Paul Holmes and Erebus

[Brian Abraham]

If one looks at the thread re Pacific Blue and their disputed departure from Queenstown, all because of a minor deviation from SOP'sAnd there's the rub. Everyone (airline management and regulator) knew from the airlines advertising that SOPs were not being complied with, yet chose to do nothing about it. If they were to claim they didn't know they are being just a tad disingenuous.

[prospector]

yet chose to do nothing about it.

Granted, but surely the Captain, by also choosing to disregard SOP's, CAA regs, with no apparent discussion with the crew, neither the first officers or the flt engineers, carried out a descent that ended the way it did must surely shoulder a portion of the blame??

If he decided to disregard the SOP's, CAA requirements for descent, the specific instructions that were laid down for descent on these sight seeing trips, then he would have had to have the same weather conditions as the previous flights, he did not have these conditions.

The decision to descend where and when they did was the captains. The disaster was caused by that descent, therefor he must shoulder a major portion of the blame.

If the flight had of returned then no doubt the non conformity with SOP's and regs would not have been an issue.

It is agreed that previous non conformity with the requirements laid down for descent should have been cause for reprimand, but they were completed without any problems, so they were not. This may have had an influence on the decision of Capt Collins but it should not have, he was faced with the conditions they experienced and his safety margin was supposed to be provided by the descent requirements, which he ignored.

[Ornis]

Brian Abraham

Forget the paperwork for a minute.

Had Collins called on a radio to Auckland, "We are over Cape Hallett", the response might have been, "Thanks, Jim, have a nice day."

Had he called operations later and said, "I've found a bit of a hole in the cloud so I'm going to descend to 2000ft", what do you think the response would have been? Yes, No or be careful?

And then, had he called to say he was on the coast somewhere at 1500ft but couldn't see the mountains; never mind he was going to lock onto the AINS and fly to "McMurdo"? What would the answer have been? "Turn North and climb" or "Come home immediately."

[ampan]

That unannounced descent was Dambuster's stuff.

Lucas would have asked the question, but he was back in the cabin.

What was the question?: "Why are we going between the cloud and the ice VMC when it's very difficult to tell the difference?"

[pakeha-boy]

The crew has to be ulitmately responsible.....

I follow my company,s SOP,s......not always to the hilt.....

SOP,s, state flaps 3 landings is normal ldg procedure.....sometimes I do flaps full(for obvious reason,s)

SOP,s state...must fly most fuel efficent altitude @ CI 35 on prog page......I deviate from this also(for obvious reasons)....

There are many area,s where SOP,S are stated.....and pilots deviate from these...generally SOP,S are "Recomended"......and some SOPS,there is no deviation(for obvious reasons)............

.......any for evey airline Ive ever flown for ,Mgt/Company/Govt Regulating agency.....Tin-plate their Backsides.....by stateing

The Pilot(PIC) is ULTIMATELY resonsible for the safe operation of that A/C.......and whether or not the above controlling agencies cock it up or not......I dont buy into the argument that(the crew) were not responsible....

[4Greens]

Sooner or later ppruners will reread Chippendale's report and realise he was mostly correct in the first place.

[ampan]

“The probable cause of this accident was the decision of the captain to continue the flight at low level toward an area of poor surface and horizon definition when the crew was not certain of their position and the subsequent inability to detect the rising terrain which intercepted the aircraft’s flight path. Although the accident would have been avoided if the aircraft had not descended below safety height it was not inevitable until the aircraft reached 1500 feet AMSL on track to McMurdo and maintained a heading toward GRID north. Had the aircraft been turned toward the true north even at that late stage and either climbed to safety altitude or the crew pinpointed their position and headed towards lower terrain the accident could still have been averted. This is not to say that such a manoeuvre is in any way condoned. The pilot probably assumed that he would be able to see any and all obstructions clearly with a 2000 foot cloud base and 40 miles visibility below the cloud. It is not likely that the potential whiteout hazard indicated by the reports of horizon and surface definition was appreciated by the crew.” (Chippindale Report, pages 53 & 54)


The only thing he got wrong was the last two sentences, given that the captain was aware of the visual problem.

[Ornis]

pakeha-boy

You see, your "problem" is you live in the real world. An analogy, and an analogy is only an analogy, is rape. We all know men should not rape women, and the feminists tell us rape is rape and a woman can say NO at any point.

But if a skimpily dressed woman goes back to a hotel room at 2am with some bloke she met in bar at 1am, is that wise if she is not interested in sex? If she is raped, what use was the law to her?

Or if a teacher supervising a group of children barges onto a pedestrian crossing without making sure the car has stopped, is that wise? Yes, we all know cars should stop; equally we know that sometimes they don't. So if a kid is run over, is she blameless? (She won't be prosecuted.)

Good airmanship means making wise decisions, regardless of the law, company policies or pressure from anyone, to keep the aircraft flying and keep it safe.

I can understand the difficulty of attributing a percentage of blame to the crew and to the company. In my view they both failed miserably. The company's failings I can comprehend: shoddy organisation to the point of sheer confusion. The commander's I find more difficult. It be the human factors my old mother called a "brainstorm".

When I fly down to Ohakea this week and Wanaka next week in my little aircraft, I know things could go wrong. I even accept, although I will have my usual "copilot" to help, things might go horribly wrong. But Collins behaved as if nothing could go wrong.

Brian Abraham writes some of us would have liked Collins to have survived so he could be punished. I would have liked him to have given himself such a hell of a fright he never flew again and the company saw sense. To me that would have been the best outcome anyone could have hoped for in this shocking affair.

[ampan]

Brian Abraham is steering the argument from one he can't win towards one he can. Yes, Reason Model, Swiss Cheese, etc, all good stuff - but what's the relevant issue?

The relevant issue is whether the captain should be "exonerated". No blame at all. So of course there were multiple causes, and of course others in the airline were also to blame, but no-one could reasonably suggest that the captain displayed faultless airmanship.

If I had to select one particular AirNZ employee who has to shoulder most of the blame, it would be Captain Collins. That might not suit his surviving family members, but their feelings are completely irrelevant. Every dead careless pilot had a family.

[framer]

The relevant issue is whether the captain should be "exonerated". No blame at all. So of course there were multiple causes, and of course others in the airline were also to blame, but no-one could reasonably suggest that the captain displayed faultless airmanship.

If I had to select one particular AirNZ employee who has to shoulder most of the blame, it would be Captain Collins. That might not suit his surviving family members, but their feelings are completely irrelevant. Every dead careless pilot had a family.
Thats it in a nutshell right there.

[Ornis]

ampan, I agree. Brian gives as an example a young lad sent to do a task by the RAAF, for which he was probably not sufficiently trained and experienced.

Collins was perfectly well trained and experienced to do what AirNZ tasked: stay above 16000ft to "McMurdo" (clear of Erebus whatever the track) and descend to 6000ft in VMC after liaison with ATC (radar).

He was well enough prepared to do this task, whatever the deficiencies we see now. What he was not prepared for, although he could have been, with his background and qualifications, was to descend on the coast and fly to "McMurdo".

It's not so much that AirNZ changed the goalposts as Captain Collins changed the game. It changed from an airline operation to a specialist polar operation, and AirNZ did not do this. Captain Collins did, all on his very own.

[grip pipe]

It's a funny thing the way this accident plays in the public mind and resurfaces from time to time, such as here at PPrune re the Paul Holmes publication. I recall the day the news of the aircraft was overdue became public knowledge and immediately knew what that meant and I don't think there was an Australian or New Zealander who was not both shocked but saddened by the accident. That it was the Antartic gave it a different mystique.

Sadly a perfectly serviceable DC-10 and 257 lives were destroyed that day on what was supposed to be a routine sightseeing charter flight. All the inquiries and investigations have shown that each and every level there were failures in systems and processes, some with human causes, some with not, but the layers of protection for Captain Collins and FO Cassin and the FE were steadily removed. The Chippendale report is as a black letter report, correct, possible cause and avoidance actions are as they were described by Mr Chippendale. CRM failed and before danger was recognised, the accident occurred. Mr Holmes would do well to understand the description of Ron Chippendale as an individual provided by Mr Justice Mahon to appreciate the man was 'old school' and by the book that is all.

Mr Justice Mahon's Commission of Inquiry pulled back the covers on the various layers of the fabric that constituted air safety and found them wanting. His findings are unimpeachable on matters of fact or law.

Critically, the relatioship between the hard chart documents and what was in the FMS of the DC-10 were different at a critical point in the aircraft's route. The reasons for this are established. The behaviour and cultures of various organisations both the Department and Air New Zealand were less than impressive for either honesty or integrity and a certain sloppiness had crept into a non scheduled route flight briefing and managment for flights involving this large aircraft and the area in which it was to be operated that was to prove fatal. The furtive activities of some were immature responses to a very real tragedy in New Zealand, like minds behave like but are not necessarily conspiring.

The original question posed was the issue of exoneration for the crew. The question is unnecessary, the crew was always to be exonerated for while they made a mistake, they were not at fault as they were deceived by the information they had and a severe lack of personal knowledge of the physical geography they were overflying. The safety systems of Air NZ failed the crew not the crew Air NZ. So there is no matter of guilt. The men and their passengers already paid for their mistake with their lives and that in my judgment is enough of a penalty.

We should let all involved rest and let time heal the wounds.

[framer]

Nobody is talking about guilt Grip. We are talking about responsibility.

The original question posed was the issue of exoneration for the crew. The question is unnecessary, the crew was always to be exonerated for while they made a mistake, they were not at fault as they were deceived by the information they had and a severe lack of personal knowledge of the physical geography they were overflying. The safety systems of Air NZ failed the crew not the crew Air NZ.

Are you sure they made a mistake Grip?
If so was it a lapse or a slip?

The safety system that you talk of should definately have been robust enough to withstand one or two of these without catastrophe.

Are you sure there wasn´t a violation involved?
Violations sometimes appear to be human errors, but they differ from slips, lapses and mistakes because they are deliberate ˜illegal actions, i.e. somebody did something knowing it to be against the rules (e.g. deliberately failing to follow proper procedures).
There is not a safety system in the world that can defend against violations.

I am not defending Air New Zealand or the CAD, there were plenty of room for improvement on all sides, but to say that the crew were in no way responsible for the crash not realistic.

[prospector]

deceived by the information they had and a severe lack of personal knowledge of the physical geography they were overflying

And with that severe lack of knowledge they decided to descend to 1500ft, trusting on the AINS for track guidance. They certainly knew Ross Is and Mt Erebus were close, but they never sighted them once, certainly not enough for a positive identification of their position.

It has been established without doubt that the AINS was not to be used for Nav below route MSA.

The route MSA was the same no matter what the final waypoint position was, the TACAN or the head of McMurdo Sound, it was FL160.

The safety systems of Air NZ failed the crew not the crew Air NZ

That statement has been proven wrong so many times by so many eminent people, including Judges, Airline Pilots, Aircraft Accident Inspectors that the only people who believe it to be correct are obviously lay people with no knowledge of the workings of Civil Aviation, Paul Holmes being a good example.

passengers already paid for their mistake with their lives
And what exactly was their mistake????

[Ornis]

I don't know what to say. Did you read any of these comments, grip pipe? Follow any of the arguments?

Let me try another analogy. You are an instructor and finally you decide to send a student on the first solo. So you depart the aircraft and tell the student to do one circuit and land. To you horror, the student vacates the aerodrome and subsequently crashes into Mt Pirongia.

So, tell me, grip pipe, are you to blame for this crash? You sent the student on a simple task you judged him ready for and he buggers off to do his own thing.

No grip pipe. The fact of the matter is, and it's harsh, Captain Collins took the aircraft down below MSA without adequate preparation and safeguards and killed his passengers.

Happens all the time in General Aviation. The difference with this crash is the refusal to face the truth and the classic "Appeal to Authority" argument. Mahon might well have been right about about AirNZ, but he didn't have a clue about aviation. And that's a fact. I don't know much either but I know bull**** when I see it.

[pakeha-boy]

Quote....grip pipe......The original question posed was the issue of exoneration for the crew. The question is unnecessary, the crew was always to be exonerated for while they made a mistake, they were not at fault as they were deceived by the information they had and a severe lack of personal knowledge of the physical geography they were overflying. The safety systems of Air NZ failed the crew not the crew Air NZ. So there is no matter of guilt. The men and their passengers already paid for their mistake with their lives and that in my judgment is enough of a penalty.

nothing personal grip.....but that, I find disturbing....we have come along way in the many years since this very sad situation,(Training CRM Accident investigation)..that could have been easily averted.........I have learned from it myself.....but once Collins accepted and signed that Dispatch release(as it is today also), HE...becomes ultimately responsible ..........as I am when I accept the release...and yes there are many factors in this situation........but Collins becomes the end game

[grip pipe]

Gentleman, your strong condemnation of the crew is of concern to me as the issues that resonate most about this tragedy, concern what was known and what was not known and thus inform us about the probable state of mind of the PIC of this flight. That was what Justice Mahon was on about, the reasons not just the acts. Chippendale's version is about the acts not the reasons. Neither Commission of Inquiry or Accident Investigation is comfortable or pleasant reading.

In defence of the crew on the day there are a lot of presumptions made but none really known except what we found out later from the hard physical facts of the evidence that remained. There are a lot of assumptions about safety systems and CRM and there are a lot of assumptions about SOPS.

The issue of deception is critical to understanding what went on that day.

