. It doesn't even mention clearance to descend below 6,000 feet, which in most cases was suggested by McMurdo, and if the rules were followed as closely as you desire, would be declined on every occasion.

Going back to the conditions for previous flights, again we can only speculate on what they were, as no records were kept. Chippindale says that other flights occurred in "brilliantly clear conditions", but he must himself have been speculating as I'm sure he didn't interview every single pilot that went down there, and even if he did I doubt strongly that they'd have been able to paint an accurate picture of the conditions they were flying in in the months previously. So to say that the crew on this occasion acted contrary to established procedure is disingenuous in the extreme. Also, sector whiteout can occur even in clear conditions, as mentioned earlier in the thread.

The only proven difference between the accident flight and those prior was the switch in co-ordinates. That being the case, if any of those flights (or indeed any of the following flights, had Collins been luckier and his flight returned) had flown the INS waypoints handed out that day, any one of them could have impacted Erebus. Certainly speaking for myself, this is why I think that ascribing the primary cause as pilot error was completely myopic.

Antarctica is a harsh and unforgiving terrain, certainly - and flying in the area definitely requires a degree of care over and above normal operations. But between ANZ, Civil Aviation and the pilots, they got it as close to normal operations as was possible at the time. Maybe they shoudn't have - but this wasn't a small Twin Otter operation bouncing around at low level where everything is at the pilot's risk and discretion, this was a tri-monthly scheduled service that had been performed for around two years. Collins had no reason to expect that he would be in any more danger than his peers, and even given that it would seem he prepared diligently - certainly giving it more attention than any regular scheduled "Auckland to Los Angeles" flight.

Finally, Mahon's report was recognised as an official report into the disaster when it was tabled in the New Zealand Parliament on the 25th of August 1999.

[prospector]

Dozey Wannabe,

(or indeed any of the following flights, had Collins been luckier and his flight returned"

And how many following flights were there?? and just by the by, luck should not have any part of the process of moving people by air, even on a sightseeing flight.

"So to say that the crew on this occasion acted contrary to established procedure is disingenuous in the extreme."

Why?? everybody else came back so something must have been contrary.

As has been stated on this thread a number of times, once that descent below 16,000ft was commenced, this crew was well outside their experience level. That situation should not have been allowed to happen. Why was it allowed to happen?? who demanded that these flights be shared amongst their members in contravention of the wisdom developed by other operators who regularly flew to the Antarctic?? why did not Justice Mahon even mention this fact in his summing up??.

[workingman303]

Regarding the rulebook we're banging our heads against here - we need to take into account the fact that the majority of ANZ flights to the Antarctic descended to levels between 3,000 and 1,500 feet. There is no definitive proof of the weather conditions on those flights either, and if your position is such that the regulation should have been followed to the letter, then you should at least concede that ANZ were remiss in not identifying this as a problem and disciplining the pilots concerned

So you are saying that the other option, because the requirements were so stringent it was unlikely that the aircraft could ever descend so the pax wouldn't have got much of a view so the flights would have been eventually canned. That this option wasn't possible? Are you going to pull out a leaked memorandum showing that crews would be demoted if they didn't bend the rules?

The crew had to break the SOPs that were there in the first place to provide a degree of safety that the company and CAD was happy with.

So why bother having any requirements at all that allowed descent below MSA, why not just say, "Hey, you have flown lots of time to LA you go ahead and descend as you see fit" which is precisely what the crew in this instance did.

Hitting the hill was irrelevant, the cause of the accident was what Chippendale was required to find and that was the crew's decision to descend below MSA.

No-one here is denying that Air NZ's behaviour subsequent to wasn't the greatest but I have yet to hear anyone here say they would have done eactly the same as Collins and crew did given the same set of circumstances.

So Dozywannabee you would have happily busted the SOPs, descended IMC, relied utterly on the aircrafts INS and never actually checked the coordinates and change in heading with each track change as a regular part of your operation?

So we have a dangerous mix of weather conditions, a company SOP's that take this into account, an aircraft that is lost because the SOPs are not applied and the crew are blameless because the weather conditions are hazardous. The SOPs are there because of the weather and somewhere there Collins is paid to make command decisions. I have no idea how Morrie Davis could have forced Collins to descend.

