Former concorde captain speaks out on erebus

[Fantome]

Dear Tidbinbilla . . . .. . I do regret that you have again to assess whether there is any point in allowing further debate here on Erebus. It seems it will not lie down. Probably never will. The blue touch paper has been ignited again in the NZ press. Paul Holmes, Peter Mahon, Jim Collins et al have been attacked by one Captain Derek Ellis, once a commander on Concorde, no less. Hence the floodgates of bias and opinion are ratcheted wide once more.



Quote:
The call by Paul Holmes and Peter Dunne for exoneration of the pilots of the Air New Zealand DC10 aircraft which crashed into Mt Erebus is not appropriate.


It is the prime duty of an airline captain to deliver his passengers safely to their destination. Captain Jim Collins failed in this duty.

I say this as a professional airline pilot with no connection to any person affected by the accident, which probably makes mine unique among the opinions expressed on this tragedy.

We all have absolute sympathy for the relatives of those tragically killed in the Erebus accident. There is no similar sympathy on the part of Peter Dunne and Paul Holmes for those Air New Zealand personnel, and their families, unfairly and incorrectly blamed by the late Peter Mahon for the DC10 accident on Mt Erebus. Peter Mahon's allegation that they had lied under oath when giving evidence was successfully appealed by Judicial Review to the New Zealand Court of Appeal. This caused the resignation of Peter Mahon as a judge. His subsequent appeal to the Privy Council supported the finding of the New Zealand Court of Appeal.

Responsibility for the Erebus tragedy must remain with Captain Collins, as found by the official accident investigation. This finding is still valid.

Unquote

These extracts are from the recent New Zealand Herald article by Derek Ellis, a retired British Airways captain living in New Zealand.
It strikes me that despite Ellis's undoubted competency and experience as an airline pilot, he is another to join the band waggon of those many who have prejudged the causes of this accident. Perhaps, behind the scenes, the media saw an opportunity to hit back at Paul Holmes, consequently calling upon a man such as Ellis to wade in with the
old claymore, delivering blow after blow to Collins at the same time.

Whether or not this theory holds water, the fact remains that Ellis has out of hand condemned Collins, most regrettably receiving in this attack, wide media coverage under the banner of his expert status. Hence the public yet again are inflamed to believe not only that there were, and possibly still are, maverick airline pilots on the loose, but moreover that Collins, in the case of the Erebus tragedy, must bear the entire blame. This is manifestly absurd. To get to the causal truths is no simple task. It requires much study of the huge file that has amassed since the first enquiry. Yet the partial, inadequate, biased and uninformed execration of Collins and Mahon goes on and on.
(Madame Defarge knitting by the guillotine is not a totally unapposite image.)


Where Ellis gratuitously states that . .. . .
"it is the prime duty of an airline captain to deliver his passengers safely to their destination. Captain Jim Collins failed in this duty" . . .. many will be those who themselves, through their professional lives, know the truth of this injunction, in their water, but who will wince to hear this absolute given trotted out by Ellis with the glib rider that Jim Collins in effect stuffed up. Had forgotten this creed. One he earnestly held high every day of his working life. Not good enough Captain Ellis. Please study every aspect of this most complex accident before you again pass summary judgement.

[Mach E Avelli]

He sounds like the archtypical arrogant BA Captain who simply because he was privileged enough to fly Concorde, thinks he knows it all. He probably never made an error in his life, let alone got caught out as a result of other errors in the system, such was the perfection of the BA machine and perhaps the RAF (if he came from that into civil aviation). The Brits NEVER make mistakes....
Before re-igniting this from the safety of his armchair, he needs to study James Reason.
The Captain of the Titanic was far more culpable than Capt Collins, who probably had never experienced white-out conditions. But even with prior experience of fog and icebergs, the Titanic Captain's poor seamanship can be partially explained (if not excused, and as a sailor I am not inclined to excuse him) by his belief that his ship was unsinkable, that icebergs normally would not be so far south, so the risk was acceptable, and that the Company's reputation to complete Atlantic crossings on schedule justified the (perceived) small risk etc. Chuck in the apparent failure of the radio operator to relay the latest on iceberg sightings and it's classic James Reason stuff. Ditto Erebus.

[remoak]

Unfortunately, Ellis is right. Jim Collins DID stuff up... but his was by no means the ONLY stuff-up. This we should all have figured out by now.

I remember Erebus - and the subsequent fallout - very clearly. I don't think that Jim Collins was a "maverick airline pilot", however he was part of an organisation that was arrogant in the extreme - not unlike British Airways at the time, which was the very model of an arrogant, self-serving organisation, that was effectively a law unto itself for many years.

Whilst there were mitigating factors, the sad truth is that Jim Collins failed to take the correct action when faced with a loss of visibility and in the face of uncertainty regarding his position. He was undoubtedly under commercial pressure, but that doesn't excuse pressing on when you can't clearly see where you are going - one of the fundamental principles of VFR flight that all student pilots learn very early on in their training.

So Ellis is right when he says "it is the prime duty of an airline captain to deliver his passengers safely to their destination. Captain Jim Collins failed in this duty", but he clearly isn't seeing the big picture.

As for Paul Holmes, he is a sensationalist know-nothing who is so in love with himself that he thinks he can comment sensibly on the subject. He can't (and hasn't).

[gobbledock]

Where Ellis gratuitously states that . .. . ."it is the prime duty of
an airline captain to deliver his passengers safely to their destination. Captain Jim Collins failed in this duty" Hmmm. I wonder if Ellis feels the same about his former colleague Capt Christian Marty?? Did Marty also 'fail in his duty' on that fateful day?

[john_tullamarine]

Jim Collins failed to take the correct action when faced with a loss of visibility

Long time since I have read the story but .. was it not a case of being in severe clear but not being able to perceive the mountain ahead due to the higher overcast reflections and effective whiteout conditions ?

[gobbledock]

Long time since I have read the story but .. was it not a
case of being in severe clear but not being able to perceive the mountain ahead
due to the higher overcast reflections and effective whiteout conditions ?
Correct. This accident was a catalyst for 'whiteout' studies as one of the confusing and difficult things to understand at the time was why Capt Collins didn't simply see the mountain in front of him and take evasive action earlier. The phenomenom is much better understood now than it was then. It is still hard to describe 'whiteout' to somebody who doesn''t understand it's nature or has ever experienced it, but there are some very good Air Force examples on record to back this condition.

Sadly ANZ and of course the parasitic government and spin doctors of the day tried to throw the accident back on to Capt Collins and they tried to make out that the last line of defence - Him not taking evasive action contributed to the disaster. Bollocks!!
However I am going to stop at that as the loop is about to start cycling again.

[Wally Mk2]

It's amazing this story gets dragged up time & time again.

It's obvious that the end result was human error,always has been & always will be when man & machine are involved.We can't change that fact we can't bring back those who departed this world on that faithful day anymore than we can the many that went to their graves at the bottom of the Atlantic 100 years ago yesterday (14/15th) so I see little point in trying to apportion blame to anyone side of the debate. Collins didn't get out of bed that morning to take his plane into the side of the mountain it was an error pure & simple!
We are ALL capable of doing what Collins did!

Have we learnt anything from this? ........yeah we have & that's to see/hear what some humans will do to show that mankind hasn't proceeded any further than the cave!:ugh:

Wmk2

[4Greens]

There are only two things we know for certain about an accident. Firstly there is always more than one 'contributory factor'. Secondly there is always human error somewhere in the system.

[remoak]

was it not a case of being in severe clear but not being able to perceive the mountain ahead due to the higher overcast reflections and effective whiteout conditions ?

Partially... the other part being a navigation error caused by a somewhat more complex set of factors.

The point remains that, unless you can positively identify what you are flying towards, be that snow, ice, water or a volcano, you should do the right thing and climb immediately to MSA.

Airmanship 101.

[compressor stall]

Great theory, except when you're not expecting to see anything there and don't.

Which raises the obvious point that should you be there in the first place.

[remoak]

Yeah but you SHOULD be expecting to see something if you are navigating visually (which they were attempting to do). Are you seriously suggesting that it's a good idea to fly a DC10 around below MSA, with high ground in the vicinity, without visual reference? Particularly as the whole point of the exercise was to see stuff.

I do tend to think that it was an accident borne of the arrogance of Air NZ at the time, and that Jim Collins was to a large extent an unwitting victim, however the basic rules of airmanship still apply, and having the judgement and determination to apply those rules appropriately is pretty much the only reason that airline pilots get paid the big bucks.

In this case, Capt Collins was relying on the INS putting him where he expected to be, and descending without visual reference on that basis. Not his fault that the track had been changed without his knowledge... BUT... my guess is that he wasn't entirely happy with what he was doing.

[compressor stall]

Are you seriously suggesting that it's a good idea to fly a DC10 around below MSA, with high ground in the vicinity, without visual reference?

Not at all. Hence line 2.

[Whiskery]

"......and again, around and around we go!"

Lock it up for goodness sake.

[Brian Abraham]

and descending without visual referenceA sticking point that many have trouble with. There is no factual information anywhere that they were not in anything but VMC conditions.

A couple of quotes from Chippendale,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.

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.
I've not dug out the direct quote, but Chippendale also comments on people having difficulty in understanding the whiteout phenomena, until they get to experience for themselves. ie how can you not see a mountain directly in front of you.

For readers, take anything compressor stall has to say re Antarctic ops as gospel. You can take it to the bank so to speak.
Lock it up for goodness sakeUnderstand your sentiment, but if the discussion could be left to the aviation fraternity, and not have those who evidently have an axe to grind taking it off the rails, all would be well.

We'll have to leave it to the Mods to adjudicate.

For me, Ellis just shows how little he knows about accident causation.

[Fantome]

Dear whiskers -

1. you do not have to open the thread if you feel that way

2. this is one of history's most intriguing, complex and in
some key areas, still not entirely resolved accidents.

3. until an expert, definitive account of the accident is written there will
always be grounds for study and review. (And probably
thereafter , as well.)


If you have a deep abiding interest in a subject you will always want to read
and study what new light might be brought to bear. Hence, for example, the proliferation of biographies on persons of perennial significance.
(Still, makes you think how many fresh slants can authors come up with when they get stuck into the entrails of Shaw or Orwell, Voltaire or
Robespierre, Freud or Jung.)

[remoak]

A sticking point that many have trouble with. There is no factual information anywhere that they were not in anything but VMC conditions.

VMC conditions and having visual reference are not the same thing. In whiteout conditions, you have no visual reference at all and yet you may well be (and probably are) in VMC.

Having encountered this phenomenon myself while flying in the Alps, I still think that if you do not have POSITIVE visual reference, you have no business being below MSA. I agree with Compressor Stall and his line 2... ;)

[john_tullamarine]

as I recall from the reports at the time ..

.. one of the salient findings related to

(a) ANZ not having much in the way of corporate knowledge of Antarctic operations

yet ..

(b) they could have asked the USN NZ base folk for some guidance ?

A follow on problem is having knowledge and experience sufficient to be able to identify conditions conducive to whiteout.

[prospector]

Ellis sounds like the archtypical arrogant BA Captain who simply because he was privileged enough to fly Concorde, thinks he knows it all.

He was also at one time President of BALPA.. He was also a 747 Captain. His opinion, coming from such an experienced aviator is of a lot more value than some of the gumbashers garbage on this subject.

If you could do a bit of research before quoting such garbage you will no doubt have discovered that when he read the Mahon report he was gratified that it was not pilot error. However, he states that after reading Gordon Vette's " Impact Erebus" his belief in the cause of the accident shifted more to agreeing with Ron Chippendale.

As Captain Ellis is still alive, unlike Ron Chippendale, as Poor Gnomes waited years to happen before he could post his garbage on the abilities of our Chief Aircraft Accident Inspector, one should be circumspect before posting material that could be classed as libel.



A sticking point that many have trouble with. There is no factual information anywhere that they were not in anything but VMC conditions.

A sticking point you obviously have bigger problems with is that the only approved descent was VMC in the area as laid down in the Company approved descent procedure, specifically to avoid Mt Erebus.

[Brian Abraham]

Mods please lock prospector out of this conversation. He, ampan and Ornis have demonstrated time and time again that they have no interest in anyones view point but their own. They only accept that it was all Captain Collins fault. We only need look at the language already being used to discredit posters - gumbashers garbage and Poor Gnomes.

Captain Ellis is demonstrably an experienced aviator, but his level of knowledge of this particular accident may very well be minimal, and what arctic knowledge does he have, by way of experience or study?

[prospector]

Mods,

Once again Brian Abraham has called for the thread to be locked. Rather than answer a direct factual question, he whaffles on about holes in cheese.

The descent requirements for this flight have been stated many times, they were printed in black and white, the descent procedure was practiced in the simulator, there was a copy of these descent instructions found in the cockpit in the wreckage, there can be no dispute that the crew were aware of these requirements, and they complied with none of them. The AINs was not cleared for Nav below MSA, these are all fact, not apologist theory.