The deception caused by the change in the route coordinates. The deception of time and place and geographical illusions combined with visual illusions. The deception that comes from a reliance on SOPS which were inadequate and poorly thought out.

What was not known was the change in the nav coordinates by AIR NZ flight planning, what was not known was that the changes placed the aircraft in a perilous position at a critical phase in flight where it was expected that the aircraft would be visual, positive of the position and positive about what they were seeing. They were deceived about where they were going to fly.

They were decieved by what they saw. So you think you are one place,your somewhere else, you look out the window and it looks the same, it appears to look like it should ice and sea about the right shape and orientation, but you have never seen it before, you look out the window and it is a sodden grey-white sky with a sodden grey-white surface below. What you may have expected to see and what you were actually seeing may have even been quite incomprehensible except to a trained and experienced eye.

They were deceived by the complacency that was created by past flights operating below MSA without problems in the most inhospitable place on the planet.

The overall deception of safety that was created by the view that it was just another charter flight.

The deception of what to expect and see created by not having current and relevant visual photographic materials and charts properly put together as a briefing aid.

The deception created by the reliance on visual identification to a person who was not part of the flight crew nor an experienced aviator.

The deception of how to to do it when you got there created by not doing sim sessions, where white-out could be experienced and phases of the flight practiced, particularly if a crisis or emergency arose. So a descendng high speed visual fly up into a funnel of rising terrain in an area guaranteed to be probelematic due to visual illusions became an acceptable current airline operational practice and was not practised.

So when a critical decision was finally made to climb out to safety in the right direction was made, the crew were completely and thoroughly deceived and hence not clear about what they were doing and where they were doing it and they forgot how to do it. The leisurely way in which the crew reacted tells you everything about the state of complacency brought about by the deceptions which lulled them into that place in the first place and which promptly killed them and everyone else.

So you would hold Capt Collins responsible for his and this deception?

I cannot.

I can hold him accountable for his mistakes but not the debauched way in which he was led to make them.

The flights should never have been conducted as they were in the first place. The flights should never have been authorised or approved by either the Airline or the Regulator. They were not properly planned, briefed or practised. The aircraft carried no appropriate survival or safety equipment. There was no appropriate alternate place of safe landing once past 60 degrees south.

Those failures of responsibility belong to the Chief Pilot and the Chief Check Pilot and the Operations Department and the Airlines management. They were all responsible.

So no one really asks the critical question:

Is it really a safe thing to do to fly a commercial airliner carrying 257 passengers over the Antarctic and past or near to a mountain range and a volcano that is 12,500 ft high into possible white-out conditions that virtually coincides with the PNR without safety equipment and alternatives ?

And the answer to that is a simple - No it is not and as the events show it was not. The outcome was always predictable, if it had not been Captain Collins and his passengers that day, then it would have been another Captain and another crew another day at some time.

So it is my view that no one is absolved of blame in this one, no one.

[framer]

Gentleman, your strong condemnation of the crew is of concern to me

Grip I don't think many here actually want to knock the crew. I think most were happy to let time pass and stay quiet. It is the cal for "exoneration" that has promted some of us to point out that the crew hold some responsibility for the jet flying into Erebus and therefore an exoneration is not appropriate.

Your last sentence So it is my view that no one is absolved of blame in this one, no one. seems to be in agreance with that because if no one is absolved of blame then there can be no exoneration.

At the end of the day Collins took his heavy jet down to 1500 feet at 250kts, clean, in an unfamiliar location not long after he had made comment on the difficulty to distinguish between the ice and the sky.He didn't do this once south of Erebus. It would have been a very uncomfortable flight deck.

[ampan]

Very uncomfortable: Just before getting down to 2000 feet, and three minutes before the decision to climb out, F/E Brooks said "Where's Erebus in relation to us at the moment?" followed by "I'm just thinking of any high ground in the area, that's all".

Everyone, including Vette, Holmes, and Collins, accepts that the DC10's inertial nav system wasn't to be used to go below MSA.

"But he was visual", says NZALPA.

No, he wasn't - and he knew he wasn't. The captain's repeated "VMC" utterances on the way down did not make it any easier to distinguish the cloud from the ice.

Yes, other captains went below MSA. So what? They were visual. No-one else did what Collins did. Dalziel took the alternate route, while Ruffell went to the Dry Valleys. The rest had blue skies, and went where they pleased, perfectly safely.

[prospector]

Is it really a safe thing to do to fly a commercial airliner carrying 257 passengers over the Antarctic and past or near to a mountain range and a volcano that is 12,500 ft high into possible white-out conditions that virtually coincides with the PNR without safety equipment and alternatives ?


Yes it is, if proper respect for the mandatory requirements re descent and low level flight are complied with. And a modicum of common sense re suitable weather conditions for these low level sight seeing flights is exercised.

There was a number of flights carried out without any drama, even though CAA requirements of minimum altitudes were allegedly abused, by some very senior pilots, including at least one check pilot.

If these flights are inherently dangerous why are they still being carried out by another airline??

Antarctica Flights (http://www.antarcticaflights.com.au/)
Have a look at the flight route for 15th Jan 2012. Observe the amount of bare rock at the summit of Mt Erebus, completely shoots down the Mahon argument that there would be no return from the radar due to dry snow on the mountain, Was the Radar even turned on?? or was that another mistake.

If as you say flying in the Antarctic is so very dangerous why do many service aircraft operate there regularly, even transporting VIP's, without any problem???

And the answer to that is a simple - No it is not and as the events show it was not. The outcome was always predictable, if it had not been Captain Collins and his passengers that day, then it would have been another Captain and another crew another day at some time

Not unless the same blatant disregard for all the requirements that had to be complied with before descent below route MSA were not complied with.

[pakeha-boy]

Quote grip..."So when a critical decision was finally made to climb out to safety in the right direction was made'....

Not sure about that mate.....is that when the GWPS went off ..or are we taliking something else??

[reubee]

Quote grip..."So when a critical decision was finally made to climb out to safety in the right direction was made'....

Not sure about that mate.....is that when the GWPS went off ..or are we taliking something else??

14 seconds prior to the GPWS sounding, the captain made the decision to get out of there.

2 seconds before the GPWS sounded, they selected heading select to turn the aircraft around.

They didn't like what they could see and interpret , they reacted accordingly. Unfortunately for them the big area of white/grey they could see in front of them they didn't interpret as a mountain.

Just as the cliffs either side they could see they interpreted as McMurdo Sound and not Lewis Bay

[ampan]

It's by no means certain that the captain thought he was in McMurdo Sound when he pulled out the heading select knob, given the direction he turned it.

[Ornis]

ampan. The ALPA spin is that the change in "McMurdo" upset Collins' situational awareness. No, he never had proper situational awareness; he had a mindset.

I stand to be corrected on this, but I don't "see" Lewis Bay with Ross Island on my right looking anything like McMurdo Sound with Ross Island on my left. Any pilot familiar with the area given an opinion on this?

I cannot help but think if it looked the same they didn't see much (notwithstanding the sector whiteout south) despite the reported visibility at McMurdo Station 40nm? clear (with whiteout). Were the cliffs obscured by fog (Mahon)?

Naturally any VFR flight would track to BYRD, but it was a IFR flightplan, that's the nub.

[framer]

Thats actually all irrelevent in my opinion Ornis.
They should never have been there in the first place. They should have been at FL 160 repeatedly trying to make contact on VHF. They would have made contact about then anyway and all would have become clear.

[ampan]

I think the rules back then required Chippindale to find the point where the accident became inevitable, which is why he ended up down at 2000 feet, rather than back up at 16000 feet.

[framer]

Yeah , i just think there is no point getting into what they potentially thought they could or couldn´t see once they had descended to 1500 feet.
It was his job and responsibility to separate the aircraft from terrain, there were several different ways he could have gone about it. The option he chose was both illegal and unsuccessful.

[topend3]

Thats actually all irrelevent in my opinion Ornis.
They should never have been there in the first place. They should have been at FL 160 repeatedly trying to make contact on VHF. They would have made contact about then anyway and all would have become clear.

A very valid point for the "let's exonerate" team to remember. Why did the fact they had lost VHF coverage lead to a descent down to 2000 feet?

The accident could have been averted at that point. Then the issues surrounding the changed flight plan, briefing anomalies etc could have been resolved when the aircraft arrived back at Auckland. 257 lives would have been saved. I think Collins got his priorities mixed up and was more intent on giving the punters a better sightseeing experience.

[pakeha-boy]

so...the "CAPTAIN" of the Aircraft is not "responsible" ...for the final out come of the(a) flight???.......just asking......Im missing something here.....

[Ornis]

I am curious to know just what they saw on the coast. If you saw the coast clearly for >20km each way would you realise you were not west of Erebus.

People, even those who know a bit about aviation, are being duped by Poor Gnomes, I've spoken with some.

In the mid 60s I flew in a SPANZ DC3 from Dunedin to Auckland via Nelson. It was a spectacular day and the pilot deviated to show us Ruapehu. Don't know what altitude flights typically were, not much above 8000ft I guess. And that's the thing Mahon and Holmes can't see, you have to choose your day. As our pilot did.

[ampan]

I think that this is why the old captains (ie, Prospector from Imperial Airways, Derek Ellis from BA, ex-Concorde, the late Sir Rochford Hughes, and many more) get so pissed off about this nonsense.

Fly with your eyes when you can see. If not, you're on instruments.

[deadhead]

So why don't the old captains do something concrete about it, instead of periodically rising off their corporeal slabs and sobbing to the nearest newspaper editor ?

[DozyWannabe]

Yeah , i just think there is no point getting into what they potentially thought they could or couldn´t see once they had descended to 1500 feet.

"Potential" has nothing to do with it. The entire crew were *certain* they were over McMurdo Sound, and as soon as they weren't certain about being visual they elected to attempt an escape.

There's a reason that Chippindale's attitude of the buck stopping with the Captain regardless of the circumstances died off in the early '80s and that every successful accident investigatory agency has since used Mahon's deductions as a blueprint, and that reason is the inescapable fact that with airlines becoming multi-billion dollar conglomerates, the chain of responsibility becomes more complex.

The only person that knew they were headed into Lewis Bay rather than McMurdo Sound at the time of the accident was Chief Navigator Hewitt, and he was in his office in Auckland at the time.

The ability for Lewis Bay to appear very similar to McMurdo Sound is an unfortunate coincidence of topology, distance and perspective. Certainly something that a pilot headed down there for the first time would not know about - it even seemed to convince the late Peter Mulgrew.

There's another aspect to this that I'd forgotten about, by the way. ANZ was limited in terms of liability for the lives lost by international agreement. However NZCA was not, and if it became a matter of legal record that NZCA were in any way responsible for the loss of TE901, then it had the potential to bankrupt the Muldoon government. Chippindale may not have been aware of this, but you can bet his bosses were.

[baron_beeza]

The entire crew were *certain* they were over McMurdo Sound

That I very much doubt. Some were not even in the cockpit.
All the warnings were there but the Capt still elected to operate below MSA.
The crew thought they were going to descend under radar guidance.

The Captain initiated a descent without even consulting the crew.

How did they ascertain their position before the descent ? I believe they did not.

[DozyWannabe]

That I very much doubt. Some were not even in the cockpit.

One wasn't - and that was par for the course, because Mulgrew had to be in there.

All the warnings were there

What warnings?

The crew thought they were going to descend under radar guidance.

They thought they *were* under radar guidance, and so did the Captain (by way of the transponder light blinking on and off).

The Captain initiated a descent without even consulting the crew.

The CVR says different. How's a DC-10 Captain supposed to initiate a descent without the FO seeing the control column, altimeter and artificual horizon? The first words of unease came once they were already down, and the Captain immediately decided to climb.

How did they ascertain their position before the descent ? I believe they did not.

That's the million-dollar question. Captain Collins' ringbinder, in which he kept all his material, was retrieved from the mountain ice with all its pages intact and with legible writing, according to the team member that found it. It was handed to ANZ's Chief Pilot Capt. Gemmell for "safe keeping", and subsequently appeared in Auckland at the inquest with all its pages missing.

This had the effect of destroying the one piece of evidence that could conclusively confirm or refute that Capt. Collins had done his due diligence and was checking off his position, and making sure that it would forever be in doubt. For my part, I'm deeply suspicious of the fact that the evidence disappeared while in the care of the man who had a lot to lose if pilot error was not found to be the cause.

[prospector]

They thought they *were* under radar guidance, and so did the Captain (by way of the transponder light blinking on and off).

If you were aware of basic rules and regulations appertaining to this flight you might come up with something better to justify your posts.

Radar descent could not be started until there was direct VHF contact between FLT 901 and McMurdo radar.

VHF contact was never established. All communication was via HF.

What warnings?

This has been stated so many time one wonders if you bother to read any of the posts.

We will try again.

VHF is line of sight, there was no radar contact, there was no reception of the DME from the TACAN and no receipt of VHF communications. They were well within range of these services, they should have had reception but they did not, now what could be the only thing that could stop reception of these services?? they were not where they thought they were because Mt Erebus was between them and the TX stations.

[Flt.Lt Zed]

Dozy.......Since when did a blinking transponder [2 blinks from memory] equate to being radar identified ? First you must hear the magic words ' You are identified [position]' followed by tracking and descent INSTRUCTIONS. Since there was no VHF contact....No Radar service.