What amazes me is that all Vette did was bring whiteout to the attention of the general flying community, the US military had known about it for years as had most likely any operator flying to Antartica. Except Air NZ was never supposed to get an aircraft into a situation where whiteout could be a factor, the SOPs should have protected the paying public from that.

The only way that Collins can be exonerated is if you say he was way outside his level of experience once he descended and yet this is precisely why the SOPs were written as they were for the Antartica flights.

[ampan]

flatfootsam: The suicide argument is silly lawyer’s stuff. It’s not a choice between ‘blameless’ and ‘suicidal’. Positioned between the two is ‘negligent’. If the information given to the captain about the final waypoint was consistent, then it could be argued that he was blameless. But it was not. At the briefing, the captain was told that the track went to McMurdo Station. This is an undisputable fact: The briefing included an audiovisual presentation. The audio part was read out, from a script, which was as follows:


ALL FLIGHTS FOR THE ANTARTIC REGION WILL BE PLANNED TO DEPART AUCKLAND WITH FULL TANKS. AS AN APPROXIMATE FIGURE THIS WILL BE 109 TONNES OF FUEL. BASED ON AN ANTICIPATED ZERO FUEL WEIGHT OF 140 TONNES. A TAKE-OFF WEIGHT OF ALMOST 250 TONNES CAN BE ANTICIPATED FOR ALL FLIGHTS.

PAUSE 4 SECONDS

CHANGE BOTH SLIDES.

TWO ROUTES ARE AVAILABLE. FLIGHT DESPATCH HAS BEEN INSTRUCTED TO PREPARE TWO FLIGHT PLANS REGARDLESS OF THE FLIGHT FORECAST. BOTH ROUTES FOLLOW COMMON TRACKS TO CAPE HALLETT, THEN DEPENDENT ON WEATHER CONDITIONS EXISTING IN THE REGION ONE ROUTE PROCEEDS TO MCMURDO AND RETURN WHILST THE SECONDARY ROUTE IS VIA THE NINNIS GLACIER AND THE SOUTH MAGNETIC POLE. IT IS ANTICIPATED WIND FORECAST WILL BE SCANT, HOWEVER A COMPONENT OF MINUS 10 – 15 KNOTS CAN BE EXPECTED.

HEMISPHERICAL RULES WILL APPLY REGARDING FLIGHT LEVELS EN ROUTE – REFER TO THE RNC4 CHART – BUT NO PROBLEMS ARE ANTICIPATED WITH DRIFT CLIMB PROCEDURES AND BLOCK CLEARANCE ALTITUDES. REMEMBER THE LIMITING FACTOR WILL BE THE TIME SPENT IN THE MCMURDO OR SOUTH MAGNETIC POLE AREA AS THE FUEL REQUIREMENT FOR THE RETURN MUST BE BASED ON THE DEPRESSURISED LEVEL. DETAILS OF THE ROUTE INFORMATION WILL BE SUPPLIED IN A SEPARATE HAND-OUT.

PAUSE 4 SECONDS

CHANGE BOTH SLIDES

A STANDARD ROUTE DEFINITION WILL BE USED EMPLOYING THE FROM-VIA-TO FORMAT. ENTER NZAA THEN 78S/167E THIS BEING THE APPROXIMATE CO-ORDINATES OF MCMURDO STATION. NZCH IS ENTERED IN THE NORMAL WAY. NEW PLYMOUTH AND NELSON MAY BE ENTERED AS STANDARD IDENTS HOWEVER ALL OTHER ENTRIES WILL BE REQUIRED TO BE BY LATITUDE AND LONGITUDE. REMEMBER FLIGHT PLAN OVERFLOW WILL OCCUR WITH MORE THAN 15 LATITUDE AND LONGITUDE ENTRIES. NO DIFFICULTY WILL BE EXPERIENCED IN ASSEMBLING THE ROUTE TO BEYOND MCMURDO SOUND IN THE FIRST INSTANCE.
THE DIVERSION ROUTE NZCH-NZAA WOULD BE ACCESSED FROM THE AVAILABLE AIRWAYS FROM CH.
MCMURDO TACAN IS NOT INCLUDED IN THE TAPE THEREFORE NO UPDATE WILL OCCUR BEYOND THE RANGE OF THE CHRISTCHURCH VOR/DME.
PAUSE 4 SECONDS / CHANGE BOTH SLIDES.