Moderators, no doubt you will note that only people who disagree with Brian Abrahams posts are the one he calls to be locked out of this debate, how is it he can be so certain his theory, and that is all it is, is the correct one???

Why does he not call for people who make statements that impugn the reputations of highly qualified, far more qualified than he, statements on this thread to be banned?????

[remoak]

My memory of this is that the descent procedure wasn't the issue... the crew complied with it as they were supposed to. Unfortunately, the track they were descending on wasn't the one they THOUGHT they were descending on. So instead of descending in VMC to a safe point from which they could commence their "tour", they actually descended directly into a mountain. I can't remember exactly, but I seem to recall that the modified track (of which the crew were not aware) was displaced some 10 km from the track they thought they were on. All this was in the report.

In fact, the "Swiss cheese" model is particularly appropriate to this accident... it was the result of several adverse factors.

To me, the "lost diary" of Capt Collins probably holds many of the answers... but as far as I know, it is still "lost" (probably in an Air NZ filing cabinet, assuming it wasn't destroyed).

One thing is absolutely for sure... they descended without having adequate visual reference. No matter what else may have happened, that was the final, gaping hole in the Swiss cheese.

[prospector]

My memory of this is that the descent procedure wasn't the issue..

There has been much published on this point, much of it written by people who were closely involved. Relying on memory 32 years after the event is not really good enough,

The weather at McMurdo was given to the crew prior to descent, it was well below that required for the approved descent. Prior to coming anywhere near the approved descent point a descent was commenced through a hole in the clouds, and what the approved descent procedure was designed to avoid, flying into Mt Erebus, was not achieved.

It would be interesting if somebody with a good knowledge of Ross Island could advise at what point Mt Erebus actually begins. I would have thought that strictly speaking 1480ft impact point could still be called impacting Ross Island rather than Mt Erebus..

[compressor stall]

On that side, it's a pretty continuous slope to the water. IMHO you could use either. Map here, n.b. heights in metres. (http://usarc.usgs.gov/drgs/dir1/c77190s1.jpg)

As for the fact that this bloke commenting on the issue was a Concorde captain, well good on him; lucky fella. Doesn't mean that his opinion on an accident in an area and conditions that he likely has not flown is automatically any more valid than others' in the industry.

[remoak]

and what the approved descent procedure was designed to avoid, flying into Mt Erebus, was not achieved.

Possibly because the flight was some 27 miles from where the crew thought it was - over McMurdo sound?

[Mach E Avelli]

In fact, because he was a Concorde Captain and President of BALPA etc, all the more reason for him to show some restraint in passing summary judgement on a deceased fellow professional. Those held in high esteem by their peers must be even more careful than those of us obviously given to unqualified, ill-considered and libellous statements. What was the term used - gumbashers garbage?
btw, I have some experience of white-out conditions in the Arctic, so despite the lack of Concorde time, do feel every bit as qualified to comment and defend Capt Collins - albeit also from the safety of my armchair. Sadly, I also knew, and had flown with, First Officer Cassin who was on the ill-fated flight.

[grip pipe]

I agree, the issue of taking sides has been de rigeur at the post re Paul Holmes.

I think there are a number of things worth saying and there not about the facts of the accident but the issues raised by the former Airline Captain, the fact he flew a Concorde is irrelevant.

The fact that former Justice Mahon was chastised about findings of guilt, that is people lied is a matter of legal technicality, as a Royal Commissioner he can make no such findings they are matters for a Court of Law, it does not change what Mahon said. Legally he was not empowered to say it.

What I have found most curious about the whole Erebus saga is that despite all the lip service in the industry to risk management and the notional model for accident causation postulated by Professor Reason, that when such a model is applied to an accident such as occured at Mt Erebus in Antarctica and the various layers that led to the accident are revealed which they were with Mahon's Commission nobody wants to accept the findings or the process and have argued about it ever since. Everyone is still stuck on the matter of fault as if finding fault will change or prevent a future reoccurence of a similar type. The bottom line is everyone had a hand in this accident happening and that is it from any rational or empirical perspective.

Also, a lot of people still have a very strong emotional attachment to events at Mt Erebus and those who seek to reignite or re-open the debate today have no respect for the feelings of the partners, wifes, husbands, mother, fathers, children and friends of the two hundred and fifty seven people who lost their lives that day.

We all can read about the facts of the accident, the events and actions of all involved, the trick is to ensure that knowing this, another accident involving a passenger aircraft in Antarctica does not occur again, and it was to operations in Antarctica that the good gentleman with no doubt significant command experience in commercial passenger operations should have addressed his views not generalist comments on airlines operations, apart from Antarctica, Air New Zealand appears to have run a pretty safe operation for a long time.

[Luke SkyToddler]

Gordon Vette was / is one of the greatest, most highly regarded, distinguished and decorated aviators this country has ever produced. I don't need to espouse his CV on here but it more than stands up to that of some loudmouth who reckons that just because he flew Concorde he has a right to pass judgment on things he had nothing to do with.

In addition, Gordon was uniquely close to, and had unique levels of access to, the whole investigation while it was still ongoing. This bloke did not. I know who I prefer to believe.

Whether one sides with Chippendale or Vette / Mahon, I really don't see all this fresh muck raking from Holmes and now this, as adding anything new or relevant to the 30 year old debate.

[Brian Abraham]

Relying on memory 32 years after the event is not really good enough,Would it rank with the the unprovable assertion that the 6,000 foot MDA was due to Skuas?

[Ornis]

Brian Abraham calls for some commenting to be excluded because they won't kowtow to him. Brian Abraham never answers any questions he doesn't like, preferring to quote a guru. Well, that is not an argument. It is an appeal. Furthermore, Brian Abraham is free with his insults but give him a serve and he suggests you need medication. Oh, the wit, the originality.

The simple facts are: the accident was not inevitable when the aircraft left NZ; Collins descended below MSA and couldn't see the mountain he knew was somewhere about. Where did he think it was? The putative visibility was 40nm. So, what does a pilot do? Fly into nothingness on the AINS at 1500ft?

Some pilots cannot accept pilot error because Collins' actions were so stupid that they cannot believe it. I can list probably 10 fatal accidents in the last 10 years where a pilot I knew left me shaking my head. The only difference is the number of passengers.

The cold hard reality is (1) Collins' pilotage was 100% defective. (2) Air NZ's organisation, planning and briefings were 100% defective.

Who is fooled by Brian Abraham's arguing some peripheral point, like the height skuas fly? Whatever the reason for MDA being 6000ft it is entirely irrelevant. That should be obvious even to a helicopter pilot.

[Fantome]

Agree with all you say grip pipe. Except that on the NZALPA hosted website devoted to the Mount Erebus accident, there's evidence that family and friends of the deceased are content that there the deceased are honoured and remembered and that forums are maintained for those with opinions to air.

Erebus Disaster|Mt Erebus Plane Crash OFFICAL Facts Website|1979 Air NZ|NZALPA (http://www.erebus.co.nz/)


The home page quotes this -

"We have not set out to apportion blame but to show that even in the most tragic of accidents the lessons learnt eventually lead to improvements in air safety".



Captain Mark Rammell, President, NZALPA

Which is no less than what you are saying GP?

P.S. -


Furthermore, Brian Abraham is free with his insults but give him a serve and he suggests you need medication. Oh, the wit, the originality.

THINKS - Without this sort of clap trap, would there be any Kiwi jokes?

[Ornis]

Ha Ha Ha, a half wit.

[TWT]

Why not just accept that various people see things differently and leave it at that instead of resorting to personal insults ? Time to move on,after 33 years......

[Ornis]

Time to move on? A bold step forward or a shuffle in some kind of folk dance? The NZALPA wants Collins exonerated by Parliament. As an informed - and opinionated - sometime passenger in airliners, just like Brian Abraham, I find that frightening.

I'll take my chances in my own aircraft. I don't follow my GPS into mountainous areas when I can't see the mountain. The last VFR pilot to pull that stunt, Geoff Smale, died in ZK-SML. Recently.

My GPS puts my recorded track on the runway at Ardmore every time. After hundreds of landings that gives me some confidence. Would I ever use it when I couldn't see the runway? Maybe, if I were running out of fuel, daylight and had nowhere else to go. An emergency.

Before Easter I emailed the NZALPA to ask what proportion of members believed Collins was blameless. I await an answer. Actually, I don't: I already know the answer, more or less.

Those who think Collins blameless should ask themselves why airliners have pilots. To sit on fat wallets in fancy dress, a charade to please bored passengers? To deal with events and problems computers are not human-like enough to solve, perhaps?

[prospector]

Luke Skytoddler

Most on here would be aware of Gordon Vette's pedigree. But he also stated, and this has been printed in the previous thread on Erebus.

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

[quote] 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

And who was it that started the ball rolling with a 1500ft flypast because "the radar operator invited him to do it"????

And what was the requirement he would have scoffed at?? Surely not the descent requirements as laid down in consultation with the people who had experience in Antarctic ops, or the NZCAA. The word Hubris fits the scene very well.

[Fantome]

The descent requirements for this flight have been stated many times, they were printed in black and white, the descent procedure was practiced in the simulator, there was a copy of these descent instructions found in the cockpit in the wreckage, there can be no dispute that the crew were aware of these requirements, and they complied with none of them. The AINs was not cleared for Nav below MSA, these are all fact, not apologist theory.

dear prospector . .. . . . it seems you have fastened onto this one proviso to the extent that all other considerations are to you largely irrelevant. I suggest that to see the story of the Erebus crash in it's entirety, to see the many complexities interwoven throughout the multiple strands of evidence, hearsay and fact, can only be achieved through exhaustive study and the most open of minds.

And if you have arrived there. . . . .. then you're a better man than I am Gunga Din.

yours sincerely . . ..

[Ornis]

Captain Vette's trying to argue sector whiteout was something new and undiscovered.

Captain Collins attended a briefing by the RNZAF, which was well aware of the pitfalls of polar flying. Yet he descended through a hole in the cloud and flew at 1500ft, remarking how difficult it was to tell the difference between the ice and the cloud.

Vette might have done a beat-up, stupid and dangerous, but he could see Erebus and knew exactly where he was. Smacks of an apology for the bizarre and uncharacteristic actions of a friend to me.

Erebus was a shocking disaster. Chippindale was right about the crash: pilots must be accountable for their flying. Mahon was pretty right about Air NZ: undisciplined and dysfunctional.

How you weight the two is a matter of personal preference (or bias), and, largely irrelevant as long as both groups learn. I'm waiting.

Who got hauled onto the carpet for the fiasco at Perpignan? Or was it just swept under the rug?

[prospector]

dear prospector . .. . . . it seems you have fastened onto this one proviso to the extent that all other considerations are to you largely irrelevant.

That is correct, they are largely irrelevant.

If I went to a new aerodrome, and the weather was inclement, and I had to perform the published Instrument Approach, and for whatever reason I went below a DME stepdown, or went below MDA, or in any other way stuffed up the approach and impacted the ground, I would accept I had stuffed up and the ground arose to smite me.

I am sure many people would try to align Swiss cheese holes to explain why this bad error on my part as Captain in Command, but in the end, because I deviated from the set instrument procedure, that many qualified people had published to ensure a safe approach,and it was not complied with, then I would expect to carry the can.

[Brian Abraham]

David Beaty published in 1991 “The Naked Pilot – The Human Factor in Aircraft Accidents”.
Who is David Beaty? You can read his bio here Obituary: David Beaty - Arts & Entertainment - The Independent (http://www.independent.co.uk/arts-entertainment/obituary-david-beaty-1134036.html)

The following comes from his previously mentioned book, and I think pertinent to this thread.

What is pilot error?
This inaccurate and unfair verdict arose for two main reasons. First was the indecent haste we all feel to attribute an accident to something, to find an outlet for our grief and dismay, to blame somebody - in other words to find as mankind has done down the ages, a scapegoat. We want to be assured that it won’t happen again and, more importantly, that it won’t happen to us. The second reason lay in the implicit belief that flying as a skill was very difficult.

Yet very few accidents attributable to airline pilot error are as a result of errors in flying skill. With the advent of simulators and excellent training programmes, piloting errors have become rare. As aircraft became stronger and more reliable, mechanical causes of accidents fell sharply. Nearly all civil aircraft accidents are due to simple mistakes and errors which arise out of our human condition and are common to each and every one of us, in varying degrees and at varying times. So is a pilot more or less likely to make them than we who ride behind him in the passenger compartment? Certainly he is more frequently exposed to the risk of making such errors.

If and when the pilot does make that human error, it won’t be in isolation. It will more than likely be the culminating one of a series of errors made by other people. Perhaps as small as the straw that broke the camel’s back, perhaps a much larger one. But the likelihood is that there will already be errors in the system upon which his error puts the final seal. And those errors already in the aviation system of which he is the apex will be human ones.
Slowly, in the case at least of pilots, this is beginning to be accepted. And though the RAF still use the term and the media splash it about indiscriminately when there is an aircraft accident, pilot error in informed aviation circles is very gradually being dropped.