[framer]

Dozy will never get it because he´s never done it. We can try and try to explain these things to him but at the end of the day he has reached a conclusion and then just builds arguments around that conclusion.
There is a pattern, the loudest most outspoken lobbyists for an exoneration have never flown an airliner. They have most likely never been responsible for anybodies safety but their own and will never quite get what that means or entails.

[ampan]

Dozy is leading himself astray with conspiracy theories, just like Mahon. For example, he links the missing pages from the ring binder with the issue of whether the crew were certain of their position, when they are not actually related at all. Let's assume that one of the missing pages had the final waypoint at 164E, in the middle of the Sound. So what? We already know that Captain Collins thought that's where the waypoint was (unless it was a murder/suicide). The real point is that the universal rule for a 1970s DC-10 captain was that the inertial nav system was not sufficient for a descent below MSA (which is why the captain pretended to be visual). If he was actually certain of his position before he went down, then he had no right to be. And if he was so confident in the accuracy of the AINS, then why was he so pleased to receive the offer of the radar-assist?

The correct precedure was reasonably obvious, wasn't it?: Stay above MSA to the waypoint. If still no VHF contact, go to the Dry Valleys. The only issue would be whether the TACAN alone could be used to confirm the aircraft's position before going through the cloud layer. Given that it only provided distance information, it would be a 50/50 situation, which means you would think about for a few seconds and then forget it and head for the Dry Valleys.

[Brian Abraham]

If these flights are inherently dangerous why are they still being carried out by another airline??Because at no stage do they ever descend below 16,000. Done the trip and highly recommended.
If he decided to disregard the SOP's, CAA requirements for descentReally?? The brief said,
THE LOW FEQUENCY NDB APPROACH AT MCMURDO, WHICH PREVIOUSLY PROVIDED OUR ANTARTIC FLIGHTS WITH AN AUTHORISED CLOUD BREAK PROCEDURE TO 6000 FEET, HAS BEEN WITHDRAWN, CONSEQUENTLY THE LET-DOWN BELOW THE COMPANY SECTOR SAFE ALTITUDE OF 16,000 FEET, IS STRICTLY VISUAL AND PERMISSION HAS BEEN GIVEN TO DESCENT TO 6000 FEET QNH IN VMC.It is agreed that previous non conformity with the requirements laid down for descent should have been cause for reprimand, but they were completed without any problems, so they were not. This may have had an influence on the decision of Capt Collins but it should not have, he was faced with the conditions they experienced and his safety margin was supposed to be provided by the descent requirements, which he ignored.As far as I read it he complied exactly with the descent requirements, save the 6,000 feet. - further below.
Chippendale got it right when he said,
The pilot probably assumed that he would be able to see any and all obstructions clearly with a 2000 foot cloud base and 40 miles visibility below the cloud. It is not likely that the potential whiteout hazard indicated by the reports of horizon and surface definition was appreciated by the crew.Their lack of appreciation comes from the fact they had never been exposed to the conditions previously. Book learning is OK up to a point, but at some stage you have to experience it to make sense of it. It is not for nothing that VFR operations (helo) down on the ice cease if there is an overcast. The one exception to that rule is if they are operating on the coast where surface definition between land/ice/water is available.

Nor is it for nothing that the aircrew who operate down on the ice go through an extensive hands on training program (besides the book learning) before being let loose on their own.

Spent the last week camping with a group of friends, one of whom commanded the first RAAF C-130 to go into McMurdo, and was responsible for training all RAAF crews who followed. He commented that he was "staggered" (his word) that on his first trip to the ice (with another C-130 operator), they permitted him to be the PF. Felt thrown into the deep end, even though the Captain, Nav and FE were all old ice hands providing the mentoring.
"But he was visual", says NZALPA.

No, he wasn't - and he knew he wasn't.
The captain himself told some "simple bloody lies" during the final 30 minutes of his life, given the various references to VMC. Thats about as libellous as you can get.

There is absolutely no proof that the descent below MSA was carried out in anything other than VMC conditions. That the descent was continued below 6,000 is moot, had the cloud base been 4,000 feet higher in order that the 6,000 minimum could be complied with, the accident site would merely be 4,000 feet higher up the mountain side. The Flight Operations Manager said it did not occur to him that knowledge of whiteout and altered perception could be of help to a pilot at 6,000 feet to decide whether he was in VMC. From my own experience on the one trip to the ice I found it impossible to tell that we were VMC in whiteout conditions at 18,000 feet. The only give away was the shadows of isolated cloud on the ice/snow. You could not see the cloud of course, just the shadow, yet visibility was to the horizon - I say to the horizon because we flew for approx 30 or 40 minutes on that particular leg at 18,000 and could detect isolated cloud shadow continuously.
Yes, other captains went below MSA. So what? They were visual.Just as Collins was, though in "better" conditions.

We seem to have a misunderstanding to some degree about what VMC is. In VMC an aircraft can be considered to be at the centre of a sterile bubble whose vertical and horizontal dimensions are laid down by authorities. It relies upon the pilots vision to detect any intrusions into that sterile bubble, whether it be terrain, fog, cloud, smoke, aircraft, rain, radio antenna, snow, or whatever other obscuration you may think of. All detection systems have limits, whether it be radar or anything else, and the eye is no exception. Whiteout is one of those limitations. It only detects a very small part of the electromagnetic spectrum, and would be of great help if it could pick up infra red in this situation.

The basic tenet of VMC is that you can pluck a pilot and place him in an aircraft anywhere in the world without a map, or him knowing where he is, and he can fly all day as long as his fuel and bladder can hold out. The only time a map comes in handy is knowing where an airfield is when the fuel gauge starts bouncing on "E", or the bladder needs draining.

Much is made about the use of radar in the mapping mode, and the crews apparent lack of use. Once again a simple question to a complex issue. The interpretation of ground returns is once again a skill that is not in the average airline pilots bag of tricks, beyond the delineation of surfaces with markedly different dielectrics eg land/water. Should you wish to delve into the complexities of interpretation when ice/snow are introduced, have a read of a good primer, "Radar Reflectivity of Land and Sea" by Maurice W. Long.

Not for nothing do military crews use radar maps so they can make sense of what's showing on the screen.
Brian Abraham is steering the argument from one he can't win towards one he can. Yes, Reason Model, Swiss Cheese, etc, all good stuff - but what's the relevant issue?You need a new crystal ball my friend, because your current one is giving you static. As to asking "what is the relevant issue" displays a total lack of understanding how accidents come to be just that. You might redigest grip pipes excellent post reproduced below.
If I had to select one particular AirNZ employee who has to shoulder most of the blame, it would be Captain Collins.Once again a statement that shows absolutely no understanding of accident causation. Everyones hands are sullied, regulator, airline and crew. Unfortunately the crews actions on the day were tainted by the flagrant lack of adherence to SOPs by nearly all who went before, and an underwriting of the lack of adherence by all within the airline and the regulator.

A house built on poor foundations.

I'm not in the business of picking a particular employee to blame, as there is more than enough humble pie to be served, but a question I would have raised would have been regarding the route from Hallett to McMurdo. Why directly overhead Erebus, and not following the RNC route down the sound?

Overflying the crater of an active volcano, with frequent Strombolian eruptions known to toss bombs up to 3 metres in diameter a kilometre into the sky and 700 metres laterally, does not show due diligence by whoever was responsible for route planning. There is a reason the RNC route runs down the sound well clear of Erebus.

Lets assume Captain Collins maintained his sanctioned 16,000 feet overflying Erebus, and took a lava bomb which caused the destruction of the aircraft. Does he carry the ultimate responsibly as argued by some? Or might it fall elsewhere?

Gentleman, your strong condemnation of the crew is of concern to me as the issues that resonate most about this tragedy, concern what was known and what was not known and thus inform us about the probable state of mind of the PIC of this flight. That was what Justice Mahon was on about, the reasons not just the acts. Chippendale's version is about the acts not the reasons. Neither Commission of Inquiry or Accident Investigation is comfortable or pleasant reading.

In defence of the crew on the day there are a lot of presumptions made but none really known except what we found out later from the hard physical facts of the evidence that remained. There are a lot of assumptions about safety systems and CRM and there are a lot of assumptions about SOPS.

The issue of deception is critical to understanding what went on that day.

The deception caused by the change in the route coordinates. The deception of time and place and geographical illusions combined with visual illusions. The deception that comes from a reliance on SOPS which were inadequate and poorly thought out.

What was not known was the change in the nav coordinates by AIR NZ flight planning, what was not known was that the changes placed the aircraft in a perilous position at a critical phase in flight where it was expected that the aircraft would be visual, positive of the position and positive about what they were seeing. They were deceived about where they were going to fly.

They were decieved by what they saw. So you think you are one place,your somewhere else, you look out the window and it looks the same, it appears to look like it should ice and sea about the right shape and orientation, but you have never seen it before, you look out the window and it is a sodden grey-white sky with a sodden grey-white surface below. What you may have expected to see and what you were actually seeing may have even been quite incomprehensible except to a trained and experienced eye.

They were deceived by the complacency that was created by past flights operating below MSA without problems in the most inhospitable place on the planet.

The overall deception of safety that was created by the view that it was just another charter flight.

The deception of what to expect and see created by not having current and relevant visual photographic materials and charts properly put together as a briefing aid.

The deception created by the reliance on visual identification to a person who was not part of the flight crew nor an experienced aviator.

The deception of how to to do it when you got there created by not doing sim sessions, where white-out could be experienced and phases of the flight practiced, particularly if a crisis or emergency arose. So a descendng high speed visual fly up into a funnel of rising terrain in an area guaranteed to be probelematic due to visual illusions became an acceptable current airline operational practice and was not practised.

So when a critical decision was finally made to climb out to safety in the right direction was made, the crew were completely and thoroughly deceived and hence not clear about what they were doing and where they were doing it and they forgot how to do it. The leisurely way in which the crew reacted tells you everything about the state of complacency brought about by the deceptions which lulled them into that place in the first place and which promptly killed them and everyone else.

So you would hold Capt Collins responsible for his and this deception?

I cannot.

I can hold him accountable for his mistakes but not the debauched way in which he was led to make them.

The flights should never have been conducted as they were in the first place. The flights should never have been authorised or approved by either the Airline or the Regulator. They were not properly planned, briefed or practised. The aircraft carried no appropriate survival or safety equipment. There was no appropriate alternate place of safe landing once past 60 degrees south.

Those failures of responsibility belong to the Chief Pilot and the Chief Check Pilot and the Operations Department and the Airlines management. They were all responsible.

So no one really asks the critical question:

Is it really a safe thing to do to fly a commercial airliner carrying 257 passengers over the Antarctic and past or near to a mountain range and a volcano that is 12,500 ft high into possible white-out conditions that virtually coincides with the PNR without safety equipment and alternatives ?

And the answer to that is a simple - No it is not and as the events show it was not. The outcome was always predictable, if it had not been Captain Collins and his passengers that day, then it would have been another Captain and another crew another day at some time.

So it is my view that no one is absolved of blame in this one, no one. On the money grip pipe, well said.

"All truths are easy to understand once they are discovered; the point is to discover them." - Galileo

[topend3]

I'm not in the business of picking a particular employee to blame, as there is more than enough humble pie to be served, but a question I would have raised would have been regarding the route from Hallett to McMurdo. Why directly overhead Erebus, and not following the RNC route down the sound?


I understand Air New Zealand chose this particular route (even though the previous flights operated on the other plan) in order to remain clear of military traffic going into McMurdo...

[prospector]

Really?? The brief said,


It also said,

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

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

They never got a DME lockon to TACAN 29. They were never identified by radar so how could they be advised of other traffic?? or other traffic advised of their presence??

All the rest has been debated backward and forward and sideways, but if those two mandatory requirements for VMC descent below FL160 were complied with then there would have been no crash.

[framer]

Brian, do you think the crew should be officially exonerated from any responsibility like Holmes and Dunne are calling for?
After reading your well thought out post I am genuinely interested to know.
Cheers.

[Brian Abraham]

do you think the crew should be officially exonerated from any responsibility
framer, you ask a most difficult question.

Aviation has always been bedevilled by the "you don't know what you don't know". Aviators of old were killing themselves by entering what came to be known as a "Parkes Dive". Wilfred Parke, a test pilot, accidentally entered one of these "dives" at 700 feet, and after much difficulty recovered at a height of fifty feet, the first man to ever effect recovery. You, I, and the rest of the world now know a "Parkes Dive" as a spin. This was in 1912, and it wasn't until WWI that the spin recovery procedure he discovered was taught to pilots. So pilots continued to die in the interim, because they didn't know what they didn't know.

During WWII the USAAF taught aircrew that flight through a thunderstorm was a non event for a properly trained aviator. Today we know better. They didn't know what they didn't know, at least until Robert N. Buck conducted thunderstorm research during WWII. His book "North Star Over My Shoulder" describes all.

Fast forward to more recent times and jet aircraft were crashing on take off and on approach. It took Prof. Ted Fujita to discover the microburst phenomena to explain the accidents, and so procedures (escape manoeuvre) and equipment (doppler radar) were developed to counter same. Crews were caught by not knowing what they didn't know.

Captain Collins was caught out by whiteout, as described by Chippendale. He didn't know what he didn't know, the result of inadequate training. But then, those in management writing the procedures for the polar flights probably didn't know what they didn't know. Might an attitude of "aviation invented here" be prevalent within the company at the time? It occurs in many organisations who are loath to seek advice from others with the necessary expertise outside.