[DozyWannabe]

And how many following flights were there?? and just by the by, luck should not have any part of the process of moving people by air, even on a sightseeing flight.
Well none, obviously - the point I was trying to make was that the Collins flight was the first to be dispatched with a computerised track that entered Lewis Bay and crossed Erebus. If the computerised track had been entered correctly in the first place, then every flight from 1978 onwards would have taken that route - and if the pilots of those flights had descended and encountered whiteout, it could well have been they, and not Collins, who had the misfortune to hit the mountain. That's all I mean by "luck".

Workingman303, I'm not saying any of those things - for a start I can't say what I would have done as I am not a line pilot, and I was barely a year old when the accident happened - a lot has happened in the pursuit of airline safety in that time, and in fact Justice Mahon's expanding of aircraft accident investigation parameters had a lot to do with it. With 20/20 hindsight it's obvious that ANZ's operating procedures regarding these flights started out with the best of intentions, but they gradually slipped as the trips became commonplace. If ANZ wanted the rules strictly adhered to, then they should have enforced those rules and not allowed a culture to develop whereby pilots routinely disregarded those rules. Instead, they published and reprinted promotional articles that explicitly stated that low flying was the norm. In fact ANZ's behaviour *prior* to the accident was just as detrimental to the safe handling of those flights.

Regarding

I have yet to hear anyone here say they would have done eactly the same as Collins and crew did given the same set of circumstances.

I imagine that the situation that Collins was unwittingly placed into would cause most pilots to break out into a cold sweat.

Ampan - I don't know where you sourced your copy of the briefing material from, but it should be pointed out that along with the audiovisual presentation, pilots being briefed on the route were also handed a folder of supplementary material. Included in this from 1978 onwards was a photocopy of the route down McMurdo Sound on an air navigation chart, which appears to have been plotted to the incorrect co-ordinates at the end of McMurdo Sound. In fact all briefing materials bar one show this route - that single sheet was included in Chippindale's report as Annex J. It is not proven whether Annex J was included in the briefing materials given to Collins and Simpson at their briefing, but certainly, all other supplementary material showed the McMurdo Sound route, and not the "official" track over Erebus.

While I can't say what "I would have done" - far too presumptuous for a non-pilot like me - I would hope that in a modern operation, the Chief Navigator would have felt safe to escalate his discovery of the error and get all appropriate briefing materials changed before another flight was allowed to depart instead of playing it down and changing the co-ordinates the night before departure with little to no notification of the change. In fact, even better to notify the whole company of how the error came about and to re-instate the "check, cross-check and re-check" mantra. Even if you don't consider Collins blameless, you have to admit that dispatching two pilots (Simpson and Collins) who had attended the same briefing with different INS flight plans was pretty woeful practise.

[ampan]

DozyWannabee - The "charts" you refer to showed the military route, from Cape Hallett to the Byrd Reporting Point. The crew were told, at the briefing, that they would not be flying the military route. But I accept that the material was inconsistent. The prime example is the sample flightplan. This, however, does not save the captain. Once he noted the inconsistency, as he would have done the night before, it was his job to resolve it. Instead, he assumed that the sample flightplan was correct and that the statements at the briefing were not. That can't be anything other than a bad mistake which, I suspect, the captain had begun to appreciate just before he died.

[ampan]

Graybeard: The F/E’s comment was made 26 seconds before impact and the captain reacted to it within six seconds, so there isn’t much in that. Of more interest is the decision to turn left.



0049.24GMT F/E Brooks “I don’t like this”

Six seconds later - Capt. Collins: “We’re twenty six miles north we’ll have to climb out of this”

Three seconds later – F/O Cassin: “It’s clear on the right and (well) ahead”

Capt. Collins: “Is it?”