Now with the belated acceptance of human error, the question is: ‘What human errors?’ How do we sort out and identify them? And are there some to which the pilot is particularly prone?

The psychologists Billings and Reynard have termed the problem of human errors ‘the last great frontier in aviation’. What seems clear is that most of the tendencies to error run into one another. Like the limbs of the human body which they are so firmly planted within, human factors are separately defined, but they are mutually supportive and difficult to separate. For the purposes of clarity, in this book human factors will be separated. And in the following chapters a number of human factors will be identified in a number of aircraft accident scenarios.

It seems clear that many of these errors arise from our biological inheritance, from the very valuable mechanisms which helped us to survive in a primitive environment, and which have now become something of a liability; and though the pilot is no more prone than anyone else, he is more at risk of making errors, because he has been catapulted ahead of the field into a more frustrating and unforgiving environment.

For most of us, the world today is by no means an ideal environment for our biological make-up. In many ways it is a strait-jacket. We possess attributes and skills we don’t have an outlet for, and many more that have gradually atrophied for lack of use. The basic drives of hunger, thirst, sex, for domination and for shelter we cope with, and indeed enlarge upon. Hunger, thirst and sex have to be constantly titillated so that they can be more and more exotically and expensively satisfied, and few people would be content with a centrally-heated cave for a shelter. Advertising sees to the creation of ever new needs and the ever more expensive satisfying of them.
But we don’t need to hunt and kill our food or physically capture our mates, so the aggression we needed for these activities, if not consigned to the depths of our seething sub- conscious id or canalised into sports, augments the ego and helps create the macho image. Society smiles on this. We talk of an aggressive businessman, salesman, lawyer, politician - in terms of approval. The male pilot, too, has his fair share of aggression. He is a masculine type. On a list of adjectives in which the first officers described their captains, 90 per cent of the terms related to aggression, authoritarianism or egotism. There is also a fair sprinkling of such epithets in how the captains see their first officers. So the aggression, or the perception of it, is probably two—way.

But studies of accidents have shown that another human factor is constantly observed in first officers, frequently with fatal results - that of conformity, or the desire to please. Our ancestors learned early on to band together for safety and sustenance, to rub along easily with the next hominid and to defer to the leader. We find it very difficult to slough off a habit arguably millions of years old.

If conformity is a habit, however, a healthy animal curiosity seems to be in the very marrow of our bones. It is at its best a life force, a learning device, an inducement to explore, try harder, look further, find juicier berries — and is at the heart of every invention. But it is stifled by what primitive man rarely knew, and what is probably a luxury of civilisation but a pilot’s burden - long periods of inaction which induce inattention and boredom.

Curiosity attempting to alleviate boredom has caused fatal flying accidents. Boredom on its own has led to inattention, to simple slips and caused yet more fatalities.

One attribute which man’s natural curiosity sharpened was a particular sort of vision. Unfortunately for pilots it was not the all-round vision possessed by birds, so a definite drawback in the sky, and one to whose severe limitations psychologists are addressing themselves. At one time it was supposed that we all saw what was in front of us. If a pilot had another aircraft in front of him for x seconds and he didn’t see it, then of course it was a pilot error. But any man or woman in the street could have told the experts differently. We have all hunted around for what we have subsequently found was ‘staring us in the face’. The reason why is explored in Chapter 5, on Perception, where we see how, in the unforgiving environment of the air, such momentary lack of seeing can spell disaster.

So many of these errors, safe on earth, are harmless, almost lovable failings. Most people have reversed telephone numbers or turned to the left when they should have turned right. But in an aircraft, having a laterality problem, mixing your left and right, can kill.

So too can another human factor to which we, like many animals, are prone. In the face of fatigue, or sudden danger, we tend to regress. Children under stress regress to thumb—sucking, bed-wetting and anti-social behaviour. Curling up in the foetal position is a well recognised form of regressional behaviour. In difficult circumstances we reach for a drink, chew sweets, light a cigarette — all substitutes for our mother’s comforting breast. And in the sudden shock of an oncoming car, many people revert to the action they would have taken in the previous car they drove. Accidents are documented where pilots have done exactly this in aircraft.

Fatigue and sudden danger release many of the tendencies which lie beneath the conscious mind. Fatigue in pilots has been studied and written about, flight-time limitations have been introduced, and yet we seem little nearer to understanding it. We all know what it feels like to be tired. ‘But is feeling tired being fatigued?’ the pundits ask. The problem is as inescapable as it is intractable. What is also inescapable is that most aircraft accidents occur in the landing phase — at a time when it is likely that the pilot will be tired.
We are all creatures of a certain sort of time. Not the time on our wrist watches or on the airline timetables, but of a natural rhythm which we and the natural world share. We are part of the cycle. Our bodies are cyclical. Primitive man lived not just by night and day, but by the moon phases and the seasons and the rhythms of his own body. What effect, then, does hurtling regularly across time—zones have upon the anthropoid within? How does his mind and body react to sleep deprivation, the interruption of his diurnal rhythm, his eating patterns? Can he think and act as competently? The answer is simple. We don’t know.

What we do know is that one of our oldest and arguably most abused endowments, that of communicating with one another, is of paramount importance on the flight deck. ln common with the rest of the animal kingdom, we used to communicate with clarity and purpose. ‘Only connect,’ says E. M. Forster. The cry has been echoed down the centuries. Communicate. Yet despite, or maybe because of, all the communications media, we communicate less and less on any significant level.
We know that communication is of desperate importance on the flight deck. Courses on how crew should communicate with one another have become a thriving concern. Yet ‘failure to communicate at all levels’ figures in the reports on accident investigations, and cockpit voice recorders (CVRs) taping the last seconds before disaster show the pilots’ chilling inability to say the words that might save them.

It is in an effort to probe the human factors involved and to communicate some of their effects that the ensuing chapters have been written.

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

As long ago as 1980, Stanley Roscoe wrote that:

The tenacious retention of ‘pilot error’ as an accident ‘cause factor’ by governmental agencies, equipment manufacturers and airline management, and even by pilot unions indirectly, 9 is a subtle manifestation of the apparently natural human inclination to narrow the responsibility for tragic events that receive wide public attention. If the responsibility can be isolated to the momentary defection of a single individual, the captain in command, then other members of the aviation community remain untarnished. The unions briefly acknowledge the inescapable conclusion that pilots can make errors and thereby gain a few bargaining points with management for the future.

Everyone else, including other crew members, remains clean. The airline accepts the inevitable financial liability for losses but escapes blame for inadequate training programmes or procedural indoctrination. Equipment manufacturers avoid product liability for faulty design. Regulatory agencies are not criticised for approving an unsafe operation, failing to invoke obviously needed precautionary restrictions, or, worse yet, contributing directly by injudicious control or unsafe clearance authorisations. Only the pilot who made the ‘error’ and his family suffer, and their suffering may be assuaged by a liberal pension in exchange for his quiet early retirement- in the event that he was fortunate enough to survive the accident.

Unfair? Examples of unions fighting hard for their members are mentioned in previous pages. Managements and aircraft manufacturers have their problems and are by no means all bad, but sufficient examples of lack of foresight, cost—cutting, cover- ups, greed, buck-passing, blindness and refusal to face facts and other human factors can be shown to justify the generality of Roscoe’s condemnation.

What is clear is that no aviation accident can be justifiably blamed on one individual. The mistake is a collective mistake, and the responsibility is a collective responsibility

Yet it is only recently that very dubious management mal- practices are being identified and their contribution to accidents given sufficient weight. For though the pilot’s actions are at the tip of the iceberg of responsibility, many other people have had a hand in it — faceless people in aircraft design and manufacture, in computer technology and software, in maintenance, in flying control, in accounts departments and in the corridors of power. But the pilot is available and identifiable, and, if he isn’t conveniently dead, he probably feels himself responsible. Besides, he has no powerful financial lobby like the aircraft manufacturers or the big airlines.

That is not to say that there are not far too many human factor accidents on the flight deck. There are. And one of the reasons human factors took decades to be accepted is because of the pilots themselves, who understandably shied away from too much introspection. For the purposes of survival, nature appears to have endowed us with an inherited conviction that ‘success’ is ‘good’, even though success often contains its own element of failure. As a result, we draw away from those who make mistakes, lest we are associated with them. This is why mistakes are so often repeated and why it is taking us so long to understand them.

What should be stressed is that the pilot is not alone in his human condition. Nor is aviation alone in its management errors. A high proportion of recent world disasters — Three Mile Island, Bhopal, Challenger, Chernobyl, and the King’s Cross Under- ground fires, the Herald of Free Enterprise —— have occurred mainly as a result of latent management errors. In the recent Zeebrugge trial it was disclosed that no members of the marine and technical departments had a nautical or deck background and had scorned the idea of bridge indicator lights to confirm that the bow door was shut. So in aviation accidents, where the error is rather easier to cover up in the boardroom than on the flight deck.

Professor Reason points out that what is being relatively neglected are ‘measures aimed at enhancing the system’s tolerance to latent human failures committed by high-level decision—makers, regulators, managers, builders and maintenance personnel. In other words, we need to find ways of detecting and neutralising these fallible decisions before they come into adverse conjunction with active on—the-spot failures and local triggering factors.’ How can the total organisation be managed so as to enhance its intrinsic safety?

The ‘management factor’ in aviation, as it is now called - not, it should be noted wryly, management error`- should be measured against various parameters to get it into perspective: firstly, against the time scale of aviation endeavour; secondly against the safety measures that have already evolved.

The incredible speed of aviation evolution is self-evident. So is the ingenuity and courage of the human beings concerned in it.

[teresa green]

I just love armchair pilots, if you were not on the flight deck at the time, you cannot be completely sure what went on. I don't give a ratz about the BA skippers qualifications, he was not there, none of us were obviously. From the robbery at the dead Skippers house to the lies, back downs, and blame from the ATC to the cleaners, it was a terrible tragedy, that will remain a blot in world aviation history. Let them rest in peace.

[prospector]

I just love armchair pilots, if you were not on the flight deck at the time, you cannot be completely sure what went on.

Perhaps not in the cockpit, but we all certainly know what happened to the aircraft, and the fare paying pax, who after all paid for a return flight.

[teresa green]

And mate its not going to bring them back. Leave them be.

[Ornis]

Brian Abraham. Greetings. I don't disagree with most of your last post, which is a repeat dose. As Liberace said, too much of a good thing is absolutely wonderful. Perhaps he was being tongue-in-cheek, so to speak. (I am 69 today.)

Scenario: A theatre nurse mistakenly selects the wrong substance; the surgeon injects it. The surgeon and the hospital might be sued because the doctor is accountable for his actions and the hospital is responsible for a safe environment. The nurse must demonstrate the phial and the doctor must read the label, every time.

Scenario: I own an airline. I want to consult you. How do you get from a general discussion of human frailty to organising an operation that is safe? From a passenger point of view that means their aeroplane doesn't crash.

Let us find some common ground. Do we agree a pilot is responsible for the safely of the aircraft and must be accountable for his actions? Yes/No.

[prospector]

If Paul Holmes had refrained from publishing Daughters of Erebus, which is full of biased, untrue, and complete emotional claptrap, then this thread would not need to have eventuated, again.

[Brian Abraham]

Aviation Week & Space Technology, Monday, March 19, 2007
Making "Safe" Safer
The NTSB Relishes The Recent Air Record

The unfortunate fact of our existence upon this good earth is that there will always be accidents -- otherwise, they could stop building trauma centers in hospitals. Some years ago, an ICAO official was asked by a reporter (when a zero rate in some aviation accident statistic had been reached): "I guess you'll be breaking out the champagne then?"

The ICAO official's cynical (albeit ungrammatical) retort: "No. We consider it to be a statistical aberration that we don't ever expect to see repeated again." Perhaps he was just trying to emphasize the fickle nature of statistical conclusions.

From the Report Card submitted by the National Transportation Safety Board last week, the industry as a whole has an outstanding record of which we can all be proud, but that doesn't mean we can rest on our laurels and not strive for that elusive zero rate in spite of the ICAO assessment.

After all, the oft-repeated "that could've easily been me" runs through our minds each and every time we turn on the television and see the ruinous aftermath of yet another seemingly inexplicable accident. The other sobering aspect of any such record is that it's necessarily historical and that the only thing that counts for you, and those you hold dear, is what's coming down the pike to change it all -- "for better or for worse" as they say in that other commonplace disaster. More on that gloomy perspective later.

So what was good in that NTSB summary? First, the overall accident rate dropped again in 2006, although marginally. Passenger and cargo carriers operating larger aircraft under 14 CFR Part 121 continued, as expected, to have the lowest accident rates in civil aviation. In 2006, they carried 750 million passengers more than 8 billion miles while logging more than 19 million flight hours.

The cost was 31 accidents, a more than 20 percent drop from 2005. Only 2 of those 31 accidents were fatal, resulting in 50 fatalities. It equals .01 accidents per 100,000 flight hours or .018 accidents per 100,000 departures. For those who like their statistics mirror imaged, this translates to, on average, only 1 accident every 266 million miles, 630,000 hours flown, or 368,000 departures. The odds are that everybody has a much better than even chance of not making one of those unfortunate TV appearances.