There is a theory called "The Normalisation of Deviance", developed by Prof. Diane Vaughan to explain the "Challenger" space shuttle accident. NASA management became accustomed to the "O" ring degradation phenomena on the boosters when no serious consequences resulted. Normalisation of deviance was present in the loss of space shuttle "Columbia" as well. Specifications called for the external tank not to shed foam. The majority of shuttle launches recorded foam strikes and thermal tile scarring, even causing a dent four inches wide and three inches deep on one flight. Engineers came to see the foam shedding and debris strikes as inevitable and unresolvable, and a maintenance problem, not a safety of flight issue.

Normalisation of deviance is seen in the operation of the polar flights as well. The failure to comply with SOPs was known to all, and the company got away with it for a time, but as inevitable as night follows day, the inherent failures caught up with the company. That the man in the seat on that fateful day was Captain Collins is neither here, nor there, as grip pipe so eloquently put it,
The outcome was always predictable, if it had not been Captain Collins and his passengers that day, then it would have been another Captain and another crew another day at some time.You can only roll the dice so often.

While the polar flights were a cowboy operation, Captain Collins played his role, and as such can not be exonerated, as is being called for in some quarters. But nor can he be blamed. Seeking to blame is for lawyers looking to savage someones bank account, and ambulance chasers. It has no place in understanding how accidents eventuate.
Avoid Mt Erebus area by operating in an arc from 120 Grid through 360 grid to 270 grid from McMurdo FieldThey had no means of determining their azimuth from McMurdo, so that wasn't going to work.
but if those two mandatory requirements for VMC descent below FL160 were complied with then there would have been no crashOnce again a complete failure to understand the whiteout phenomena.

[ampan]

I don't see how anyone can seriously suggest that the captain was visual. As a matter of fact, he obviously was not, given what occurred. So the issue is what he believed at the time, and we know that he believed that it was very difficult to tell the difference between the cloud and the ice. The captain did not have to have experienced a whiteout before in order to appreciate the problem (just as he did not have to have flown VMC at night in order to appreciate the problems in that regard).

So why did he purport to be visual? The probable answer is that he was actually relying on the AINS - and the AINS alone, given that he couldn't get the Tower on VHF radio. Was that allowed? Definitely not. So how was he going to get to see the scattered shacks at McMurdo Station ("I prefer here first") for the first time? Pretend to be visual.

PS - That's not defamatory, because the captain is dead. Paul Holmes knows that rule back the front.

[prospector]

They had no means of determining their azimuth from McMurdo, so that wasn't going to work.


So, what in effect you are stating is that the AINS was accurate enough to establish a position with enough accuracy to be blatting around at 1500 ft illegally, but not accurate enough to establish a position within the required arc and distance of the McMurdo TACAN above route MSA quite legally?????


While the polar flights were a cowboy operation, Captain Collins played his role, and as such can not be exonerated, as is being called for in some quarters.

And surely that is what the whole thread is about? The points that have been made are not so much to pin blame, but to disagree with the call by Paul Holmes and others for complete exoneration of the crew, especially Capt Collins.

[ampan]

"But he was visual" says NZALPA again.

So it all gets back to the VMC point.

Brian Abraham spends many words explaining the principles of visual flying, but studiously ignores the crucial sentence from the CVR transcript.

The following are undisputed facts:

Captain Collins knew that it was very difficult to tell the difference between the cloud and the ice.

He knew there was a 13000 foot mountain in the vicinity, covered in ice.

He descended from above the cloud to below the cloud, thereby putting the cloud above the aircraft and the ice below.

He descended below MSA and below the height of the known hazard.

He purported to descend VMC, which meant that took responsibility for keeping the aircraft clear of terrain, his primary tool being his eyes.

To repeat, the terrain below was covered in ice, which he knew.

To repeat, the cloud was above, which he knew.

To repeat, it was very difficult to tell the difference between the cloud above and the ice-covered terrain below, which he knew.

So did he have visual meteorological conditions below the cloud? Of course he didn't. If Brian Abraham can cite one single solitary source that says that a pilot is VMC in the above circumstances, then I'll eat my cat.

[framer]

Thanks Brian,

framer, you ask a most difficult question.

it is THE question of this thread. It is very easy for me to answer.

Captain Collins played his role, and as such can not be exonerated, as is being called for in some quarters. But nor can he be blamed. Seeking to blame is for lawyers looking to savage someones bank account, and ambulance chasers.

I agree he cannot be exonerated and that is what this Paul Holmes discussion is all about. As for laying blame, it seems every time someone says they shouldn't be exonerated others jump up and down saying "you shouldn't look for someone to blame". It's not about laying blame, it's about being realistic and accepting that the Captain of that airliner did hold some responsibility for it hitting the mountain and therefore a public exoneration is not appropriate.

[framer]

Brian,along the lines of "you don't know what you don't know", do you think that Collins a) didn't know that it was unorthidox to operate a heavy jet at 1500feet clean, 250 knots while trying to navigate visually in an area he'd never been to, with visibility issues ("very difficult to tell the difference between the cloud and the ice"), no VHF contact that he had been expecting, known ice covered terrain in the area, and crew members saying things such as "where is Erebus from here?, I'm just thinking of terrain thats all", while 14,000ft below MSA?
or b) knew that it was unorthidox but was wrapped up the ANZ culture of getting the job done and made a series of poor decisions as a result?

[Brian Abraham]

It's not about laying blameUnfortunately some of our friends are not of the same mind, even apportioning blame in percentages.
it's about being realistic and accepting that the Captain of that airliner did hold some responsibility for it hitting the mountain and therefore a public exoneration is not appropriate. Fully concur.

ampan, absolutely nothing in your latest in anyway proves that the aircraft was in anything other than VMC. Flying the cloud break procedure and breaking out at the required 6,000 would present them with exactly the same issues.

Captain Collins knew that it was very difficult to tell the difference between the cloud and the ice. Tick

He knew there was a 13000 foot mountain in the vicinity, covered in ice. Tick

He descended from above the cloud to below the cloud, thereby putting the cloud above the aircraft and the ice below. Tick

He descended below MSA and below the height of the known hazard. By an approved means, Tick

He purported to descend VMC, which meant that took responsibility for keeping the aircraft clear of terrain, his primary tool being his eyes. Tick - once breaking out at 6,000

To repeat, the terrain below was covered in ice, which he knew. Tick

To repeat, the cloud was above, which he knew. Tick

To repeat, it was very difficult to tell the difference between the cloud above and the ice-covered terrain below TickThe entire concept of attempting VMC below the MSA was fraught, and entirely at odds with those who do it for a living.
I'll eat my catYou want fries with that?

Just joshing my friend. ;)

knew that it was unorthidox but was wrapped up the ANZ culture of getting the job done and made a series of poor decisions as a result?It is impossible to know what Collins thought of course, or why he did what he did on the particular flight. I'm inclined to come down on the side of "Normalisation of Deviance" as mentioned previously. The culture was not to comply with SOPs, and the fact that that was so was widely advertised. If I were to be asked I would say the decisions made by Collins on that fateful day were influenced by the conduct of the previous flights. But of course we will never know.

I flew for Esso in the offshore oil industry for 27 years and it was interesting to see new boys come on board. We made no attempt to comply with regulations, and despite the new boys protestations about what was asked of them, they soon happily fell into line. Such is the influence of organisational demands and perceived peer pressure. I say perceived because no actual pressure came from the other pilots, other than the old boys going out and getting the job done.

[prospector]

The entire concept of attempting VMC below the MSA was fraught, and entirely at odds with those who do it for a living.

That surely was why the only descent available was as quoted many times on this thread.



Quote:



They had no means of determining their azimuth from McMurdo, so that wasn't going to work.

So, what in effect you are stating is that the AINS was accurate enough to establish a position with enough accuracy to be blatting around at 1500 ft illegally, but not accurate enough to establish a position within the required arc and distance of the McMurdo TACAN above route MSA quite legally?????

Could you advise if you think this statement is incorrect, and if so why???

He descended below MSA and below the height of the known hazard. By an approved means, Tick

I cannot agree with that tick.

[ampan]

As you well know Prospector, there's no answer.

It appears that everyone accepts that Captain Collins was not blameless and should not be exonerated. My question is whether his error/s was/were more culpable than the error made by Captain Van Zanten in 1977.

In my view, Captain Collins was more culpable. He should not have gone below MSA, but having made that mistake, he had 20 minutes to retrieve the situation. Van Zanten never got that chance.

[Brian Abraham]

That surely was why the only descent available was as quoted many times on this thread.And they would still be subject to the vagaries of whiteout.

As I said.
Flying the cloud break procedure and breaking out at the required 6,000 would present them with exactly the same issues.
I cannot agree with that tick.Sorry, I did not make it clear. The ticks refer to if the cloud break procedure was flown.

[prospector]

Yes, starting to split hairs a bit here, but basically the accident was caused by non compliance with SOP's and CAA regs,

Not as Mahon and NZALPA claim the shifting of a waypoint.

When a senior check pilot accepts a invitation from a radar operator for a low level run at 1500ft, and makes that fact known to all and sundry and no action is taken by either the Company or CAA then it can be called a cowboy operation.

As was stated earlier in the thread Hubris on the part of some ANZ Captains of the time had a part to play also.

[ampan]

F*ck "Hubris", Prospector (whatever that is).

Captain Collins was the worst pilot ever employed by AirNZ, or TEAL. According to Holmes' book, he couldn't even manage to pass School C. The only surprising aspect about his death in 1979 is that it took that long to happen.

Any arguments?

[prospector]

Hubris: Arrogance or overconfidence, especially when likely to result in disaster or ruin.


Any arguments?


You are having a bad day. .

[topend3]

Holmes does a good job of using selected arguments to mount his case whilst conveniently ignoring others (such as the FL160 requirement).

He also hones in on Chippindales actions involving the CVR tapes, taking them to Farnborough for further analysis on his own, as pointed out by Mahon at the Royal Commission.

All valid points, however that doesn't change the facts. Holmes is not a pilot with any considerable experience, just like Chippindale wasn't. But the crews decision to leave FL160 and then descend below 6000' without being fully aware of their exact position was still the point at which the accident became inevitable, as Chippindale pointed out.

[ampan]

Prospector: Did you get School C?

What does the altitude of 6000 feet have to do with this accident? Let's assume that the captain levelled out at 6000 feet instead of 2000. So what: He would still have hit Erebus.

[prospector]

just like Chippindale wasn't

From a previous post of mine. Holmes and Mahon would have the public believe the nonsense they portray as to Ron Chippendales experience in the Aviation Feild.

From John Kings "New Zealand Tragedies,Aviation.

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

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

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

[QUOTE] What does the altitude of 6000 feet have to do with this accident? Let's assume that the captain levelled out at 6000 feet instead of 2000. So what: He would still have hit Erebus.

Not if they descended in the approved let down arc and distance from the TACAN station, and if at the bottom of that descent they could not still see Erebus, or any of the buildings at McMurdo they would know they did not have the required VMC conditions and no doubt would have climbed back to MSA within that same arc and DME distance. If you read the descent instructions you will note they were specifically designed to avoid Erebus.

You will no doubt have noticed that those descent instructions state that the only descent is VMC in that arc. It was not a cloud break procedure. No where is it approved to invent your own VMC descent.

The fact that civil equipment was not designed to receive azimuth information from the TACAN is irrelevant, The AINS was quite capable of providing that information. Remember it was a VMC descent they were supposed to carry out so using the AINS below MSA was quite legal

.

[ampan]

I'm slightly disappointed, Prospector. Imperial was the British empire's version of Pan Am - and they took you on without School C?

Your rule-based argument can't work. If the "SOP" for SYD-AKL said to go under the harbour bridge on landing approach, would you do it? Of course not.

Your airmanship argument, however, cannot be argued with. I've followed it for years and it turned me right around.

[prospector]

If the "SOP" for SYD-AKL said to go under the harbour bridge on landing approach, would you do it? Of course not.

It would never say that. SOPS, as in this case, are for the most part laid down by senior, highly qualified staff. If they prove to be not appropriate then they are amended.

[prospector]

This from Gordon Vette's "Impact Erebus" publication page 213.

When I flew visually in the Antarctic I believed there was no problem. Prior to my research on the Antarctic crash, I would have scoffed at this requirement. I am now firmly convinced that under certain lighting conditions an aircrew could fly into terrain, even when that terrain is in the field of view and with plenty of time to take avoiding action. Therefor descent below the top of Mt Erebus, or other Polar terrain, even in clear conditions, is hazardous. It appears to me that those of us who conducted the Antarctic flights may unwittingly have exposed ourselves, our passengers and crew, to a similar danger.[/QUOTE

Now relate that to the descent requirements laid down by the company for this flight. They have been posted many times before but the intent of certain key words seem to have been missed entirely by some posters.

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

1. Vis 20 km plus.
2. No snow showers in area.
3. Avoid MT EREBUS area by operating in an arc from 120 Grid through 360 Grid to 270Grid from McMurdo Field, within 20 nm of TACAN CH29.
4. Descent to be coordinated with local radar control as they may have other traffic in the area.