Five seconds later – F/O Cassin: “Yes you’re clear to turn right there’s no high”

Capt. Collins: “No negative”

F/O Cassin: “No high ground if you do a one eighty”


Four seconds later, Capt. Collins pulled out the Heading Select knob and initiated a LEFT turn using the autopilot.

Two seconds later, the GPWS sounded.

Six seconds later, impact.



Why go left if you think you’re in the middle of McMurdo Sound with high ground to left and with your F/O recommending a right turn? Answer: Pennies started to drop.

[DozyWannabe]

ampan:
This, however, does not save the captain. Once he noted the inconsistency, as he would have done the night before, it was his job to resolve it.
But the point I was making was that roughly 42 pilots (estimate based on 3 flights a month for 14 months after the route was computerised) prior to Collins were given the same inconsistent briefing materials - by your standards all of them should have noted the inconsistency -why single Collins out? This was a systemic failure.

Why go left if you think you’re in the middle of McMurdo Sound with high ground to left and with your F/O recommending a right turn? Answer: Pennies started to drop.
It's all conjecture. While digging up material to try and make sense of this I found an interesting write-up here:

The Briefing Room: Investigate Nov 05, Return to Erebus (http://www.investigatemagazine.com/archives/2006/03/investigate_nov_4.html)

in which an alternate (and IMO equally plausible) theory is put forward:

49:30 Collins: We’re twenty six miles north we’ll have to climb out of this. [Sounds puzzled not worried.]
Unidentified : OK
49:33 Cassin: It’s clear on on the right. [In right hand seat, he can still see terrain on right, so he is not yet in full whiteout.]
Collins: Is it?
Cassin: Yep.
49:35 Mulgrew/Moloney: You can see (Ross Island). [Probably Mulgrew. Could not be positively distinguished.]
49:38 Cassin: You’re clear to turn right there’s
Collins: No negative [Sitting on left, Collins has lost sight of terrain on right, so is unwilling to fly to the right. He is in full whiteout to the right]
Cassin: No high ground if you do a one eighty. [Cassin on the right can still see terrain to the right, so he repeats his suggestion.]
49:44 ((Ground proximity warning tone – warning continues until impact))

Which I hope you'll agree is also fair. In this version of events, they simply ran out of time.

Regarding what you call the "military route" chart, I remember reading that overlaying the chart on a map with the false waypoint plotted matched almost exactly. Whether this was an exceptionally unfortunate coincidence, or whether the track had indeed been plotted against the false waypoint we'll probably never know for certain, though I reckon it's pretty academic at this point.

[ampan]

As regards the number of flights in the preceding 14 months, they only flew to Antartica in October and November, so as to get the best weather. There were only about six flights per season (which is why it was a dead loss commercially).

As regards the captains of the previous flights, one of them (Capt. Simpson) noted 'something'. But even if those captains were performing aerobatics over the summit of Mt Erebus, that doesn't absolve Capt. Collins. He must have noted the difference between the statements at the briefing and the sample flightplan. All he had to do was to check that waypoint when it was entered, or, at the very least, check it against the chart after reaching Cape Hallet, especially given that he had decided to descend below the minimum safe altitude.

As regards the Investigate article, I don't see any alternative theory put forward. The words in square brackets are just some journalist's notes, inserted to make the transcript more readable. In any event, how can this alternative theory assist the crew? If anything, it makes them look even less certain of their position.

Whatever be the background, it is clear that the F/O wanted to go right and the captain did not. It is also clear that the only way out was to the left.

As regards the military route, the so-called "false" waypoint was reasonably close, but further to the southwest. You wouldn't get an exact match with an overlay. It should be noted that the military aircraft were to land at McMurdo Station, hence the Byrd Reporting Point in the middle of the Sound. The military aircraft would head for Byrd using their two-platform INS (cf the DC10's better three-platform INS) at above the Minimum Safe Altitude until McMurdo fixed their position by radar. They would then go below MSA and turn left at Byrd, knowing they were lined up for landing.