On-demand part 135 operators had 54 accidents, down almost 20 percent from 2005, with 10 of those accidents resulting in 16 fatalities (or 1.5 accidents and .28 fatal accidents for every 100,000 hours flown). Part 135 covers air taxi, air tour and air medical operations. Scheduled Part 135 (commuter) operators experienced only 3 accidents, one of them fatal, resulting in two fatalities.

In General Aviation there was a total of 1,515 accidents, 303 of them fatal, resulting in 698 fatalities. Even though GA accounts for half of all civil aviation flight hour activity, it should be noted that the claimed drop-off in accidents is partly related to a decline in GA activity. Since 1990, according to NTSB, GA activity has declined by 20 percent and the rate has thus remained stable at 7.5 accidents per 100,000 flight hours.

What are the factors in the looking glass that could reflect or inflict future changes in our presently stable stats? Disregarding security concerns, there are a dismal myriad of these:

a. Looming pilot shortages and some of the measures being taken to address the situation (ICAO's MPL or Multi-crew Pilot's License).

b. Outsourcing of maintenance as driven by the need to pare costs and boost profit margins.

c. New technologies (including the next generation air traffic control system).

d. The rise in low-cost minimalist operations under deregulation worldwide.

e. Directly related to d., a marked trend toward tasking pilots up to the legal limits.

f. The Very Light Jet swarm (and the manning of those fleets).

g. The increasing popularity of sports aviation.

h. A denser air traffic environment.

i. Diminishing experience levels among air traffic controllers, some of which will be related to their perceptions of their longer term prospects in a different ATC environment (NextGEN).

We've not mentioned the new age limit of age 65 retirement, because that is extremely unlikely to blip any statistic anywhere. And we'll not even stand by to eat our words on that claim. To borrow a phrase from that well-known non-aviator Forrest Gump: "Safety is as Safety Does". Only the really dumb take chances.

[prospector]

Ornis,

Yes/No, would appear to be to much to ask.

[remoak]

Ornis,

Yes/No, would appear to be to much to ask.

Not really.

The answer is YES. It has always been YES. It will always be YES.

I still remember the first airline I flew for. One of the senior (non-flying) managers explained to us that the company viewed all it's captains as senior managers. Why? Because an errant captain could single-handedly shut down the airline by making one serious mistake. There are several examples out there of airlines that didn't survive a serious accident that involved heavy loss of life.

That's the whole point about being a captain. It comes with money, perks and prestige... but it also infers an awesome responsibility. A captain may be called upon, at any moment and probably at very short notice (ask Capt Sullenberger), to make a decision that will have dire consequences if he or she gets it wrong. Quite a few captains have had to make decisions that ended their own (and their crews) lives, in the hope of not causing further casualties on the ground. A captain has to balance safety with service, and know how to resist commercial pressure. He or she has to have the backbone to be accountable for their decisions (quite possibly in a courtroom if things go bad).

Of course, for 99.9% of captains, it'll never happen. But for the few to whom it does happen... well, that's why airlines invest so much money and trust in their captains.

So I would say, and taught during my airline career, that all captains should always be saying to themselves, "what is the safest possible course of action in these circumstances?"

Proceeding visually below MSA when one does not have adequate visual reference would seem, to me, to NOT be the safest possible course of action.

What this thread does demonstrate to me, is that some people will never learn from the mistakes of others. All down to today's "no blame" culture, I suppose...

[Ornis]

Brian Abraham, okay, let's leave Question 1, the responsibility and accountability of pilots.

Question 2. Does your recurrent analysis of the human psyche translate into organising an airline and operating large airliners? Yes/No.

As an aside, and I don't want to distract you from considering the question: almost without exception the pilots whom I have known die in light aircraft have done something remarkably stupid, often despite being warned, sometimes repeatedly. Some of these pilots were wealthy and clever professional men.

Prospector, I too spent time in the military. Typically the response is: "The answer is, NO, now what's the question?"

Remoak, I think your comments paint a very balanced appraisal of the crash and the organisation. Thank you.

[framer]

almost without exception the pilots whom I have known die in light aircraft have done something remarkably stupid, often despite being warned, sometimes repeatedly. Some of these pilots were wealthy and clever professional men.



What seems to us on the ground after the consequences become obvious, to be remarkably stupid, would not have appeared that way to the person about to do it, otherwise they wouldn't do it. I struggle to compare light aircraft crashes with airline crashes because of the structure, training, and experience required in the latter.
What you say about the pilots being wealthy and clever professional men interests me because I've long suspected a link between business success and poor descision making airborne. I haven't looked into it so I may just be imagining it but I suspect that the same ego/confidence that works well for someone in the business world can cause trouble when the cloud base is lowering and the terrain is rising.

[trashie]

I have not commented on this accident to date. I was actually on the flight deck of the US C141 Starlifter that day as they attempted to call the DC10.

The reason I was on the C141 was to attend a survival course at McMurdo before joining Deep Freeze operations. Certainly white outs where emphasised during the course so to say not much was known of white outs is untrue.

There were a number of systemic contributing factors, but in my opinion the final defence shield was broken by CaptCollins. In all my flying, breaking the lowest safe was a no no unless you had the visual cues.

In discussing the tragic accidents with the base operations people at McMurdo this was an accident waiting to happen with most airlines operating sight seeing flights apparently breaking agreed minimums with fly-bys of the bases. How much awareness training and awareness of sector white out was provided to any of the crews who flew these flights from all the airlines including the Red Rat.

[prospector]

Thanks trashie, a very good insight from someone who was much closer to the action than the rest of us.

with most airlines operating sight seeing flights apparently breaking agreed minimums with fly-bys of the bases.

Says it all really.

[Ornis]

framer. Light aircraft is my domain; I am not attempting to extrapolate to airliners.

A retired sea captain acquired a kit-built and decided to fly to the RNZAF 75th anniversary show at Ohakea. He was told several times where he could refuel; it seems he didn't. It had a Rotax engine and he didn't want to use avgas. Splat.

A maxillo-facial surgeon bought a twin. Late in the day after a farewell at the hospital he took off with his two young sons from Feilding. One engine stopped - he had turned the fuel off himself - and he returned to FI, despite being told many times in the event of an engine failure to go to Palmerston North. He turned into the dead engine. Splat.

An instructor strapped a very fat man in an aerobatic acft, filled it with fuel, climbed vertically until it went into an (anticipated) inverted spin, ~150kg overweight. Splat.

These are examples that spring to mind. I think you have serendipitously put your finger on the problem: people do stupid things "without thinking" because they don't see the danger, don't assess the risk. Sometimes people just don't think, even clever people. The difference is, once a problem has been identified, clever people do better solving it.

Flying presents a strange dichotomy. Pilots must be very confident yet avoid all unnecessary risk. That is a matter of judgement.

Business people must take risks. If they succeed they think they are clever. It might be just luck. Read: Everything is Obvious - Once You Know the Answer; Duncan J Watts, formerly Australian Navy, now sociologist with a difference - PhD in theoretical mechanics.

[Fantome]

Despite repeated calls here of late to let 'sleeping dogs lie' etc., I again contend that there will be grounds for review for many years to come. Though others will deride, if I have learned anything of life, it is that truth is more often than not an artefact. Truth is constructed. That being so, the line between fact and opinion becomes blurred. We need to remember that much of the time opinions slip and slide around to become stories that people make up, and are seduced into believing.

Bearing this in mind, and hypothesising for a moment, it is as well when a matter as crucial as say an expert revisionist's post mortem on Erebus is concerned, to be judiciously guarded, hesitant even, before advancing opinion or comment on his published work. Sir Richard Williams, the First World War Australian Flying Corp pilot who rose to the rank of Air Marshal, (Chief of Air Staff and later Director-General of Civil Aviation), titled his autobiography 'These are Facts', a bizarre, bumptious, brave banner to run with. How stern. How uncompromising. Not a little startling that a man in his exhaulted position, who'd experienced so much, could admit of no shades between black and white. With Erebus, those who purport to see the broad picture, trot out nevertheless their Readers' Digest condensed version, (at times tainted with temerity, gross presumption even), that 'a' followed by 'b', followed by 'c' is all there is to know and all you need to know. Purblind they are and purblind they will ever be. Moreover, they are woefully unaware that where you find that events have been selected or omitted, that people involved have been given the roles of heroes or villains, interpretation is unavoidable. This is all to the good, so long as the interpretations are credible.

There has probably been no other accident in air transport history that equals this one in terms of protracted, unresolved debate, combined with strident polarised opinion, though the R101 story with all its attendant cover-up and intrigue does invite comparison. That said, when it comes down to it, one of the overlays is a natural, very human fascination with the multifarious strands of the story. So in these cases, when high drama is evoked, as the specifics of terrible misfortune unfold, many are the comparisons that may be drawn, such as the Titanic, the Hindenburg and Space Shuttle Challenger.

What befell TE901 is no less complex, no less intriguing. It will continue to exercise curious minds while life as we know it falters on. He who would set out to comprehensively write the story afresh is of course obliged to be as accurate, as scrupulous, as he possibly can. He will have borrowed large parts of his account from actual people who actually lived. He owes them his best shot at the truth. He is a kind of crook if he doesn't pay up.

[Ornis]

A very dim source of light provides photons one at a time that pass through two close narrow slits to hit a screen behind. Each particle passes through both slits, interferes with itself and changes direction to form an interference pattern: a pattern of illuminated lines with dark lines between. How come? How can one particle pass through two slits? It is a mystery.

A DC10 hitting Erebus is no mystery. There are no contradictions. The pathway was poorly formed and the pilot stumbled.

The road to reality is different. Few of us will follow it to the present end. Fewer will build it. Some will never see it; they will die believing there is no pathway forward. They would doom us all to beat around the bush, wringing our hands, declaring it is the human condition: we are all lost.

[pakeha-boy]

Quote Ornis....
Let us find some common ground. Do we agree a pilot is responsible for the safely of the aircraft and must be accountable for his actions? Yes/No

Well Brian.....As a current Captain on an A/C that does carry more than a "few"......if you walked onto my A/C and informed me that the above quoted statement does not apply to me (As the "Designated" Captain of that flight)........I would have you escorted off the flight,..there has to be checks and balances and someone(the Captain) must enforce them

Spent qiute a few years flying in Alaska....several years contracted to the local NTSB office in Anchorage.......our job was to fly them to the scene of A/C accidents ....and during that time I talked with a lot of them,actively trying to learn as I much as I could about what caused the accident,how it could have been avoided,what led up to it,the medical state of the pilot...etc etc...you get my drift....................the one thing they always said and agreed upon was .....the PIC was/is always responsible for the safety and operation of his/her A/C........PERIOD!!

[Brian Abraham]

PB, certainly the captain is responsible. But so are the airline management, maintenance, nav department. A whole range of people have responsibility, not just the two people occupying the font seats. A work mate died in the DC-10 at O'Hare which had an engine fall off. The crew crashed a perfectly flyable aircraft, they could have flown a circuit and safely landed. Everyone perished. Was it the crews fault? Do they carry the entire responsibility? Interested to hear your view.

[john_tullamarine]

A whole range of people have responsibility, not just the two people occupying the font seats

.. which is why, in the often inevitable court case after the mishap, judgement often apportions various percentages of damages according to the court's assessment of the relative culpability of various of the players.

[pakeha-boy]

Gidday Brian..........mate I have read all your posts on this subject,I agree with a lot of the opinion and fact you have brought to the table.......sorry to hear about your mate in ORD...I have read the NTSB report..........Regarding the Moderators post,I can only agree 100% with it......all you have to do follow the Concorde crash,and see where the blame is being "apportioned"

But ,,..the premis that the Captain is not solely responsible for the saftey of his/her flight seems to allude you........I see it no other way.....regardless of who may have contributed to that flights demise........As the Captain,no matter what happens on that flight whether it be at my hands or others,.....I am still responsible to deal with the "situation" at hand ......and are responsible no matter what the outcome.............

I am lucky that Ive been in the left-seat for many years.....maybe its my training,maybe experience....maybe a lot of things...I am never to old to learn.......but the one thing that has never changed is my"ultimate" Responsibilty...How that Responsibilty is "gauged"....not sure their is one...other than what the controlling agencies and Airlines, say what it is....I consider it, from way before the flight takes place until I walk out of the cockpit and "Release" the A/C back to the company..... I hope you can see that.......

[remoak]

Tricky business, apportioning blame.

Many aircraft have been doomed from the moment they took off, and nothing the crew could or did do would have saved them (the Alaska Airlines 261 crash for example, where a control failure led to loss of control). In that case, it's hard to see how any blame could be paid at the Captain's door. Others, like Erebus, are a combination of factors. My view is that Erebus would never had happened had the Captain not ignored the basic tenets of visual flight.