It has been stated a number of times that it was not possible to use the azimuth information from the TACAN with civilian equipment. That is correct, but we have also been told how accurate the AINS was and as this was a VMC descent below MSA it was quite acceptable to use this information gained from the AINS.
You will note that it states the only let down available is VMC below FL160.
There was at the enquiry held by Mahon considerable discussion over the meaning of the word ONLY.
You will also note that nothing is mentioned of a cloud break procedure, it is specified VMC between FL160 and 6,000ft.
Nowhere is it specified that a radar monitored descent is acceptable. Nowhere is it specified that any VMC descent in any other area is acceptable.
To my way of thinking there can be no misinterpretaion of the word ONLY
The reported weather was such at McMurdo that this approved descent was not possible so a diversion to the alternate sightseeing area, which was reported as having clear weather conditions was the obvious choice.

The word Hubris would appear to be very appropriate after we read from Gordon Vette's publication what he realised after his research into Antarctic conditions relative to visibility.

Many people were well aware of these vis problems in the Antarctic, that is why the descent instructions were so restrictive and specific. It is why the other airline QANTAS carrying out these scenic flights to the Antarctic does not allow any flight below FL160 under any circumstance. Obviously the punters are satisfied they get their monies worth at this altitude, the flights have been conducted for a number of years with no problem.

There have been some eloquently phrased posts supporting the actions of Capt Collins and crew, the only problem is they have been short on fact, and missinterpretation of the word ONLY.

[Brian Abraham]

Captain Collins was the worst pilot ever employed by AirNZ, or TEAL. According to Holmes' book, he couldn't even manage to pass School C. The only surprising aspect about his death in 1979 is that it took that long to happen.Thank you for confirming what I said in a previous post
I come away from the threads here that some people would have preferred Captain Collins to have survived the accident, so that he could be hung, drawn and quartered, and his head stuck on a pike in the town square. It seems that there is absolutely nothing you will not say in an attempt to demonise, denigrate, malign or besmirch the good man.

There are any number of people who have abysmal school records, including pilots, who have gone onto excel in their chosen career. Lets have the justification of him being "the worst pilot". Put up or shut up with your libellous outpourings.

Sadly further discussion seems rather pointless with such a poisoned and closed mind.

[topend3]

Good post prospector. What continues to amaze me is that Holmes has as yet (I am not finished yet) no mention of the arc requirement and avoiding Mt Erebus, in his book. He's got plenty of inspiring thoughts of the "innocent hero" of the day, Captain Collins though...

[ampan]

The whole "arc requirement" was unrealistic, given the comfortable bank angle for passengers travelling at close to cruising speed. No-one took much notice of it.

To repeat: All but two of the captains had blue skies. Of those two, Dalziel didn't even bother going to Cape Hallett. Ruffell did, but headed off to the Dry Valleys once he got the weather report. If anyone has Vette's book, the cover photo is of Cape Washington, in the Dry Valleys' area, taken by a Jap film crew at 10,000 feet, with Ruffell in the left-hand seat.

[prospector]

The whole "arc requirement" was unrealistic, given the comfortable?? bank angle for passengers travelling at close to cruising speed. No-one took much notice of it.


I would have to strongly disagree with that statement. If the DC10 could not comfortably do a 180 degree turn in under 20 miles, even at 260 kts then Capt Collins must have really upset his passengers during his lower orbiting descent, the racetrack pattern had legs at some 8 to 10 miles apart. I am sure the turns were not enough to alarm any of the passengers.

The arc requirement would have been set up, and then approved by senior captains on the DC10, I am quite certain they would not have demanded any maneouver that would have upset the Pax.

.

[ampan]

"Brian Abraham" (whoever that might be) needs to check his law books.

For the second time, you can't defame the dead.

[Whiskery]

Brian Abraham is Brian Abraham. He doesn't hide behind User Names and Anonymous Facebook/Twitter handles.
I have always found his arguments and comments to be balanced,relevant and to the point.
A typical military man !
:ok::ok:

[Ornis]

Brian Abraham

There are always going to be differences of opinion depending on how you weight outcomes. If you drive through a red light you might get a warning, you might get a fine. If you drive through a red light and kill someone you will be done for dangerous driving causing death. Why? What changed?

Police and ambulances drive through red lights because they need to. Collins did not need to "drive through a red light", but did so; the consequences were catastrophic.

I have not changed my opinion from the day of the crash. AirNZ was out of its depth and Collins was a very stupid man. He was not asked to take the aircraft down the way he did. That is the point. Had he been asked to do so that would have been an entirely different matter.

Had he called operations in Auckland and said he was at 1500ft about to head to "McMurdo" he would have been asked if he was he out of his mind.

You can make all the excuses you like but at the end of the day they are only excuses. Collins cannot be exonerated by parliament, which is what the discussion here in NZ is about. It would be absurd.

I am now at Warbirds over Wanaka and if I can find one single pilot who thinks otherwise I'll let you know.

And yes, you can know SOMETHING when you don't know. You can know you THAT don't know and stick to what you do know. Which is why I didn't fly into Franz Josef Glacier and around Mt Cook coming down the West Coast. I am an old pilot who wants to keep out of trouble.

Collins went looking for trouble and he found it. Fact.

[Brian Abraham]

Collins went looking for trouble and he found it. Fact. I'll end my participation by saying that Collins did not go looking for trouble, and that is as good a fact as any. As has been said on so many occasions, the manner in which the operation was run it was inevitable that at some stage a catastrophe was going to occur. If not Collins and crew, it would be some other.

Any attempt to argue otherwise shows a total and complete lack of understanding of accident causation.

Quite right, you cannot libel the dead, although it is possible that a comment about someone no longer living may be libellous of that person’s relatives, colleagues or friends. I repeat, It seems that there is absolutely nothing you will not say in an attempt to demonise, denigrate, malign or besmirch the good man.

Brian Abraham" (whoever that might be)You'll find me at 3 Ivy Court, Sale, Victoria, Australia, 3850 PH (03) 51441060

[prospector]

Quite right, you cannot libel the dead, although it is possible that a comment about someone no longer living may be libellous of that person’s relatives, colleagues or friends. I repeat, It seems that there is absolutely nothing you will not say in an attempt to demonise, denigrate, malign or besmirch the good man.



If the odious little man called Paul Holmes would not publish such rubbish as is in his book Daughters of Erebus, and libel other people who were doing their jobs successfully, then these threads would not need be started.

I notice you make no comment on the cloud break procedure, descent requirements, or other statements you made that were patently wrong.


Your are no doubt aware of Gordon Vette's pedigree, and when he wrote the following he at least knew that he had stuffed up, and been very lucky to get away with it.

That sentence may well be interpreted as

It appears to me that those of us who conducted the Antarctic flights and completely ignored SOPs and CAA regs, may unwittingly have exposed ourselves, our passengers and crew, to a similar danger.[/QUOTE

[topend3]

I'll end my participation by saying that Collins did not go looking for trouble

Interesting observation, if what he didn't do was "go looking for trouble" some of the decisions he made on that day are highly questionable...

[Brian Abraham]

Interesting observation, if what he didn't do was "go looking for trouble" some of the decisions he made on that day are highly questionable...Highly questionable? Whatever questionable decisions Captain Collins made on the day would take the skills of a person trained in psychology (the study of the mind, occurring partly via the study of behaviour) to answer. A subject I, and I'll bet nobody posting here, have any knowledge. Do a little study on "The Normalisation of Deviance" if you want to understand why Captain Collins may have made questionable decisions.

Very few accidents are the result of the actions of any one man or crew acting in isolation. The following is a listing of a few slices of swiss cheese, blocking any one had the capability of preventing the accident.

1. Regulator - knowing SOPs were not being complied with sat on their hands
2. Airline Management - ditto
3. Route Planning - over the top of Erebus subjecting aircraft to possible volcanic ejecta
4. Crew Training - lack of
5. Nav Department - input data into flight plan without any idea where the waypoint was
6. Nav Department - changing flight plan data without any idea from where they were changing it
7. Nav Department - failure to provide notification of waypoint change as was required
8. Previous Flights - failure to comply with SOPs
9. Previous Flights - failure to detect waypoint was 26 miles in error, other than Captain Simpson, which then set in train 6 and 7
10. Captain Collins - having been diligent enough to plot the expected track (something which nobody else apparently had) did not ask why there was no flight plan leg to McMurdo for a possible cloud break
You can make all the excuses you like but at the end of the day they are only excusesI'm not making excuses, I look for rational explainable reasons. Of course he can not be exonerated, but we need to understand why and how it happened, which was not the result of any one mans actions.

[Fantome]

Ahhhh . .. . dear Brian, once more I have to dip me lid to your superior grasp of not just the fundamentals, but the complex, very complex, multitude of factors that have led to this never-ending tragic story.

As Horace said about the " braying crowd tossing their stinking greasy caps in the air" (admittedly my memory of 'Odi profanum vulgus' is poor, but you get the drift), that allusion does induce a puzzlement as to WHY??
Why persist in arguing a case with those whose prejudices, biases and ignorance lend absolutely nothing to reasoned debate.

Some of them are just the sort who would if they could, contrive to 'send the boys round'.

Incidently, when I do at last come your way it will be clutching a bottle of good single malt, relishing the prospect of much Rumpolian reminiscence.

"Here's to the good old days" "Here's to the old country" "What old country?" "Any old country!"

[prospector]

I'm not making excuses, I look for rational explainable reasons. Of course he can not be exonerated, but we need to understand why and how it happened, which was not the result of any one mans actions.

Errors of omission and commission, in abundance, from many quarters.

Just one point I would differ on your post.

4. Crew Training - lack of

It has been stated by Holmes himself that Collins and Lucas attended a briefing on whiteout conducted by RNZAF personnel. It has been stated that the descent procedure as laid down many times in this thread, was practiced in the simulator by this crew.


But, I do believe it has been established, without fear of contradiction, that Holmes book calling for exoneration of Capt Collins is completely misguided, and of all the politicians he gave a copy to, only Peter Dunne is stupid enough to go public and call for Parliament to proclaim this exoneration is justified.

[Brian Abraham]

4. Crew Training - lack ofWhat ever crew training was carried out it was sadly deficient. No other operator that I am aware of has ever allowed a crew to operate over, or on the ice, without having travelled as a supernumerary observing, or having a very experienced old hand mentoring.

There is no demonstration on this thread that any one has any real concept of the white out phenomena.

clutching a bottle of good single maltHate the stuff I'm afraid Fantome. On the other hand, any passable red :ok:

Why persist in arguing a case with those whose prejudices, biases and ignorance lend absolutely nothing to reasoned debate. I would presume that there are those who don't have a grasp on aviation reading, and would hate to see them take away the venomous messages being broadcast here denigrating a good man. I find it quite sickening.

[prospector]

What ever crew training was carried out it was sadly deficient.

When one blatantly disregards what one has been taught, and flagrantly breaks company SOP's and CAA regs, then one must bare some responsibility for the consequences, even Gordon Vette acknowledges that when he states It appears to me that those of us who conducted the Antarctic flights may unwittingly have exposed ourselves, our passengers and crew, to a similar danger.[/QUOTE


Bare in mind that these flights were originally limited to not below FL160, the CAA required the Captain to have done one flight either as FO or observer. It was NZALPA that agitated for their senior captains to be allocated these flights. Is the company to be castigated for bowing to their demands? We will never know, but there was an Airline inspector scheduled to travel on Flt 901, I would not think the flight would have been carried out the way it was if the Captain knew he was being watched by CAA. Lack of training or not, he would of known his descent was not an approved manouver.
I would presume that there are those who don't have a grasp on aviation reading, and would hate to see them take away the venomous messages being broadcast here denigrating a good man. I find it quite sickening.

I find it quite sickening that Paul Holmes can publish a book, for consumption by the general public, that so distorts the facts of this crash and uses at its main theme that the Captain and crew were blameless. Even you admit that he cannot be "exonerated", the crew must carry some of the responsiblity, and the Captain the most.

[ampan]

Brian, you have missed the whole point of Prrune. The idea is to assess the comment, irrespective of the person making it. As has been suggested several times in the past, Prospector might be some deranged housewife from Dannevirke, whose only knowledge of the operation of heavy jets has been obtained from the internet - and I might fall into the same category, or might not.

Forget the man, and play the ball. Not VMC. Couldn't use the AINS. Still went below MSA. Didn't get School C. To put things at their most polite, Captain Collins was a very stupid person.

[Brian Abraham]

Captain Collins was a very stupid person.Foregive me, that is the most stupid post I've ever seen posted on Pprune.

[Fantome]

. . . . and to reiterate old son . . .. . n'ere worthy of response . . . . .

(whether 'sickening' or not, let them not get your goat or spoil your composure . . .. . as the late great Arthur Baird was wont to say in his broad brogue -

'He needs to be wiped laddie . . . . just like a dirty ****')

[prospector]

Reads like someone has been into the single malts.

Pompous Prat springs to mind for some reason.

[Brian Abraham]

Why persist in arguing a case with those whose prejudices, biases and ignorance lend absolutely nothing to reasoned debate. Thanks Fantome for the sage advice, but some times I just can't help myself. Wish I had your facility with words. The thread is inhabited by those who have a particularly blinkered view, and leave no stone unturned to denigrate Captain Collins, or those who don't have the same blinkered view. Pompous prat indeed.

I did my first accident investigators course with the worlds largest operator and subsequently with the RAAF. Lead my first formal accident investigation in 1971 - loss of control on take off, crew survived but aircraft reduced to ashes. Had come to rest in the middle of a mine field, on fire and with ammunition cooking off, crew were obliged to beat a hasty retreat through said field, fortunately not stepping on any thing nasty.