The Byrd Reporting Point had very little relevance to AirNZ's Nav section, because the DC10s were not going to land. The obvious location for the final waypoint was a beacon. Initially, it was the NDB. When that failed, they changed it to the TACAN. The problem was that for 14 months the waypoint was not at the NDB, so a change that was thought to be very small turned out to be of the order of 26 nautical miles.

[DozyWannabe]

ampan:
Whatever be the background, it is clear that the F/O wanted to go right and the captain did not. It is also clear that the only way out was to the left.
Typo? Your theory would suggest the only way out was to the right - though given the impact zone's location it could be argued that any evasive maneouvre at that point was too late.

OK - so the number of previous pilots is much lower, duly noted. However, that still leaves several pilots who, according to your source, received a briefing that told them they were routing direct to McMurdo Station (though the word "approximately" in the script, as well as the lack of the term "direct" does give me pause for thought as to whether that's a fair argument), while the majority of their briefing materials said they were going down McMurdo Sound. So back to my original point - why do you single Collins out for censure when any one of them, by your terms, should have reported the discrepancy?

Collins had no reason to question the waypoint - he had no idea that it had changed because nobody thought to inform dispatch. Are you seriously suggesting that having plotted the route the night before, having got the flight plan from dispatch, he should have plotted them again? One of the major points of having a whole division of the company dedicated to navigation is that line pilots should be able to trust the information that they are given, surely?

And I don't read the notes as saying they were uncertain of their position - I see them as simply saying they could not visually confirm where they were - and as a result they elected to climb out, unfortunately too late to make a difference. This was mere seconds before impact - up until then they had no reason to think they were anywhere other than where the previous flights had gone.

The obvious location for the final waypoint was a beacon. Initially, it was the NDB. When that failed, they changed it to the TACAN. The problem was that for 14 months the waypoint was not at the NDB, so a change that was thought to be very small turned out to be of the order of 26 nautical miles.
As I understood it, Chief Navigator Hewitt initially intended to set the waypoint at the ice runway for McMurdo, neither the NDB or the TACAN. What Simpson found was that following the INS track to the false waypoint he was a considerable distance from the TACAN, which he dialled in for confirmation. This is important because firstly it is not recorded whether Simpson told Nav Section how far off the waypoint was, and also because he did not report it until after his flight. Hewitt gave the instruction to correct the waypoint, believing it to be only a 2 mile difference. He did not make the check himself, and it would appear the data operator simply entered the correction without plotting the distance himself (he may not have been navigationally qualified, computers being recalcitrant things in 1979). This change went into the computer the morning of Collins' flight and no other notification was given. A major systemic failure. As such, the Byrd waypoint is somewhat irrelevant.

[ampan]

There’s no argument concerning the systemic failure. It was a monumental balls-up from start to finish. The only reason why the debate still rages is because of NZALPA’s stupid attempts to enshrine Mahon’s report and to deify the captain. I’m absolutely sure that if there is life after death, the captain will be eternally embarrassed.

I agree that from the position the left turn was commenced, it was too late. The aircraft was in the jaws of Lewis Bay, at 1500 feet, so it was doomed. But if the left turn had commenced only a few seconds beforehand, they might have made it out to the left. Not so the right, because of the high ground of Cape Bird, which extended back to about the “five o’clock” position relative to the aircraft. In other words, F/O Cassin was wrong.

You need to appreciate that this accident occurred in a different era. AirNZ’s employment policy up to the mid 1970s was to only employ air force pilots, whether they be RNZAF, RAAF, or RAF. That policy only started to relax when the supply started to dry up. Each and every captain who gave evidence to the Mahon Royal Commission had been a serving officer in an air force, usually the RNZAF. As such, they were all trained navigators and they all knew about the problems associated with briefings. The basic rule, which persists to this day, is that the pilot-in-command is responsible for the route. You can’t put the blame on contradictory information, because the pilot’s job is to sort that out and establish where he/she is going to. That is a fundamental aspect of piloting, and driving, and walking.

I guarantee that almost every 1970s captain will recall receiving contradictory information about a route. What was the response? Pick one and hope it’s right?