Having said that, he probably took what he assessed as a reasonable risk in the circumstances... and if the other factors had not come into play (inaccurate position due changes made without his knowledge), he almost certainly would have got away with it.

So maybe the argument should really be, "what is a reasonable risk when commanding an aircraft"?

Some would say no risk is reasonable, others would say every part of flying is a risk and just needs to be managed properly. I tend to the latter view.

I think most of us know instinctively when we are straying from the path, it's what we do next that matters.

[teresa green]

To me it all boils down to discipline. Discipline from the LAME that signed my aircraft out, discipline from the avionic LAME that signed my aircraft out, discipline from what we called loadmasters, to get the weight right, discipline from the CC who know their job backward and can perform it well and I am not talking about serving tea, a competent and disciplined flight crew, and last of all a dedicated and disciplined Captain. That is what the public pay for and that is what they should get. However like the Captain of the Titanic, we are all human, we make mistakes, we forget the best advise we ever had from our first flying Instructor," if in doubt, don't." And my old flying instructor gave me the best advice ever. "Don't ever trust the bastards" because the day you do, it could be over for you and your pax. And work with what you have, not what you have lost. That advice was given 53 years ago, it still stands, regardless of all the bells and whistles that pilots have today, the A380 showed that. This is not to say that the TE crew were not disciplined, I have no doubt that all were excellent Airmen, but placed in a incredibly difficult position that was totally unfamiliar to them, and then it comes back to "if in doubt, don't." Stuff the company, stuff the PAX, you are the boss if your experience, your airmanship (that old word) tells you its wrong, get the hell out of there. Everytime.

[ampan]

The reason for all of this continued nonsense is that Mahon was completely wrong.

Brian A: Yes, they could, in a perfect world, have recovered the DC-10 at O'Hare. Do the crew have any of the blame? Definitely not.

TE901 was nothing like that. It was a standard CFIT accident, caused by a captain attempting to fly VMC, when he wasn't, and when he knew he wasn't.

[framer]

I see it no other way.....regardless of who may have contributed to that flights demise........As the Captain,no matter what happens on that flight whether it be at my hands or others,.....I am still responsible to deal with the "situation" at hand ......and are responsible no matter what the outcome.............


I feel the same way about my flights. When things go wrong, sometimes it is obvious that someone else has made the error, so be it, it's my ship and I wear it, I don't want it any other way. I don't feel like that is a bad thing or a burden. I feel like that is what I get paid to do. I also think that this 'all encompassing' sense of responsibility is what makes a flight safe, if someone wasn't carrying the can then all too often nobody would put their foot down and say "No". That sense of responsibility is what prevents a slow slide into unsafe practices. Think about it...why do we have Captains? Why, through the 80's and 90's with a proliferation of PC "we're all part of a team" idealism did they not do away with the role of Captain? Because if they did planes would crash. Any outfit where the consequences are high has clear divisions of authority with only one person in charge. It's the sense of responsibility that keeps us safe.

[remoak]

"Don't ever trust the bastards" because the day you do, it could be over for you and your pax.

Complete BS.

Modern aviation is built on a system of trust, and can't possibly function any other way. You have no choice but to trust your engineers (unless you propose disassembling and rebuilding your aircraft before you fly it), your loadmaster/dispatcher/baggage loaders (unless you propose loading your own aircraft and calculating your own mass and balance), your fueller (when was the last time you fuelled your own jet transport), your crew, and so on.

The unfortunate thing is that if any of the people mentioned above screw up, you get to wear the consequences. A bit like Jim Collins ended up wearing the consequences of his Flight Ops department stuffing up. Well, partly.

It's fine to be wary, but at the end of the day you have to trust your team. Otherwise, the operation just falls apart.

[4Greens]

As an ex airline Captain I'm often asked how I coped with the responsibility for 300 plus people.

No problem I reply.' At the front you generally hit first, if I get there the pax will get there'

[teresa green]

Remoak, I was referring to the aircraft. Not the engineers or anybody else involved in its flight. Read my post again. Aircraft are built to fly, always have been, but sometimes they don't, for what ever reason. Sometimes that reason sneaks up on you, sometimes its right in your face (like birdstrike) what the old flying instructor was saying, don't expect it to always do what is expected, to do so is folly, always expect the unexpected, I don't care if it is a Tiger Moth or a A380, or as he also used to say, if it has wings or t$ts, its going to give you trouble somewhere down the track. He was not wrong.

[remoak]

Ah OK my mistake. I didn't realise that an inanimate object could be of illegitimate provenance. I'll read you post a few hundred times more until I get it... ;)

[Ornis]

Nothing can be gained by allotting blame now. The operation was out of the ordinary and Air NZ was out of its depth.

Under air law Captain Collins gets all the blame and it's unlikely Chippindale's finding can be challenged, but the outcome of any court case depends on how smart your lawyers are, what expert witnesses they can net in and the whim of jury members. We have seen already how Mahon painted, with colour and style, Collins as the victim.

In a statistical sense how much blame you get depends on how well you performed compared with your peers; that can only be conjecture since we cannot repeat the flight. How many pilots would have conducted it the way Collins did given the same circumstances? How many would have been saved by intelligence and airmanship?

From the airmanship perspective, the sympathy for Collins is worrying. NZALPA opines Captain Collins left NZ with the "wrong" situational awareness due to the unannounced change in coordinates for "McMurdo". I call that a mindset. For a humble VFR pilot, situational awareness is seeing where I am and where I am going, and if uncertain then flying the aircraft in a safe manner until that's resolved.

Below cloud and at 1500ft, nobody on the flight deck was certain of the aircraft's position - everybody was guessing - and the decision by the PIC to continue south smacks of get-home-itis.

Most likely had the "McMurdo" coordinates Collins entered into the AINS been the same as he plotted the night before, the crash would not have happened. That does not make his choices wise or his actions right. It would have meant he was lucky, this time.

We hear a lot about the safety culture; the attitude to safety in an organisation. Certainly an airline pilot is dependent on others knowing what they are doing and doing it. An organisation is only the people who make it; sometimes unfortunately the total is less than the sum. There need to be systems in place so there is no single point of failure.

We seem to hear less about safety as a personal philosophy or creed, perhaps it is taken for granted. At risk of incurring the wrath of the self-appointed gods of accidents, I speak again as an informed passenger on airliners. What I want up front is a pilot, not a philosopher, psychologist, political analyst or poet. A pilot who knows how to fly the aircraft and is careful.

Whether Collins was careful or not is a question of judgement. That is the crux of the matter, and one on which there seems no agreement.

[teresa green]

Precisely Ornas, precisely.

[ampan]

Then let's get back to the facts:

Only two previous flights had similar conditions. Captain Dalziel took the alternative route. Captain Ruffell did not, but he baled out once he got the weather report, and toured the Dry Valleys - with good success.

Captain Collins had blue skies in the Dry Valleys, but he "preferred [McMurdo] first". Why? So he himself could see the various shacks, which he had not seen before. So this gentleman went and did something that could only be justified in a single-seater, and pretended to be visual, when he knew he was not.

This whole argument is insane, and the root cause of it is a judge with a brain tumour and a couple of dodgy lawyers.

[deadhead]

Ampan, you need to have your medication reviewed.

Only two previous flights had similar conditions.

No they didn't. Dalziell had planned to take the alternative route well in advance of the descent because McMurdo was closed, and Ruffell essentially diverted after getting the latest weather report which also indicated McMurdo below all ops. Nothing like the Collins flight.

Captain Collins had blue skies in the Dry Valleys, but he "preferred [McMurdo] first".

It has since been shown that the words "No I prefer here first" were never spoken on the CVR. You are forgiven this belief.

Why? So he himself could see the various shacks, which he had not seen before.

Really? And what tantalising piece of knowledge do you have that no-one else has, that you can see into his long-dead mind? Also, didn't realise Collins was acting alone on the flight deck. What was in the minds of the others? Do tell.

So this gentleman went and did something that could only be justified in a single-seater, and pretended to be visual, when he knew he was not.

Ditto.

This whole argument is insane, and the root cause of it is a judge with a brain tumour and a couple of dodgy lawyers.

The first 5 words I entirely agree with, the rest you can figure it out for youself.:D

[Ornis]

I too think Captain Collins wanted to see the show himself but I didn't want to be the first to say it. Nothing else makes sense.

[Brian Abraham]

is not solely responsible for the saftey of his/her flight seems to allude youPB, not at all. Well aware after 20,000 hours who gets to carry the can. And I know full well whoever may have had a hand in the event (management etc etc) will absolve them selves of all responsibility and point their fingers towards you know who. Just wait till the Norfolk Westwind ditching accident report comes out. I'm betting we will see much finger pointing - not me Guv, honest.

[prospector]

Deadhead,

Nothing like the Collins flight.

In what way weather wise do you say the Collins flight was different??

The reported weather at McMurdo was well below minimums for the approved VMC descent procedure, why else would he resort to a hole in the clouds VMC descent??.

Nothing on Ross Island, including Mt Erebus was ever positively identified at any time. What does that say about the weather conditions at the time of descent??.

[deadhead]

I'm referring to the reported weather conditions, which were below all ops for the two flights which diverted, and 40 miles visibility for the Colllins flight.

When you say "approved" can I just get you (for my edification) to tell me what you understand by that, and who exactly was authorised to do this "approving,"

[prospector]

deadhead,

From John King's "New Zealand Tragedies, Aviation".

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

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

1. Vis 20 km plus.
2. No snow showers in area.
3. Avoid Mt Erebus area by operating in an arc from 120 Grid through 360 Grid to 270 grid 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 area.

A copy of this memorandum was recovered from cockpit wreckage.

Meanwhile the crew of Flight TE901 approaching Antarctica had discussed the weather with the McMurdo meteorological office which advised that Ross Island was under a low overcast base of 2,000ft with light snow and a visibility of 40 nautical miles.

[gobbledock]

The wheel is just going to keep on turning in relation to 'who thinks who' is to blame for the accident, to that end I will add no more.

What astounds me however is how little attention is paid to the post accident actions of ANZ and the Government.

Read 'Darker Shades Of Blue', it can be applied perfectly to ANZ and the NZ Government of that day. We bang on predominately in life about 'accidents and rogue pilots', but to me more frightening or more worrying are the holistically rogue airlines and rogue governments.
Is it any different today? Rogue regulators, rogue governments and Ministers offices and rogue senior airline executive managers. These elements all exist today, with evidence 'popping up on the radar' on an almost weekly basis. This industry is a block of Swiss cheese and the holes just keep on aligning themselves. The 'fish rots at the head', the head of powers in fact, and there has been a stinking carcas laying around for ages. Erebus was Erebus, we can't turn back the clock. The sad thing is I don't see any improvement or lessons learned within in the rogue executive airline management, government or regulatory bodies in AUS/NZ. Nothing to date, in the past 30 years changes my opinion that the next disaster has been and is lining itself up.

Tick tock

[deadhead]

Prospector, I'm not denying the briefing material nor am I sticking up for Collins on that score - I am replying to ampan's claim that the Collins flight had similar weather to the 2 diverted flights when it did not - it was patently better. But since you bring it up - did the briefing instruct the pilots on how they were to determine their azimuth from the TACAN? And, what process was undertaken to create this let-down area? Was it approved by the CAD? How? It seems to me that once the NDB was withdrawn flights to the ice should have been stopped by CAD, but that's just me, and the flights kept operating, so irrelevant I guess ..

[ampan]

deadhead:

I concede that “I prefer here first” is not in the Washington transcript. All the other significant comments made the captain, however, are – and they demonstrate what an awful piece of flying it was:

Cloud come down a bit. Very hard to tell the difference between the cloud and the ice, so can’t be VMC. No NDB, and no directional info from the TACAN. Can’t use the AINS, so we’ll have to go somewhere else. Bit of a shame, because I was looking forward to seeing McMurdo.

Radar assist! That’s great. We’ll get to see McMurdo after all. I’ll tell the passengers.


Can’t get the Tower on VHF. Must be playing up today. Will have to go to the Dry Valleys … Hang on: I can see the sea ice down there. If I duck down through this hole I can fly under the cloud to McMurdo. I know I won’t be VMC but I should be OK if I stick to my nav track. I know I’m not supposed to use the AINS for that, but I also have my eyes, even though I know they won’t work properly. Won’t be getting another break in the cloud, so its now or never. Won’t bother telling the chaps. Tally ho.

Thought I’d be getting a better view than this at 2000 feet. Can’t see horizon. Better arm the nav and drop down another 500 feet.

Still no horizon. This is a bit strange. Should be able to see McMurdo by now, but there’s nothing there. I wonder if the waypoint is where I plotted it last night. ****! I should have checked it. Maybe it’s at McMurdo, like they said at the briefing. That would mean that Erebus is dead ahead, but I can’t see it … cloud! / ice!/ no horizon! / no VHF!: I’ve got to get out of here! F/O says its clear to the right, but if Erebus is dead ahead, Mount Bird would be to the right. I’ll have to go left.