[prospector]

Brian Abraham.

Have you read, or seen quoted passages that Paul Holmes wrote in his book Daughters of Erebus??

When he calls our ex Chief Air Accident Inspector, a minor public servant, who was a stranger to the truth, who had very little aeronautical experience to base his findings on, calls the whole Air New Zealand operational management liars, even after that infamous statement of Justice Mahon "Had to listen to an orchestrated litany of lies" was shot down in flames by both our Appeal Court, and the Privy Council and then has the audacity to call for an apology from our Parliamentarians and an exoneration of Capt Collins and crew from any responsibility in regards to Erebus, then one does tend to get a bit upset.

You have even stated on this thread that exoneration is not the right action.

We know all about "Swiss Cheeses and holes" but only one person made the decision to descend below MSA without any certain knowledge of their position, and he must bare a share of the responsibility.

It is accepted that he was a very astute pilot, he must have been to have accomplished what he had in his past, but even astute pilots have bad days and make decisions that are wrong. Otherwise there would be no need for Air Accident Inspectors.

[Fantome]

If the court pleases, I seek leave to submit that the credentials of Brian Abraham in the matters of aviation safety analysis and accident investigation
are of a calibre, significance and extent that in the light of these qualifications he be accorded due recognition and furthermore . .. . .

. .. . . . be spared further attack by weasels ferrets and snapping yapping little mongrel dogs.

[prospector]

That is a rather pathetic submission, surely a man of the calibre you describe does not need protection provided by sycophants?????

[Fantome]

COMING BACK TO . . .. the search for the truth . .. . the accident in question .. . . the causal factors.. . .. the aftermath . .. .what could be of real value and lasting interest is a completely new study.

A top flight investigative writer given free rein to research and analyse . .. . . . to explore afresh the whole complex web of fact, fiction and opinion. . . to come at it with an open mind . . .. . . to have no truck with the simplistic conclusions drawn by god knows how many over the last thirty three years.

It is not, as some do almost belligerently claim, something to consign to the archives.. . . to close the book on now and forever. And that is surely in part due to the extraordinary psychological interplay that occurred . .. . the characters of the people who played the key roles over the years are in themselves enormous grist for the mill of the hypothetical, impartial, aspiring author.

[baron_beeza]

Paul Holmes and Erebus.

The book is about Paul Holmes, anything else is not really relevant.

Paul is the stirrer, and wants to be the centre of attention. You guys have no right to intrude into his territory.
We can leave the nitpicking and name calling to him please.

Peter Dunne may be a politician but he is not so stupid. We will see him reversing out of this deal anytime soon.

Preconceived ideas or not, Paul was difficult to watch as a broadcaster...... I have no intention whatsoever of reading any of his books.
If you want to find anything factual then I am sure there will be other places to look.

Everyone here seems to have come to an agreement.
The crash was no accident. It became about due to a large number of errors with the final ones coming from the crew of the aircraft.
There would be no reason to request an exoneration based on the discussion on this thread. You guys have probably put more thought into it than a certain 'author".

[ampan]

After a few single malts, I am moved to comment:

First, putting one's real name and address on a thread of this nature should not occur.

Second, a review of Brian Abraham's posts discloses many words, with nothing much to say. It's all Swiss Cheese and Reason, with a bit more grated cheese on top- but when push comes to shove, he accepts that Captain Collins wasn't actually visual when he went below MSA.

Of the two military men, I prefer the opinions of Group Captain Chippindale - who, according to recent research, passed School C with flying colours.

[Brian Abraham]

he accepts that Captain Collins wasn't actually visual when he went below MSA.No where do I say that. In fact, to be quite explicit, he was in VMC, as laid down by the regulators regulations. That's if we put to one side for the moment the 6,000 foot requirement. There is absolutely no evidence that he was not in VMC right up to impact, and photographic evidence shows that.

putting one's real name and address on a thread of this nature should not occur.For heavens sake, pray tell why not? You may wish to hide behind your anonymity to have a spray, but I won't be saying anything here that I wouldn't say to your face, in real live actual personage.

Busy with other issues at the moment, more to follow.

[prospector]

No where do I say that. In fact, to be quite explicit, he was in VMC, as laid down by the regulators regulations

He may have been VMC, but it is irrelevant, the only VMC descent procedure that could be carried out was in the area stated, specifically to avoid Mt Erebus. That descent procedure was the regulators regulations.

If he took it upon himself not to comply then when it turned to custard it was his major error.

Please read the descent requirements, there is no disputing they were aware of them, a copy was found in the cockpit after the prang. It had been practiced in the simulator, but once again totally irrelevant, the reported weather at McMurdo was well below the requirements even for the approved descent.

What is it that is so hard to understand about the word "Only".

[Brian Abraham]

What is it that is so hard to understand about the word "Only"Absolutely nothing, what is hard to understand is the word "never", as in, no one ever did it.

Chippendale comments,
As a result of questions put to some of the pilots of earlier Antarctic flights and from comments on the CVR record recovered from this flight, it was obvious that misconceptions were held about the minimum altitude to which the aircraft was permitted to descend in VMC and the actual topography below the flight planned track from Cape Hallett to McMurdo.If confusion existed why did not crews raise the issue on return so that clarification could be made at the brief? Obviously a major issue was to hand. Chippendale unfortunately does not expand on the exact nature of the confusion, nor why it may have existed. Though I have my suspicion.
Whiteout conditions can exist within the normal VMC minima and even in the conditions defined by Air New Zealand as the minima for VMC descents to 6,000 feet.

There was no explanation of the horizon and surface definition terms in the operators’ route qualification or pre-flight dispatch planning, and only a passing reference to whiteout conditions.The previous two quotes from Chippendale underlie the complete failure of both the regulator and airline to appreciate what they were asking the crews to under take. Neither they, nor the operating crews, know what they didn't know.

Not since the Battle of Britain have crews been thrust into an operational theatre so totally unprepared.

[ampan]

This whole VMC argument is becoming farcical. The principles of instrument flying are a bit complicated, but those of visual flying are not, and they are known to everyone with driver’s license, because no-one drives on instruments. If someone is driving down an unlit rural road at night and the headlights fail, what should the driver do? The answer is obvious: Stop the car. If a dimwit pilot is flying above the cloud and is considering going below it on the basis that he is visual, when he knows that it will be very difficult to distinguish the cloud from the terrain, what should the dimwit pilot do? The answer is equally obvious: Don’t do it.

Prospector and Brian Abraham refer the altitude of 6000 feet as having some sort of relevance. Why? What does 6000 feet have to do with anything when the aircraft hit a 13000 foot mountain at an altitude of 1500 feet? That's almost as irrelevant as the Swiss cheese, blah, blah, blah

[prospector]

Absolutely nothing, what is hard to understand is the word "never", as in, no one ever did it.


What anyone else did is completely irrelevant. Those requirements were laid down by the company for this flight, and with the wx conditions they encountered, and the end result, it is easy to see why.

Whiteout conditions can exist within the normal VMC minima and even in the conditions defined by Air New Zealand as the minima for VMC descents to 6,000 feet.

Perhaps so, but if the descent was carried out in the approved area, where there was no high ground, surely by the time they had descended to 6,000ft, and not seen anything, like Ross Is, or the huts at McMurdo, or anything they would know they were in whiteout conditions and climb back to MSA in the same approved area.

Even Gordon Vette acknowledges that the prior flights were lucky not to have been caught the same way.
.

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

Holmes apparently states in his book that Collins and Lucas both attended a briefing session conducted by RNZAF on Antarctic flight which no doubt would have covered white out conditions. If one was rostered to conduct one of these flights then surely one would conduct one's own research on likely problems to be encountered?? Or does airline flying demand everything be laid out on a plate, even for senior captains???


What does 6000 feet have to do with anything when the aircraft hit a 13000 foot mountain at an altitude of 1500 feet? That's almost as irrelevant as the Swiss cheese, blah, blah, blah

There were a number of reasons why 6,000ft was selected as the MDA for these flights. One of the more important being to minimize the risk of bird strike. The damage a flock of skua gulls could inflict at 260kts plus would be considerable. But as you say, relevant to hitting the mountain at 1500ft 6.000ft is not really relevant.

[Brian Abraham]

What anyone else did is completely irrelevant. Those requirements were laid down by the company for this flight, and with the wx conditions they encounteredSo please explain why the level of confusion.As a result of questions put to some of the pilots of earlier Antarctic flights and from comments on the CVR record recovered from this flight, it was obvious that misconceptions were held about the minimum altitude to which the aircraft was permitted to descend in VMC and the actual topography below the flight planned track from Cape Hallett to McMurdo.
This whole VMC argument is becoming farcical. The principles of instrument flying are a bit complicated, but those of visual flying are not, and they are known to everyone with driver’s licenseApparently not. A flight may descend below the MSA if in VMC. The person responsible for determining if VMC exists is the PIC. (Australian regs, and I doubt NZ would be any different.

[prospector]

The person responsible for determining if VMC exists is the PIC. (Australian regs, and I doubt NZ would be any different.

The previous two quotes from Chippendale underlie the complete failure of both the regulator and airline to appreciate what they were asking the crews to under take. Neither they, nor the operating crews, know what they didn't know.

It is a well known fact that Captain Gemmel (Chief Pilot ANZ) was one of the ANZ people that went to the American Deefreeze Operations people to pick their brains on any suggestions they had relative to ANZ Antarctic operations. They were well aware if white out and visibility vagaries in the Antarctic. That was why the descent requirements were so restrictive. By bypassing the requirement for the captain to have been down to the ice as an observer or FO, therefor possibily not realizing if they were in whiteout conditions or not, as Capt Vette states, they lost the right to decide if they were VMC. The descent was to be carried out as laid down to avoid high ground whether VMC or not.:ugh::ugh::ugh:

[Brian Abraham]

It is a well known fact that Captain Gemmel (Chief Pilot ANZ) was one of the ANZ people that went to the American Deefreeze Operations people to pick their brains on any suggestions they had relative to ANZ Antarctic operations. They were well aware if white out and visibility vagaries in the Antarctic. That was why the descent requirements were so restrictive. By bypassing the requirement for the captain to have been down to the ice as an observer or FO, therefor possibily not realizing if they were in whiteout conditions or not, as Capt Vette states, they lost the right to decide if they were VMC. The descent was to be carried out as laid down to avoid high ground whether VMC or not.What a load of cods wallop. You're clutching at straws prospector. The airline itself decided that pilots didn't need to take a trip as an observer. The CAA wasn't even aware the airline had bypassed the CAA requirement for the Captains to make a trip as an observer. Anything Captain Gemmel says is immediately suspect, he wouldn't know the truth if it smacked him in the balls.They were well aware if white out and visibility vagaries in the AntarcticIf that be the case they did a **** house job of passing that knowledge onto the crews.
What anyone else did is completely irrelevant.I blanch at your sang-froid.
One of the more important being to minimize the risk of bird strike. The damage a flock of skua gulls could inflict at 260kts plus would be considerableI call bull**** on this, and would love to know where you availed yourself of this information. As far as I'm aware Skuas are solitary birds and do not fly around in flocks, and nor do they fly at any considerable altitude. Never the less, I've messaged a nephew who is a glaciological scientist down on the ice to put me in touch with an individual who can answer the question. I'll let you know.The descent was to be carried out as laid down to avoid high ground whether VMC or notSo how did the flight that that diverted to the west manage to get down to 1,000 feet agl over the glaciers.

Just had a call from my nephew who confirmed you are very lucky to see a Skua flying at anything greater than head height, and nor do they fly in flocks. So it would seem your source of information regarding Skuas and their habits is full of bollox.

[prospector]

I think Ornis put it very well, post 570, so even non aviators could understand, but apparently not. Here it is again, fits this Erebus event very well.

There are always going to be differences of opinion depending on how you weight outcomes. If you drive through a red light you might get a warning, you might get a fine. If you drive through a red light and kill someone you will be done for dangerous driving causing death. Why? What changed?

Police and ambulances drive through red lights because they need to. Collins did not need to "drive through a red light", but did so; the consequences were catastrophic.

When you printed the following one thought perhaps you were correct, but now I believe yours takes the prize.

Foregive me, that is the most stupid post I've ever seen posted on

PPRuNe.
. Anything Captain Gemmel says is immediately suspect, he wouldn't know the truth if it smacked him in the balls

I was wrong on the point that Gemmell was Chief Pilot, he was in fact Manager Flight Operations at the relevant time.

On what do you base such a statement, not anything Justice Mahon said I would hope, Justice Mahon's handling of witness statements was well and truly shot down by both the NZ Appeal Court, and the Privy Council

Skua Gulls, from John King publication.
Scavenging Skua Gulls were kept at bay with flares and frequent gunshot blasts

Presumably all the recovery teams kept their heads down, below head height, and the gulls were not getting hypoxic at 1.500ft.

[Ornis]

Brian Abraham, you ignore all my arguments but pick up "went looking for trouble", which everybody knows is just an expression, normally to give an admonition. You then appear to address another's comments. Having a bit of trouble with the old memory?

Despite inadequacies in planning, training, briefing, regulatory oversight; the change in waypoint; the weather and sector whiteout: the accident was not inevitable. Or, if it was, it was only because Collins had a mindset, which NZALPA quaintly call "situational awareness". And here's me, an unpretentious recreational pilot, thinking SA was knowing where you were and where you were going, not deciding thousands of miles away you were going to look at a mountain come hell or high water.

The cause of the crash was Collins flying visual when he couldn't see Erebus, where he thought it was or anywhere, despite descending in an unapproved manner, when he knew it was close and the visibility was putatively 40nm, then, instead of climbing out over the sea which every pilot knows is safe, electing to fly south over the coast where he could not tell the difference between the ice and the cloud.

As a matter of fact I have studied psychology at university, and some psychiatry for that matter, but as good an explanation as any is my late mother's: Collins had a brainstorm. Man is descended from bacteria, fish and "crocodiles". He is inherently irrational and erratic and there is a wide range in ability to observe and think.

You seemed reluctant to hold pilots responsible for piloting. Certainly airlines know to mandate autopilot and keep aircraft out of trouble above MSA. Airbus try desperately to make their aircraft idiot-proof, but even Airbus could not stop pilots taking an A320 down to 99kts on an approach to Perpignan, contrary to the Airbus manual and good airmanship.

You can beat around the bush all you like, nothing new has emerged. Your arguments hardly get off the ground and your ammunition is all blank. Collins was given a task he was perfectly well qualified to do, but he decided to do it his way. No wonder Air NZ, for all its faults, responded negatively. Had I lost my children, I would shoot Poor Gnomes in the knees. All the better for crawling to the Collins women.

[framer]

As a matter of fact I have studied psychology at university, and some psychiatry for that matter, but as good an explanation as any is my late mother's: Collins had a brainstorm. Man is descended from bacteria, fish and "crocodiles". He is inherently irrational and erratic and there is a wide range in ability to observe and think.
I´ve thought about the psychology of it a bit over the years. It´s well established that humans tend to choose the ´sure thing´when faced between two attractive options and to gamble when faced with two unattractive options. In this case, Collins was faced with two unattractive options,

1/ Descending below MSA trying to maintain separation visually and
2/ remaining at MSA and potentially not achieving the goal of showing his passengers what they came to see.

It seems to be a fairly natural human trait to take the risky option when both choices are unattractive. I wonder if being an airline Captain requires a certain ability to overcome that natural tendency. I think it probably does.

As for determining which side you come down on when discussing the event decades later. That too is interesting from a psychological perspective.
My feeling is that people immediately recognise their own ´moral intuition´about Erebus, and then look for supporting evidence to construct their argument. With Erebus there is very powerful emotion involved (particularly surrounding Air NZ´s behaviour after the event) as well as a complex case so it is easy to find evidence supporting an argument either supporting Collins or against him.
My opinion is that accurate descriptions of the responsibilities only occur when those emotions and ´moral intuitions´are removed from the process.

[Aimpoint]

600 posts and we're still going around in circles about this...

[Brian Abraham]

we're still going around in circles
Employee to Boss: I'm sick and tired of running around in circles
Boss to Employee: Shut up, or I'll nail your other foot to the floor

We all have a cross to bear. With Easter an all, nails and crosses seem appropriate. Hope you all had a good one.

[framer]

I too wish evryone on this thread a happy Easter and hope you were lucky enough to be rostered off :)

[Brian Abraham]

hope you were lucky enough to be rostered offEvery day is rostered off framer - if I can avoid the missus and her demands that is.

[framer]

Does she give you generous 'min rest' between duties?

[Ornis]

We are not going around in circles, we are asking and answering different questions.

Some of us are asking if Collins was in any way responsible for the crash. In particular should he be exonerated as demanded by Poor Gnomes, and, it seems, a faction in NZALPA.

Some are asking how and why accidents happen and what we can do to stop them. Quite rightly so. I would say, though, accusing others of being blinkered is a bit shortsighted.

I don't agree with Brian Abraham that if it hadn't been Collins it would have been someone else, but I do agree it might have been someone else. I have no way of assessing how many flights might have occurred before a PIC:

Didn't check the McMurdo coordinates he entered into the AINS on a chart
Didn't seek clarification of "McMurdo" at a dodgy briefing
Didn't wonder why the "nowhere" waypoint he charted was not BYRD
Didn't ponder the VHF, radar, TACAN not working
Didn't proceed as planned and trained
Didn't check his position on the AINS
Didn't use the acft radar
Didn't see any substantial risk going through a "hole" to 1500ft
Didn't abort when nobody saw Erebus (or "anything") anywhere
Didn't climb out over the sea
Didn't have other pilots challenge him

Nevertheless, the crash occurred once, and accidents happen all the time. To prevent accidents we must have systems in place so there is no single point of failure, such as Collins so spectacularly demonstrated.

Mind the gap - National - NZ Herald News (http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10797201)
Here Dr Kathleen Callaghan compares Erebus and Pike River Mine disasters. In my opinion, while there are similarities, there are fundamental differences. Airline pilots mostly only have to fly an aircraft high, mine owners must employ and pay labourers to dig deep in a "minefield" and make a profit.

When I sit in an airliner I just hope nothing goes wrong, and if it does, the pilot knows what he is doing. For that reason I am mightily relieved to see someone I know. For if I know him he will be a display pilot, who knows how to fly, not a train driver of rather limited intellect.

Maybe when airlines train pilots better, so they can fly the aircraft not just monitor its flight, or stall as with AF447, I will relax.

In the meantime I won't fly Air NZ, although I know some very good pilots, because to me the Perpignan crash shows they are still up themselves. "Hubris", for any sensitive Australians.

[Brian Abraham]

For that reason I am mightily relieved to see someone I know. For if I know him he will be a display pilot, who knows how to fly, not a train driver of rather limited intellect.I understand fully what you saying, but the sad fact is that any number of exceptionally well trained display pilots have made that one crucial mistake that ended their sojourn here on earth. And the ones that have survived will relate stories that will raise the hairs on the back of your neck as to how near they came - once again from some very simple overlooked item. There was a very good thread on the Military forum some time ago where some fast jet display pilots related "how close I came" tales.

[prospector]

Ornis,

Thanks for that link, a very good article, especially the end 2. and 3.

Quick fixes- and why they often don't work

1 Fire someone: A new person may make the same mistake

2 More training: Useless if staff were already trained but knowingly did the wrong thing

3 New rules: Unlikely to work if the old rules were ignored, often with the tacit approval of managers

[Ornis]

Thank you, Brian, for your answer, and best wishes. Sometimes people are just at cross purposes and nothing can be done about it. I don't expect the owner of the hangar I was in until recently to fly his A340 the way he displays so brilliantly his Tiger Moth, let alone his Hawker Hunter. All I am saying is he knows how to fly, like a bird.

One Saturday I watched a Tiger burn after the very experienced pilot stalled in a turn climbing out; she must have looked inside and lost the "horizon" against the hills at Taumarunui. The very next Wednesday an instructor I had trusted with my daughter's life failed to recover from an inverted spin in a Steen Skybolt near Ardmore; aircraft grossly over weight. I was in that same hangar; then an Olympic yachtsman took out a Fouga Magister and killed the airport manager (former Skyhawk pilot). Another tenant took a young woman out in his Smyth Sidewinder, stalled taking off from a beach after he got lost; ex Iraqi Air Force I seem to remember.

Two Saturdays ago I had lunch with a pilot at Dargaville who crashed Sunday week when his engine stopped. This is all in the last 10 years and not all the pilots I knew now dead.

I have just completed a trip to Wanaka, some of it, into Balclutha and past Dunedin, in conditions I would not take passengers. Fortunately I fly with a German pilot who is happy to be a navigator. Only once have we been caught short, but it was home territory and we landed on a farm strip. Only once has the engine stopped. Alone, and never having fiddled with the fuel cocks before, I had switched one off instead of the other on. Looking down 5000ft I saw Rangitaiki Aerodrome. Then I "clicked". Lucky, eh?

[framer]

Boy oh boy , I think we're entering new territory.

1/ Fire someone...........this will only work if you have a "rogue employee" ie someone who is blatently reckless and violating rules and regulations because "they know best". More often than not tied to ego and/or narcacism. If the person isn't a rogue, then the systems or culture of the place is more likely to be where your trouble lies.
2/ More training is great if lack of training was the problem. In my experience there is normally sufficient quantity of training but the quality is lacking. This again links back into an outfits "culture". (try not to cringe when you hear that word)The poor quality of the training strengthens any negative attitudes towards training and safety in general ,and a sort of safety culture spiral dive ensues.
3/New Rules........again, only works if the old rules were followed, but were inadequate.

The common theme is that the safety culture of the outfit is what determines how safe the operation is. Some people don't like that sort of terminology and dismiss such statements as "new age CRM fluff" etc but safety cultures have always existed in every squadron and on building sites and in shipping companies and airlines etc etc, but recently it has been given a name.
A safety culture is never static, it's either improving or worsening and depends mainly on the leadership of the outfit although the attitudes of just a few senior operators within the operation can have great influence on it as well.
In my opinion, Chief Pilots, CEO's, Training Managers and Check Airmen need to be taught the basic concepts of how a positive safety culture is developed and maintained, then, they need to formally acknowledge that they are responsible for the safety culture of their operation and need to actively tend to it. Doing so requires very difficult decisions to be made (commercial v's safety) and not every senior person is born with the neccessary skills. I do think it can be taught in a classroom.
It takes strong leadership to reverse a culture that is worsening. It requires someone to stick their neck out a little bit in the process of reversing the trend. They certainly won't be a leader concerned with winning popularity contests.
In my opinion, a good example of where leadership of this calibre was in order but never displayed is the 2010 ANZAC Day crash of Iroquois NZ3806. The investigation revealed a dismal safety culture.

[Brian Abraham]

framer, a good post at #600, and further immediately above. You are on the money with "culture", which is what my previously mentioned "Normalisation of Deviance" is all about.

The following is from Dekker

Dekker (2002) proposed an alternative model of organisational accidents that is based on failure drift. Although he acknowledges with thanks the work of Reason, he criticises the Swiss Cheese model because it does not explain what the holes consist of or why they line up to let a failure become an accident. He maintains that without the benefit of hindsight, error is hard to define and seeing the holes is difficult and therefore the Swiss Cheese model is not necessarily helpful in accident prevention. Therefore to try and understand why an accident occurs, it is necessary to reconstruct the unfolding mindset of the organisation and individuals concerned without the benefit of hindsight. This is the perspective from which Dekker has developed his ‘Drift into Failure’ model and his new view of human error.

Dekker’s ‘Drift into Failure’ model consists of three points:

1. People involved in accidents are not criminals or immoral deviants: “Failure drift and accidents that follow them are associated with normal people doing normal work in normal organizations” (Dekker, 2005, p. 24)

2. Often work involves deciding between conflicting goals: Organisations that involve critical safety work are essentially trying to reconcile irreconcilable goals (staying safe and staying in business) (Dekker, 2005)

3. Drifting into failure is incremental. “Accidents don’t happen suddenly, nor are they preceded by monumentally bad decisions or bizarrely huge steps away from the ruling norm” (Dekker, 2005, p. 24).

Under this model “the potential of having an accident grows as a normal by-product of resource scarcity and competition“ (Dekker, 2005, p. 24).

1. The Old View
Human error is a cause of accidents
The New View
Human error is a symptom of trouble deeper inside a system.

2.The Old View
To explain failure, investigations must seek failure
The New View
To explain failure, do not try to find where people went wrong.

3. The Old View
They must find people’s inaccurate assessments, wrong decisions and bad judgements
The New View
Instead, investigate how people’s assessments and actions would have made sense at the time, given the circumstances that surrounded them.

4. The Old View
Murphy’s Law: Whatever can go wrong will.
The New View
Murphy’s law is wrong: What can go wrong usually goes right, but then we draw the wrong conclusion.

prospector, I'm most taken with your proposition that the 6,000 foot MDA was a result of Skuas.

I've been in correspondence with a scientist who studied the Skuas down there (a New Zealander, so we can take his word as being the truth, the whole truth, and nothing but the truth). He says they fly at no more than 100 metres AGL, do not fly in flocks, though they might sometimes follow one another enroute to a food source, doesn't think he saw more than 6 birds in flight at any one time.

So naturally you are going to find them scavenging on the human remains on the mountain side, but they are not going to be an in flight hazard to an aircraft, unless you're engaging in nap of the earth flight.

Any authoritative source you are able to cite? I can find nothing.

[prospector]

The danger of possible bird strike was only one of the reasons 6,000ft was the MDA, and skua's were no doubt only one of the bird species considered. I must admit to no skills as an ornitholigist, I can remember reading somewhere why 6,000ft was chosen, one of the reasons being there would never be a requirement to land down there and among other things it would keep them out of the hair of local traffic. The probability of hitting a skua was probably as remote as being hit by a boulder tossed out of Erebus perhaps.

In the grand scheme of things it is a very minor point, there have been many more very good points made, and I believe the consensus must be that no exoneration is justified, and that is what the intent of the thread was, whether such an exoneration is justified.

[Ornis]

The old: Know what you are doing.
The new: You're dumb.

The old: Be careful.
The new: Can't beat the culture.

The old: Stick to the plan.
The new: Had any brainwaves?

The old: Beware, things go wrong.
The new: It's God's will.

The old: Learn from mistakes.
The new: What mistakes?

The old: A tomato is a fruit.
The new: Put it in the fruit salad.

[Brian Abraham]

Ornis, you are so in error.

A local, North Carolina preacher said to his congregation, "Someone in this congregation has spread a rumor that I belong to the Ku Klux Klan. This is a horrible lie and one which a Christian community cannot tolerate. I am offended and do not intend to accept this. Now, I want the party who did this to stand and ask forgiveness from God and this Christian Family."