[prospector]

deadhead,

did the briefing instruct the pilots on how they were to determine their azimuth from the TACAN?

As they should have still been above MSA, 16,000ft, until they were in the designated let down area, then the AINS would have been quite sufficient to determine azimuth from the TACAN CH 29. As it was a mandatory VMC descent then if they were not positively VMC, ie positive fix from known ground features, then the descent should not have continued below MSA.

I cannot find the reference right now, but it is my belief that this descent procedure was arrived at after consultation with Deep Freeze ops and NZCAA.

[deadhead]

Ampan, if this aircraft was not in VMC the other flight crew would have taken over and ensured Collins would not be in charge of anything other than the interview chair in Gemmels office.:{ The rest of your post referencing what was going on in Collins' mind you have invented. A complete fabrication.

[deadhead]

Yes prospector, I get that, but did the briefing specifically instruct them to use the AINS to determine azimuth? Thank you in advance if you can find the reference in regard to the procedure.

[prospector]

If this aircraft was not in VMC the other flight crew would have taken over and ensured Collins would not be in charge of anything other than the interview chair in Gemmels office

Perhaps if Lucas was in the right hand seat things would have been done differently. As it was Cassin was aero club trained and Collins Air Force trained. At that time this could well have had some influence on the way things were done. It should not have, but who know's. There was an Airline Inspector from CAA scheduled to travel on the flight, but he had to cancel due family reasons I believe. If the crew were aware a CAA inspector was onboard would they have done things differently?? for my money I would say yes.

[ampan]

Deadhead: The F/O was a yes man. He should have intervened, by politely saying "didn't you say that is was very hard to tell the difference between the cloud and the ice?" The other F/O was not a yes man, but he was stuck back in the cabin with the passengers.

[deadhead]

Well, the flight engineer was most definitely NOT a yes man. The complete opposite in fact. But yes, I concede that these are valid points that might explain the dynamic on that flight deck that day. But we aren't talking about determining who should take crew rest first, the argument is whether the aircraft was VMC. Yes man or no yes man, I can't believe the others would have let Collins enter IMC deliberately.

[prospector]

deadhead,

Cannot find anything that specifically states the AINS to be used for azimuth info,yet.

From the Bolt/Kennedy Report.

In relation to the criticism that the flight route was planned over Mt Erebus, an active volcano, Bolt/Kennedy responded by saying that the duty of CAD was not to specify the route; that was for the airline and CAD's job was to set the conditions that would ensure the safety of the flight. This clearly related to the fact that the minimum safe altitude named in the Civil Aviation requirements for the flight was 16,000ft until the aircraft had passed over the McMurdo base station at which time it could descend to 6,000ft provided that the visibility was satisfactory, that is, in visual conditions. They then went on to make comment in regard to the term Visual Meteorological Conditions (VMC) in its application in the Antarctic regions where unique visibility conditions could exist.

So the argument as to whether the aircraft was VMC prior to reaching McMurdo station is not really relevant, it was a mandatory requirement to maintain above MSA until passed McMurdo Base Station,

[Brian Abraham]

What astounds me however is how little attention is paid to the post accident actions of ANZ and the Government.

Read 'Darker Shades Of Blue', it can be applied perfectly to ANZ and the NZ Government of that day. We bang on predominately in life about 'accidents and rogue pilots', but to me more frightening or more worrying are the holistically rogue airlines and rogue governments.
Is it any different today? Rogue regulators, rogue governments and Ministers offices and rogue senior airline executive managers. These elements all exist today, with evidence 'popping up on the radar' on an almost weekly basis. This industry is a block of Swiss cheese and the holes just keep on aligning themselves. The 'fish rots at the head', the head of powers in fact, and there has been a stinking carcas laying around for ages. Erebus was Erebus, we can't turn back the clock. The sad thing is I don't see any improvement or lessons learned within in the rogue executive airline management, government or regulatory bodies in AUS/NZ. Nothing to date, in the past 30 years changes my opinion that the next disaster has been and is lining itself up.

Tick tock gobbledock, how right you are Sir. Unfortunately. Trouble is, we even have people posting here who are of the belief that swiss cheese and holes is all nonsense.

[prospector]

There is no doubt Swiss Cheese and holes lining up have their place, but when SOP's and CAA rules are flagrantly breached, for whatever reason, then that must be the major cause of this crash. It was one mans decision to carry out that descent when and where it happened.

[deadhead]

Prospector:

So the argument as to whether the aircraft was VMC prior to reaching McMurdo station is not really relevant, it was a mandatory requirement to maintain above MSA until passed McMurdo Base Station,

Agreed, once again I was just discussing with ampan the weather differences between the 3 flights in question. Thanks for the information re the route planning.

ampan:

He should have intervened, by politely saying "didn't you say that is was very hard to tell the difference between the cloud and the ice?"

I wouldn't get too strung up on that, I believe that that indicates there was a reasonable horizon at the time. It's not like he said "I can't tell the difference...!" I'm more perplexed because the FO didn't say "hang on a minute, they offered us a radar letdown to which you said yes. What the hell's going on now, chum?"

[Ornis]

No, Brian, we do not believe the Gruyere model is all nonsense, but it is a model or analogy, not reality. Nevertheless, you want to talk cheese, let's talk cheese.

To see through the block of cheese a hole in each "slice" must line up. Let us suppose a man is put in charge of keeping each hole in its right place. Regardless of who failed to keep the first x holes out of alignment, who didn't guard the last slice? If the man had been attentive to the last slice, regardless of the others, would the crash have occurred? Yes/No.

You seem unwilling to admit the accident, complex as it might be, can be analysed. Surely you can see a fruit salad is made of apples, oranges, pears, peaches, passion fruit ...

The only difficulty is apportioning blame, because it is difficult to get any agreement as to how each "hole" is weighted, or whether apples contribute more than oranges to the fruit salad. That is why we have judges. Of cheese, fruit and the law.

In this case, why should we bother deciding what is more important in the fruit salad? Air NZ was responsible for providing a safe environment and Collins was responsible for flying the aircraft safely.

Air NZ is 100% to blame for a dysfunctional operation and Collins is 100% to blame for flying into a mountain he knew was somewhere but couldn't see. I mean, he wasn't playing a game of hide and seek, was he?

[ampan]

Deadhead: I'm referring to FL180, which is where they were when the fatal descent began. At that point, they were above MSA, flying on instruments, the only one being the AINS: Perfectly acceptable - you could cross the Pacific on the AINS, without even bothering to cross-check against stars or beacons. No need for a horizon, given the autopilot and the HSI. They could have been flying in the dark.

Throwing the aircraft into a figure-of-eight descent below MSA changed everything. Even a private pilot with 100 hours on the clock would get that point.

[Ornis]

deadhead, I can't believe what I am reading. I mean, do you see this "reasonable horizon" right up until you hit the mountain? Do tell.

As has already been discussed so eloquently by remoak, VMC and a positive visual reference are not the same thing.

For goodness sake, I am only an old playtime pilot, even I know flying visual you have to see where you are and where you are going. If you can't you can try your luck if you like and we all know what happens.

[deadhead]

Relax Ornis, I'm on your side. If there was no horizon even the most yessy of yes men would have said "Where's the f u c k i n g horizon." Having said that, I agree with what prospector said. VMC/IMC it doesn't matter... Notwithstanding the briefing instructions, in fact forget about those, It was a poor decision to descend to get below a 2000 ft overcast, even if the visibility was a good 40 miles...especially if a radar descent was offered, you agreed to it, then suddenly without warning you decide to orbit visually down through a hole. That isn't what a strong commander ought to be doing. Where was the rebriefing? Discussion?? That is the problem I have. An extremely poor method, Captain.

[ampan]

What is the difference between Jim Collins' performance and that of JFK Junior? (who has no flight safety award named after him).

JFK Jnr deliberately breached VMC minima and killed himself, his wife, and her sister.

Jim Collins deliberately breached VMC minima, and killed himself, his crew, and 240 passengers.

Brian Abraham can crap on all he wants about the clear air, but whatever country one might care to look at, the VMC minima rules use the word "visibility". Can you fly VMC in gin clear conditions with you eyes closed? Of course not.

[CaptainMidnight]

Recommendations for a good book on the subject?

I've seen a list of titles on the erebus.co.nz site.

[compressor stall]

Brian Abraham can crap on all he wants about the clear air, but whatever country one might care to look at, the VMC minima rules use the word "visibility".

Sigh. Here we go again.

In Antarctica, you can still be VMC - according to ICAO definitions and therefore most CAA equivalents - and not see the ground in front of you. Visibility means the "ability, as determined by atmospheric conditions and expressed in units of distance, to see and identify prominent unlighted objects by day...".

If Mt Erebus had a rock band across it at low levels, I'd say Capt Collins wouldn't have flown into it. At that time, he would have had the required visibility under any VMC definition you choose to throw at the argument. It's just that there was no prominent unlit object to see, against a background of snow with cloud above.

Maybe it's a shortcoming in the regs, but you don't need a prominent object to have VMC. Its not about flying around with your eyes closed.

As an aside, there's a place in Antarctica called the Touchdown Hills...

[Ollie Onion]

Listen it is pretty simple:

Lot's of swiss cheese holes lined up which ultimately led to a very experienced capable crew flying a perfectly good aircraft into the side of a mountain.

Where the real disgrace is in this story was the way the government of the day and Air New Zealand purposely obstructed and tried to cover up all of those minor errors that ultimately contributed to this tragedy.

I strongly suspect in this day and age that given a similar set of circumstances the airline execs in question would be facing corporate manslaughter charges as opposed to just a stern telling off in a report which was produced many years after the fact.

We have to put it in perspective though, this crash could have been avoided at any stage by the flight crew not descending through the MSA when they were only 'reasonably' certain of their position rendering all of those 'other' mistakes mute.

[Brian Abraham]

Brian Abraham can crap on all he wants about the clear air, but whatever country one might care to look atampan, you are full of it, crap that is. I'm gaining a very strong impression from your continual denigration of Captain Collins that you are in fact an ex ANZ manager from the time in question, or perhaps worked in the nav department. There is absolutely no evidence that the flight was in anything but VMC conditions up to the time of impact. Time and time again you have shown that you have absolutely no understanding of whiteout.

Ollie Onion, a most sensible consise summary.

[ampan]

I could be the bastard son of Morrie Davis. So what?

Compressor Stall: If you know that it's very difficult to tell the difference between the cloud and the ice, then you cannot be VMC between the cloud and the ice. And if you know that it's hard to see with your eyes closed, then you cannot be VMC with your eyes closed. Is this complicated stuff for you and Brian A? You gents seem to think that Antartica is such a mysterious place that only those who have been there could know what the Antartic definition of "visibility" is. Jim Collins knew what the word meant, and he knew he didn't have it.

[Ornis]

I am no apologist for Air NZ, but look here: An experienced line pilot is sent to overfly the Antarctic after being briefed and trained to descend below MSA only south of a very big mountain, only in clear sky with 20km visibility and only in radio contact with McMurdo radar.

He takes it upon himself, with no discussion with the other two pilots, one of whom had "buggered off" for whatever reason, to descend in a hole in the cloud north of Eerebus, based on his belief the route was safe and the AINS that he had not checked in any way. Blunder one.

He knows the visibility at McMurdo is 40nm but he can't see much where he is at 2000ft so he descends to 1500ft where he can't see anything where he wants to go. Never mind, if you can't see anything, because of the ice and the low cloud, it's as you would expect, "nothing" there. Blunder two.

Forget horizons: CARs don't mention horizons. Forget definitions of VMC: CARs stipulate 5km visibility, that means you can see something 5km in front of you. Not to the side, to the front. CARs don't consider or discuss whiteout where the visibility is 40nm but the brain interprets nothing, because that is outside normal operations. (Air NZ required 20km vis.)

Forget regulations, forget numbers. The essence of visual flight is seeing where you are and seeing something where you are going, far enough to be "ahead" of the aircraft. Instead of turning north over the sea and climbing out, Collins decided to continue on nav track south. Blunder three.

Brian Abraham would have us blame Swiss cheese for these blunders, this appalling flying. Collins didn't have a free will, he was the victim of circumstances. Those who don't see it this way are lesser mortals. They do not have the sagacity or authority of the gods. Amen.

[Whiskery]

Ollie Onion, says it all really.

Amen.

[compressor stall]

Ampman,

There is no Antartic [sic] definition of visibility and, as such, VMC by definition there is really no different to anywhere else in the world, including NZ. It's not a mysterious place, but VMC flight there can throw up unique hazards that require understanding. As could e.g. PNG or Saharan flying.

If you know that it's very difficult to tell the difference between the cloud and the ice, then you cannot be VMC between the cloud and the ice.

You still don't get it. :ugh::ugh:

I like Ollie Onion's succinct summary.

[Brian Abraham]

You still don't get it.Nor does Ornis unfortunately according to hisThe essence of visual flight is seeing where you are and seeing something where you are going
compressor stall (an individual you would be wise to seek council from should you venture to those southern climes)
VMC flight there can throw up unique hazards It's not that hard a concept to grasp.