No one moved. The preacher continued, "Do you have the nerve to face me and admit this is a falsehood? Remember, you will be forgiven and in your heart you will feel glory. Now stand and confess your transgression."

Again all was quiet.

Then slowly, a drop-dead gorgeous blonde with a body that would stop traffic rose from the third pew. Her head was bowed and her voice quivered as she spoke, "Reverend there has been a terrible misunderstanding. I never said you were a member of the Ku Klux Klan.

I simply told a couple of my friends that you were a wizard under the sheets."

The preacher fell to his knees, his wife fainted, and the congregation roared.

KNOWLEDGE is knowing a tomato is a fruit; but -
WISDOM is not putting it in a fruit salad.

[3 Holer]

Ornis, you sound like the proverbial Human Factors/CRM sceptic.;)

[Ornis]

Ah, Brian, you caught my little barb. Not entirely blinded by your faith, then, you do know what wisdom is. Now consider:

You stop at a red light but you really really want to go. So you look both ways, see nothing, and go. Out of nowhere appears a motorbike; the rider is killed.

You plead it was a very dull overcast day, there was a dip in the road, the bike had no lights, the rider wore grey clothes and helmet, he was speeding ...

Judge One says, yes, the council should fix up the road, by law bikes must show lights, the rider didn't slow or swerve, drivers need to be "educated" to look for bikes, you are a doctor who was rushing to an emergency, other people go through red lights, it's the culture. Human factors: tragic accident.

The police appeal; Judge Two says, no, you went through a red light. No excuses. You are going to jail.

Now change perspective: the motorcyclist is your son. He has been to see you and his mother and was going home to his wife and young children.

Which judgement seems right to you? Bit of waffle keep you happy?

Brian, we are all victims of our circumstances, all different yet woven from the same cloth. The Universe works in a way we don't understand, at the subatomic level it is entirely random and unpredictable (indeterminant). And yet, a pair of particles generated together but separated by an arbitrarily large distance remain somehow connected (entanglement).

Nobody can explain this "spooky action at a distance" (Einstein), yet you propose with a few simple analogies (gruyere cheese) and mumbo jumbo (drift into failure) to explain the human mind and control human interactions. It's nothing more than a cult: a bee in the bonnet and buzz words.

If anyone might have added something useful, it might have been Paul Callaghan FRS. One genius outweighs a million others, as Richard Feynman showed after the space shuttle Challenger disaster.

Give me two pilots who watch or guard each other; independent yet working as a team to keep the aircraft flying and safe. Each and both knowing what they're doing, for example, to wind the trim wheel when the Airbus throws the flight controls at them; not shoot up and roll inverted (Perpignan) or drop into the sea (maybe AF447).

You can have the the humbug. You can have the pilot who flies into a mountain he knows is there, somewhere, but can't see, anywhere.

[framer]

The New View
Human error is a symptom of trouble deeper inside a system.


I don't agree with that. I don't know anyone in my current training department that thinks that. Human error is not a symptom of trouble elsewhere. Human error is ever present and is a consequence of thinking. It is not something that can ever be eliminated but you can easily reduce the number of errors you make and you can learn to recognise the errors you make quickly so that you can deal with them before they cause bigger problems.

The old: Be careful.
The new: Can't beat the culture.

Are you sure you're not confusing the general left wing socialist hand-out cultural attitude of New Zealand with current aviation safety thinking? I can assure you we still try to "be careful", and "Can't beat the culture" is pretty much the opposite of the current thinking.

The old: Stick to the plan.
The new: Had any brainwaves?

Stick to the plan mindset has resulted in more than a few crashes. Brainwaves? ppfffttt.... Re-evaluating the decisions to check they are working out for you ...yes.

The old: Beware, things go wrong.
The new: It's God's will.
I've never heard that said once? Have you?

The old: Learn from mistakes.
The new: What mistakes?


Learning from mistakes? I think the old was more like "cover it up if at all possible". What mistakes? That is again pretty much the opposite of the current thinking. Mistakes are enevitable and nobody pretends that they are error free anymore....at least not outside the aero-club.

I am getting the feeling Ornis that you have very strong opinions about all these "modern attitudes" but I'm not convinced you actually know what they are. Your analogy about the red light that ends with it's the culture. Human factors: tragic accident.
is just silly and demonstrates a lack of understanding.
we are all victims of our circumstances, all different yet woven from the same cloth. The Universe works in a way we don't understand, I know it can be a bit scary sometimes but that doesn't mean we can't become better at safety or that aviation had it right 30 years ago and anything new is just rubbish.

[framer]

Each and both knowing what they're doing, for example, to wind the trim wheel when the Airbus throws the flight controls at them; not shoot up and roll inverted (Perpignan) or drop into the sea (maybe AF447).


Ornis you will never ever prevent all crashes by teaching pilots better technical skills. If that was the case there would be very few crashes involving highly technically competent pilots. There have been many. That paragraph shows that you haven't really got a grasp on how accidents like this come to be. You are basically suggesting that by ignoring the five or six non-technical errors that the Perpignan crew made in the lead up, and concentrating on one technical error that occurred subsequently,and may have salvaged the situation, we can make aviation safer. Your view would have been well recieved in 1970.

I am not suggesting that we have reached a place where we fully understand how accidents occur but I do think that we are moving in the right direction and that our attitudes have to keep evolving. We have to avoid getting stuck in the mud and saying " arrggghh we did it best 30 years ago gggrrr"

[Brian Abraham]

Now change perspective: the motorcyclist is your son.I've had a beer with those responsible for killing my brother. What perspective should I have?

[Ornis]

framer, Brian Abraham said I was in error and offered a joke. I returned the serve, mocking his list of causes.

Of course the pilots to blame for Perpignan are still alive and well in Air NZ. They thought they knew better than Airbus Industrie. Writing recently in the NZ Herald, one blamed the maintenance not being done in NZ. Still couldn't see if you test an aircraft you have to be ready waiting for failure. Dullard. Nevertheless the pilots did stall the aircraft on an approach, with the gear down, such that it "thought" it was landing, and apparently nobody knew the need to wind the THS manually.

When the A320s arrived, the CAA congratulated themselves for the speedy completion of the paperwork. Piffle, piffle and more piffle from the regulator.

I don't think I am as obstinate and ignorant as accused. I do see how accidents happen. I can almost understand how a young woman can run into a group of cyclists and kill several. But I am talking about a commander taking an aircraft and forgetting his primary responsibility to keep it safe when it is flying perfectly.

My perspective is that of an informed (and opinionated) airline passenger, but I'm not stupid. I know you know more than I do.

[Brian Abraham]

mocking his list of causesUnfortunately they are not my list of causes, but those of,

Sidney Dekker
Associate Professor
Centre for Human Factors in Aviation, IKP
Linköping Institute of Technology
SE - 581 83 Linköping
Sweden
tel. + 46 13 281646
fax. + 46 13 282579

A gentleman pre-eminent in the field of aviation safety, and well known among the professional aviation community. You can even talk to him on 'sidde at ikp dot liu dot se' should you wish.

It'd be a brave man to tell him he knows nowt about the subject.

mumbo jumbo (drift into failure) to explain the human mind and control human interactions. It's nothing more than a cult: a bee in the bonnet and buzz words. I'm forced to add, that in those few words you demonstrate a complete lack of understanding of the subject to hand - mechanisms surrounding safety, and not just in aviation.

[Ornis]

The fallacy of the Appeal to Authority. Probably 90% of university "research" is rubbish. Anyway, my "mumbo jumbo" refers to the jargon; isn't "drift into failure" what normal people call complacency?

Sorry about your brother, Brian. Sad as it is, it saved you answering the question; the fallacy of the Appeal to Emotion.

The proof of the pudding is I'm still here, so clearly I do know something about safety, and you feel the need to tell me I don't know anything about anything, so clearly I am scratching a sore point.

Since we are saying our goodbyes ... you sound like a parrot.

[Brian Abraham]

The proof of the pudding is I'm still here, so clearly I do know something about safetyNot necessarily. One does not automatically lead to the other.
The fallacy of the Appeal to AuthorityIf I have a tumour I seek the skills of a qualified medical practitioner, not the perspective of an informed (and opinionated) ex patient. Same on the subject of safety, I seek the opinion of people recognised within the industry as those to go to. Once again, not the perspective of an informed (and opinionated) airline passenger.

Although having spent my entire working life putting bread on the table via sitting in a cockpit I don't hold myself to be an expert by any means. But maybe, just maybe, a little more informed than an informed (and opinionated) airline passenger.
my "mumbo jumbo" refers to the jargonEvery industry or trade has its jargon. I can't understand anything the kids of today say.
you feel the need to tell me I don't know anything about anythingGo back and read it again. I said, "demonstrate a complete lack of understanding of the subject to hand". To whit, the formal subject of safety as applied to aviation and industry.
clearly I am scratching a sore point.Not at all, though I am amused at your presumptions.

framer commented, "Your view (Ornis) would have been well recieved in 1970." He refers to you being stuck in a period where the blame culture was rampant. I'm afraid you seem to have travelling companions in ampan and prospector. I say seem.

framer, the blame culture is still alive and well. The worlds largest multi national boasts "worlds best practice" when it comes to safety. When an event takes place however, everyone runs for cover with pointed fingers. Usually at the guy with his hand on the tiller, despite a Royal Commission finding in one fatal accident that usual suspects were to hand - superficial auditing, lack of attention to major hazards, failure to learn from previous experience, failure to respond to clear warning signs, communication problems and a lack of training. In fact end of last year the local branch was slapped with four citations by the regulator for safety deficiencies. The buck rules. Some never learn.
you sound like a parrotWhen people are stuck in the dark ages, such as a belief in the blame culture, someone has to parrot the message.we are saying our goodbyesGoodbye

[framer]

Righto, we are probably getting a little off track here. Wouldn't want the mods to close it because it was not on subject. With that in mind I'l comment on 'safety culture' as it applies to Erebus.
I'm in an interesting spot because I squarely believe that Collins held responsibility for separating the aircraft from terrain and holds some responsibility for pressing on with achieving the task at the expense of the aircrafts safety (ie his primary responsibility), yet I imagine the 'safety culture' at Air NZ at the time was lacking due to poor leadership from management.
In my mind the whole thing is like a text book example of how all the holes line up and also of how the pilots are usually the very last layer of defence. As Captain of an airliner you are given extraordinary powers and authority while airborne and there is a reason for that. You are the last defence, your primary duty is the safe return of the aircraft to the ground and that must outweigh everything else.
Brian you say that if it was another crew on that day the outcome would have been the same. Although I share many of your views about aircraft safety I don't believe that for a second. I think with those exact circumstances, the same weather, the same lack of VHF reception, most Captains would have held onto the protection of their MSA (and remained within SOP's) while they contemplated their next move and formulated a plan of action, and in that time VHF reception would have come good and all would have become clear. I hold nothing against Collins, I just think that if another Captain was rostered for that flight the outcome would have been different.That is just my personal opinion, but I believe it to be true.
Just because I have said that Collins holds that responsibility does not mean I don't think others a free of responsibility.

[ampan]

As Prospector has pointed out on numerous occasions, as did Sir Rochford Hughes, it was appalling that Air NZ allowed NZAPLA to turn the whole operation into a junket for senior captains. (Even the stand-by captains had not been down to the ice before.)

So f*cking what? When you're being paid three times the salary of the country's Prime Minister, there should, surely, be an expectation that the most basic principles of airmanship will be complied with. For example, you won't try to take off with the flaps in. Captain Collins did not make that basic mistake when getting the aircraft to cruising altitide, but he made numerous basic mistakes before he smashed the aircraft into that mountain.

Vette can crap on with his 'there but for the grace of God' nonsense, but I don't believe him. If Captain Alwyn Gordon Vette had been PIC of TE901, the passengers would have had an enjoyable tour of the Dry Valleys and would have returned alive.

[Ornis]

Birds of a Feather Flock Together on PPRuNe

Ruffled Pigeon crowed: "I bring you A Very Important Message from the famous academic flier, Professor Penguin."

"I will promulgate his every word, I will promulgate his every word," squawked his alter ego, Pretty Polly Parrot, ad nauseum, "I will, I will, I will."

"Usually a lot of rot," suggested Culture Vulture, "I'm looking forward to it."

Hawk Eye swooped: "Certainly sticks in my craw, Penguin couldn't fly off his Ivy Tower."

Henny-penny added, "Not even if the sky was falling in ... ouch, Cocky-locky, keep it to yourself, will you!"

Mrs TEAL quacked: "We want Captain Ostrich exonerated, Kiwis find flying a very unnatural practice; if we hump the odd mountain we cannot be blamed."

Eagle Air-ed his views from upon high, "The Mods won't like this, can't you be Doves for a bit, wave a white Shag and all that?"

"Well, thank goodness that Great Tit, Wannabe, flew the coop," said Miss Thrush, "He was making me itch in funny places."

"Ah", said Wise Owl, avian I am getting bored with this, I feel like Woody Woodpecker on a thick wall."

"Time to put an end to the squabbling", said the Seagulls, as if that's ever likely to happen ...

[Brian Abraham]

Your medicine is well over due. Nurse to cell 901 please.

Lock it Mods. Please.

[Tidbinbilla]

The writer of post #601 hit the nail on the head.