[prospector]

It's not that hard a concept to grasp.

The concept that one can disregard Company SOP's, CAA requirements specifically laid down to avoid Mt Erebus, and then be blameless for the consequences is something that I find hard to believe.

But obviously some folk think it more important to be VMC or not in an area that the flight should not have been anywhere near, VMC or not, in the first place, is also what I find hard to believe.

Ollie Onion is only getting close when he states

We have to put it in perspective though, this crash could have been avoided at any stage by the flight crew not descending through the MSA when they were only 'reasonably' certain of their position rendering all of those 'other' mistakes mute.

[Ornis]

Brian Abraham. I have never claimed to be anything other than a simple recreational pilot. If you can tell me where I err when I state the essence of visual flight is seeing where you are and something where you are going (I am talking about flying A to B, not aerobatics) do so, please. Anyone else feel free to chip in - this old dog is never too old to learn. Thanks.

[compressor stall]

I think you will find that my facts about the traps in VMC conditions in Antarctica actually lend weight to the argument that he should have not been there in the first place.

My recent comments here were purely intended to try and correct a recurrent misunderstanding and misrepresentation by some people trying to pin 100% of the blame on the Captain of the conditions faced by the crew and what they saw or didn't see and the conditions they were in.

In my opinion, Captain Collins may have been happy to stay in what was VMC as long as he did as he was not aware of the whiteout hazard, reinforced as out the right of the aircraft he could see the Dry Valleys.

It is my opinion again that he knew the initial descent was against SOP, but others had done it previously, it was likely VMC and so he made a calculated decision to descend and maintain flight under the cloud. In 20/20 hindsight after 25 years, we'd consider this a maverick cowboy manoeuvre but at the time likely tacitly approved by the company as is evidenced by others' previous violations.

Sadly, in making this fateful decision it is likely that he did not consider, amongst other things, external influences in the error chain (change of co-ordinates) and despite his own inexperience in the Antarctic had not been fully made aware of the dangers that lurk in VMC over snow.

Capt Collins needs to shoulder some of the blame. So does the company. So does the NZCAA. As to how to apportion blame? Well that's why we are still discussing this after 2.5 decades.....

[compressor stall]

Ornis - Visibility by definition (check ICAO or your CARs) is predicated on being able to see and identify a prominent object by day.

That is subtly but very importantly different to there needing to be a prominent object to see.

"It's the vibe of the thing your Honour," doesn't stand up in court. :} But that in itself doesn't make it a bad idea!

[pakeha-boy]

Quote ollie...."We have to put it in perspective though, this crash could have been avoided at any stage by the flight crew not descending through the MSA when they were only 'reasonably' certain of their position rendering all of those 'other' mistakes mute."

Gidday Brian....I personally have come to "my-end" of this dicussion,"s"...with the above statement By Ollie.....I,on a daily basis ,judge my performance"s"..my decisions....my actions...and ultimately...my results!!!.....Im still alive.....and thats not to say that Ive not been at fault....but as an idividual,I know the rules and I do know myself(I hope).......I only hope I dont put myself or anyone else is this position.....because through debate and continued debate....we will(and have) learned from this....and we all benefit............I walk away with the feeling that Im comfortable with my thoughts and feelings about the stand Ive taken here ...........we agree to disagree...........kia kaha

[prospector]

compressor stall,

Visibility by definition (check ICAO or your CARs) is predicated on being able to see and identify a prominent object by day.

Perhaps you may be able to explain why,in your opinion, even if the crew thought they were in the middle of McMurdo Sound, on the descent track as plotted, they must have been, and known, they were very close to Cape Bird, and Mt Bird and they never sighted these geographical points at any time? even on the descent track they were in fact on, they came to near as dammit over the Eastern side of Cape Bird and never sighted it at all. so obviously they could not have had the required 20km of vis during that descent.
Could all these missed opportunities to visually, accurately, fix their position be put down to white out??.

These are just questions to someone who has experience in this environment, it is my belief that they should not have been there at all, whether they thought they were VMC or not.

[Ornis]

I said the essence of visual flying is seeing where you are and something where you are going. I chose my words very carefully; I didn't say definition. If you cannot see something where you are going you cannot fly visually, not safely. That is the rule I apply and I don't really care about arbitrary numbers or inadequate definitions.

The whole point of having a person in charge of an aircraft is to deal with unforeseen circumstances. Otherwise you might as well totally automate the whole operation and put an actor up front to placate the sceptics.

Years ago a retired Air NZ pilot told me the story of an old pilot who used to sit in the cockpit and say to himself: Today might be the day it all turns to sh*t, am I ready? An aphorism I do repeat.

We humans should remember the sky is not our environment. We can be there one second and gone the next. Care and attention is my mantra. Stick your Swiss cheese in your fondue, it won't save you.

[Fantome]

Erebus expert? . .. hardly.....but nevertheless pretty clear as to who has a good grip and who has not.

The observation has been frequently made, that in common with many others, this accident was the result of a culmination of failures, all of which could be seen as defective links in a long chain of circumstance. To fasten onto one such link, subjecting it to minute scrutiny, to the exclusion of a similar approach to the others, is patently wrong headed.

Like for those deeply insightful armchair experts who refute Justice Peter Mahon's finding out of hand, it would improve the prospect of maintaining reasonable, rational debate if they went out and polished the car. It is impossible to take seriously anyone who disputes the findings of carelessness, neglect and duplicity.

And please, please don't take this as a cue to run up the barricades again to defend or condemn Captain Jim Collins.

Putting the findings to one side though, can anyone produce proof that the enquiry in any way failed in its task of gathering evidence and subjecting it to the most intense scrutiny? To read the report and its appendices closely is to be struck by their comprehensiveness. There is a level of precision and thoroughness akin to what is found when studying those forensic reports that are landmarks of their kind.

As to the validity or otherwise of the findings, maybe it is not too much to hope for that there will eventually be a fairly consistent consensus. There were of course those critics who were shown up to be lacking in any credibility at all. Maybe they were bent on pursuing narrow, self absorbed agendas and, no great surprise, went into denial. Such is the dross of protestations past.

What does continue to occupy those with an academic interest is wrestling with the imponderables and the complexities. In another compartment altogether, there is an unabating profound sadness for those most affected.

With an acute awareness that to touch upon the grief is to see the chasm that opens to swallow the gratuitous, when I think of the toll in human lives, predominantly those who perished on that remote icy, snow-bound slope, but also those who carried to their graves burdens of a magnitude impossible to comprehend, I see in my mind's eye a field of crosses, by which we the living stand in mute, contemplative respect. (Thoughts that only crystalised yesterday, on Anzac Day, ironically.)

Lastly, a little postscript that may be less controversial than some of the foregoing, though unrelated I admit, concerning the free flow of ideas and how counter to that is 'political correctness'. Geoffrey Blainey, an historian, speaker and writer blessed with lucidity and insight, says P.C. is hypocrisy; "the people who say it's sinful to discriminate themselves discriminate."

P.C. is in the same family as those 'isms' against which we should ever be on our guards. This website has become hugely popular, a home away from home it looks like for some of its regulars. Fanaticism? Masochism? (Incidentally, in a gentler age, one of the world's first aviation papers ran a regular column called AIRISMS.)

Thinks - best leave it to Kharon to define chauvinism, onanism , even botulism.
Can't think what the 'ism' might be for thread drift.

WANKERISM?

Have to thank ORNERY for his proof reading skills, though his sharpness in line with the Muldoon school of dry invective needs rehoning. Whether he is yet a first master of stone casting is debatable.


". . .. . .seeing where you are and seeing something where you are going"

. . . . . . . . . . at the end of the far queue at the flicks again?

[Ornis]

Nearly a Witticism. A Half-Witticism?

Edit:
What's that you say, Fantome, pot calling the kettle black? Don't like being beaten at your own game?

[Ornis]

It's for its, mute for moot, council for counsel, predominate for predominant. Perhaps the language gap makes it difficult for some to grasp the Nestle - as the Swiss say.

Nevertheless, there is no discernible disharmony: Air NZ played badly, under the baton of the CAA, first violin ALPA pulling the strings, and left the pilot to face the music.

[prospector]

Fantome,

Like for those deeply insightful armchair experts who refute Justice Peter Mahon's finding out of hand, it would improve the prospect of maintaining reasonable, rational debate if they went out and polished the car. It is impossible to take seriously anyone who disputes the findings of carelessness, neglect and duplicity.

I do not believe anyone in this debate is refuting Justice Mahons findings out of hand. It is only one part, that the Captain was blameless that is being debated. Of neccessity that is concentrated on the decision to descend when and how he did.

To call everyone who disagrees with your opinion an armchair expert is about as productive, and useless, as me calling anyone who disagrees with my position a high chair expert who should be out pedalling his tricycle.

[compressor stall]

Prospector, re your earlier request, I'd have to look at the map again in detail, overlay times and position and closure rates at 260 odd knots. I'll get back to you.

Ornis, yes, I see your question again and maybe I answered it slightly askew initially, but im used to having to take that position.:} To answer your specific essence of VMC question, my last flippant comment above shows our positions on it are not far apart. Indeed it's an environment that is best avoided where possible, especially on landing without any surrounding runway infrastructure.

[Ornis]

compressor stall. Thank you. I value your contribution and certainly do not disagree in principle.

It seems to me the impasse on this thread is the words "pilot error". I see the pilot as the goalkeeper. Whatever the others in the team are doing, he is on his own. However well or badly the others play, he is the last man standing, the final defence. The outcome depends on him; success or failure. Of course the others can make his life easy or difficult. Maybe impossible.

I do not believe Air NZ made Collins' life impossible. He was not tasked to land at McMurdo Field. That would have been an entirely different matter. I would have excused him in that scenario, given his training.

Captain Collins made choices and he was wrong. Pilot error. In the context of a dysfunctional operation? Absolutely. Disgraceful. Shocking. Inexcusable.

I don't care to apportion blame. I don't need to divide the pie. It's all unsavoury, every piece.

[Whiskery]

Ornis, you are a hypocrite.
You state I don't care to apportion blame.

..yet in post#33 you say Before Easter I emailed the NZALPA to ask what proportion of members believed Collins was blameless. I await an answer. Actually, I don't: I already know the answer, more or less.

Those who think Collins blameless should ask themselves why airliners have pilots. To sit on fat wallets in fancy dress, a charade to please bored passengers? To deal with events and problems computers are not human-like enough to solve, perhaps?


Care to comment?

[Fantome]

"To call everyone who disagrees with your opinion an armchair expert is . .. . . useless."

Point taken, even though I think you think I had particular recent commentators and critics in mind. Not so. If you are wondering about my opinion on Erebus, (and as I said before, I am the last person to claim any expertise), read my earlier posts. I think you will find that by and large on points that have been debated at length, I don't have a hard and fast opinion either way. As stated earlier , among the to and fro of the whole business that keeps the debate alive and interesting are the unresolved paradoxes.

If you read back through the reams of threads over the years, there have been certain kite fliers who've warranted the scathing remark Paul Keating was fond of, referring to an opponent having a sparrow's nest of a brain*.

Had no idea 'armchair expert' would give offence. Skins thick and thin are the norm. (Can't repeat some of the names I've been called. Might be ladies present.)

*All **** and sticks.

[prospector]

Had no idea 'armchair expert' would give offence.

No offence taken, here anyway. It just that you were assuming armchair experts. I would think there are many hours of left seat experience contributing to the debate.

[HPSOV L]

The ultimate test would be to take a sample of say, 100 of Captain Collins' colleagues at the time, have them each perform this particular flight under the exact same circumstances and observe the outcome.

If the crash result was repeated by even one, then statistically it could be argued that the cause was primarily systemic and environmental factors.

My point being that this Captain's training, beliefs and ability represented the average, or even above average, Air NZ pilot of the time. If this assumption is correct then it is not useful to accident avoidance simply argue pilot error when other factors have aligned to overwhelm an 'average' pilot.

Of course we can't actually conduct such an experiment, what with the expense and loss of life etc. But those of us who are approaching the end of our careers without incident should probably acknowledge an element of good luck!

[Ornis]

Whiskery. I implied I had a fairly good idea that many airline pilots feel Collins was neither blameless nor deserves exoneration by Parliament.

I do not care to apportion blame, that is, to assign a certain proportion of the blame to Collins, which is what apportion means. I am not keen to say he was X% to blame in the overall scheme of things, but I cannot deny I am on record as saying I think he was at least 51% to blame.

I prefer to judge each participant against a reasonable standard for the task (s)he performed, and the organisation as a whole.

[Brian Abraham]

If you can tell me where I err when I state the essence of visual flight is seeing where you are and something where you are going Ornis, compressor stall has answered with his Visibility by definition (check ICAO or your CARs) is predicated on being able to see and identify a prominent object by dayTo give an example of what we used to encounter in the maritime enviroment from time to time.

Conditions
1. High pressure centred over the area
2. No wind
3. Inversion
4. Bushfires that had been burning for some days.

The smoke would be trapped under the inversion creating a "greyout". Exactly the same as "whiteout", the only difference being the colour. No matter where you looked, up, down, sideways it was the same damn colour, and you had no idea what the actual visibily was until you came across one of compressor stalls prominent objects. In our case that might be an oil rig, work boat, or on making land fall when returning home. Except by reference to the altimeter you had absolutely no idea of height. So you can see how you might be set up for a CFIT, or into water in this case. At all times though you had absolutely legal VMC, though depending on the smoke density, visibility might range from the bare minimum, to far in excess.

Helo pilots flying offshore in the Gulf face the same issues brought about by haze.

As compressor stall has said, VFR flight can throw up its own unique hazards depending on your particular area and the nature of your operations.

I liked your succinctCaptain Collins made choices and he was wrong. Pilot error. In the context of a dysfunctional operation? Absolutely. Disgraceful. Shocking. Inexcusable.

I don't care to apportion blame. I don't need to divide the pie. It's all unsavoury, every piece. On the money, particularly the last sentence. :ok:

As for "blame", it has no place in a safety orientated organision, or when discussing issues of safety. Thats for lawyers and ambulance chasers. An organisation that has a blame culture merely buries the errors made in denial. Who's going to report safety issues if they know a bullet is the reward.

[Ornis]

Brian, I take your point, but I don't think it negates the essence of my "essence". In fact your narrative rather reinforces it, I feel. If you can't see something ahead, you're certainly looking for something, anything!

I have crossed Cook Strait at 500ft under low cloud with much of the land ahead obscured, not "letting go" of that behind until it was sighted, with the texture of the surface below helping to maintain situational awareness. I knew I was over the sea, or I wouldn't have been there.

I absolutely agree with you, in a complex operation like an airline, you have to look at the whole organisation. I do understand why "blame" is an anathema to you. Nevertheless, in everyday parlance, you do something wrong you get the blame. Open reporting within a company is another matter.

HPSOV L. Statistics is as much an art as a science and some might interpret say 1,2 or even 10,20% of "your" pilots failing "your" test as meaning the company has a lot of poor captains - it doesn't disprove pilot error. You might need to take samples from other companies. But the idea is helpful and the conclusion valid: systemic disorder is likely.

[Brian Abraham]

I do understand why "blame" is an anathema to you. Nevertheless, in everyday parlance, you do something wrong you get the blameThe trick is though, why do you do something wrong? Why did Captain Collins do what he did? That is a question that can never be answered. However, those in management and the nav department are around to answer why they failed in their respective duties, and the explanations may be very simple. Under manning, belief that any pilot can make a seemingly simple VFR flight, but being unaware of the hazards. Who knows? I would be interested in those sort of answers, but I'm not aware those questions have ever been put. Everyone had an equal hand in the disaster, and it could have been prevented by the intervention of so many.

A point I would love to see answered is, why did the vast majority of crews who made the trip have questions as to when they were permitted to descend below MSA. Chippendale notes that the crews questioned admitted to their confusion. Pity is, none seem to have attempted to clarify the situation on return, hence a red flag was not raised for those who followed. And Chippendale, other than noting that the crews were confused, does not delve into the nature of, or why, the confusion. If it were to be given an answer it may go some way to explaining Captain Collins actions. Did the confusion stem from the term "Cloud Break procedure", rather than "Descent procedure"? Alas, we know not. A simple word can have grave implications.

[ampan]

Good grief: Spare me the Shakespearian nonsense, Brian. Collins was thick, like you are: Couldn’t even pass School C. What you and Compressor Stall say about the definition of “visibility” in VMC minima regs is complete garbage – and you both know it.

[Hugh Jarse]

If Compressor Stall is the Compressor Stall I think it is, he has more time working on the Far Southern Continent than most people in the industry. :)

[HPSOV L]

The debate about VMC has finally helped me understand Donald Rumsfield's comment regarding known unknowns and unknown unknowns.
As he said; "it's the latter category that tend to be the dfficult ones".

[Brian Abraham]

The only thick person around here ampan is your good self. As thick as two short planks. You might go read up the regs on VMC for a start. You don't have a $#@&^ clue. There are enough clues about as to what compressor stall does for a living, and has done for quite some time, but you are too thick to pick up on it. Only an absolute idiot would attempt to argue the toss with him.
Couldn’t even pass School CI take it you must have been his teacher then?

[prospector]

Brian Abraham,

. Did the confusion stem from the term "Cloud Break procedure", rather than "Descent procedure"? Alas, we know not. A simple word can have grave implications.

That is an incorrect statement, the crew were well aware of the descent requirements to be met prior to descent below FL160. Those requirements have been printed on this and other threads many times. They state quite clearly the ONLY descent procedure available.

As far as descent below 6,000ft this from John King's "New Zealand Tragedies ,Aviation" page 37.

But the 6,000ft aspect was more than a company order, to be broken by pilots if they felt like it, and the weather was fine. It was a strict CAD rule, part of the original conditions for the airlines scenic flights to Antarctica, as stipulated by the Director of Civil Aviation under regulation 136(3), giving vertical clearance from Mt Aurora, the highest point in the sightseeing manoeuvring area.

This was posted earlier but is still relevant.

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

[quote] 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

And who was it that started the ball rolling with a 1500ft flypast because "the radar operator invited him to do it"????

And what was the requirement he would have scoffed at?? Surely not the descent requirements as laid down in consultation with the people who had experience in Antarctic ops, or the NZCAA. The word Hubris fits the scene very well.

Hubris: Arrogance or overconfidence, especially when likely to result in disaster or ruin. (Chambers 21st Century Dictionary)

[Brian Abraham]

That is an incorrect statementIf you reread what was written I was talking of the crews who had made the previous flights, therefore, not an incorrect statement. Please don't twist things to suit your agenda.

[prospector]

If it were to be given an answer it may go some way to explaining Captain Collins actions.

Capt Collins was influenced more by the indiscretions of previous crews rather than Company SOP's and CAA regs???

Getting back to the red light scenario again.

[Brian Abraham]

What red light senario? Who knows what influenced Captain Collins. I don't, you don't, nobody does. ampan seems to be a mind reader, or so he ever willing to tell us.

[ampan]

As to what was going on inside the head of Captain Collins, the answer is: Very little.

Could the two alleged giants of polar aviation explain the difference between the following:

"Cloud come down. Very hard to tell the difference between the cloud and the ice."

"Sun gone down. Very hard to tell the difference between the cloud and the ice."

[Ornis]

Brian Abraham. I am still thinking about the dilemma: Pilots being responsible for their aircraft and accountable for their actions versus the need for managers to know what's going on, which means, openness in reporting failures. There may be no simple answer to this, rather a question of balance and judgement. (The police use anonymity.) With respect, I don't feel your stance of no blame for pilot error is logically tenable however much we all agree prevention of accidents is paramount.

Ampan. VMC visibility means clear air, as measured by instruments if you like. But if the brain cannot make any sense out of what the eyes are seeing, what does it mean? In whiteout, like the inside of a ping pong ball? (Does that sound familiar?) I agree with you as to what was going on in Collins' head. The question is, why? Even a bird or a fly knows when it's in danger.

[Fantome]

Need to bear in mind that 'blame' is not in the agenda of the best accident investigators. On the other hand entirely, when the knives come out in a court of law only the most naive today believe that justice will always prevail . Don't we know it? . .. .the blame game brings on those well known feeding frenzies in the chambers of the filthy rich and the dubious.

"If you know what's good for you my son, you'll lead a quiet and innocent life. Far from the madding crowd."

[prospector]

Need to bear in mind that 'blame' is not in the agenda of the best accident investigators.

That is no doubt why Ron Chippindale stated only "the probable cause of the accident".

Where as This from the legal people.




Quote:



So even before the Royal Commission began its lengthy hearings, Judge Mahon had preconceived idea's about the deeper motives behind it-and about the c ause of the disaster, so had W.D. Baragwanath and G.M. Harrison, counsel assisting the Commissioner.



Quote:



In Sydney a few weeks before the commission started, while viewing QANTAS training procedures for its own Antarctic flights the two lawyers publicly stated that pilot error on Flt901 was not the problem. The disaster was caused by a navigational error by Flight operations.

Everything from then on was made to fit that theory and all evidence which suggested the captain was responsible was rejected by the Royal Commission

[ampan]

Ornis: VMC has nothing to do with "clear air". It's to do with "visibility". At night, in clear air, is a pilot VMC? In some countries, yes, as long as contact with the ground lights is maintained. But as soon as that's lost, bang, splash.

If Brian A and Compressor Stall think anything different, then it's a good thing that they're retired.

[Ornis]

Fantome. I take your point, thank you. Prospector's quote from the Chippindale report supports it. You can avoid using the word but the concept exists and is in common usage. Just as when I was a kid nobody mentioned the word sex but ...

Ampan. I think visibility in VMC is everything to do with clear air, day or night. The definition does not consider that the brain must interpret what the eyes detect for us to see meaningfully, it is the distance you would see an object if there was sufficient contrast. Collins knew the putative visibility was 40nm at McMurdo (with low overcast and whiteout?), but he could not see the mountain, where he thought it was or anywhere. That would trouble me but it does not necessarily mean he was not in legal VMC as defined.

I may be wrong; perhaps someone can explain it better.

[compressor stall]

That man doth protest too much, methinks. May I suggest a careful (re?)reading of definitions of VMC and IMC in ICAO (Annexes 2 & 6) or NZ CAR Part 1 (which does differ slightly in wording).

[Ornis]

compressor stall. You quoted FAA definition of visibility: may see a prominent object.

Could one say then, that 20km visibility in whiteout conditions might be legally VMC but require you to fly on instruments, de facto IFR, because you cannot see?

That is, does basic airmanship mean that visual flight requires positive visual reference of the terrain, positive identification of what you are flying towards?
--------------------------

Brian Abraham. We do stupid things when we're not thinking. Captain Schettino aimed the Costa Concordia at Isola del Giglio, turned too late and the stern swung onto the rocks. My late mother used to call this phenomenon a "brainstorm". Since it's ruined his life, and cost others, I'm sure he can't explain it any better either.

The decision to descend is comprehensible and I don't think Captain Collins saw any risk at all. The decision to proceed south at 1500ft instead of climbing out north over the sea is inexplicable. Why, when confronted with what must have been a strange if not weird picture, did his brain not switch on the alarm bells? What was it overriding his sense of danger? Confidence? Mindset? Backing by the F/O (groupthink)? Holiday mode? Playing to an audience? I am bound to say, based on his failure to pick up on other clues, he didn't seem very sharp on the day. He wasn't thinking.

I am not sure we can counter these imponderables. We need attitudes, protocols and systems that protect us from "brain switch off". The approach by Air NZ, that the operation was routine and visual flight is simple and easy showed no grasp of reality: The Antarctic is no place to be without specially trained pilots and robust SOPs.

[prospector]

Ornis,

You appear to be coming to the same conclusion that Bob Thomson, A scientist with DSIR Antarctic Division who had completed 75 trips to the Ice, 50 of them on the flight deck of the aircraft transporting them. He was not qualified aircrew but with that amount of experience flying South his opinion is of value. He was actually scheduled to be the guide on the fatal flight but events changed and Mulgrew went. He stated:
Had Bob Thomson felt uneasy that, but for a twist of fate he might have died that day. Not at all. I always insisted on a complete circuit of Ross Island before letting down below 17,000ft. That way I could get an idea of the complete situation, what the weather was like, where the clouds were.
captain didn't give
The attention to the problems that he might have around there. These people were taking a Sunday drive. When I heard the transcript of the CVR I fell out of my chair. Most of the times Mulgrew had been there he had gone in by sea, and all his travel from Scott Base had been to the South. Hardly anybody went into Lewis Bay.

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

[Ornis]

prospector. Maybe the picture was weird but he expected it to be strange and didn't know any better. Brave or fool? Look at Charles Upham, the only combat soldier to receive the VC twice. Climbing a fence he became entangled in barbed wire with a guard pointing a pistol at his head and threatening to shoot. Upham calmly ignored him and lit a cigarette. Maybe the answer depends partly on the outcome, but we remember Upham had nothing to lose.

I have had one weird, actually exhilarating experience. Trying to get back to Ardmore from Waipukurau I flew around East Cape and landed SVFR at Tauranga. I could see a stationary hole above the road over the Kaimais to Matamata. The controller gave me a clearance but tried to dissuade me; as we approached the hole, with cloud around and fog below, we could see fields on the other side quite clearly. As we passed over the saddle it felt like being in a tunnel of white light, rather like I imagine dying might be. At no time did I not have a positive visual reference.

When you go fishing, it is far easier to catch small fish - big fish are much more wary. When conservationists set traps, some animals go in and some won't, no matter what. When a number of aircraft flew through Lindis Pass returning from Warbirds Over Wanaka 2000, a C206 crashed killing all six pilots, the others got through. The PIC stalled turning back and spun in.

We might all be playing the same game, but some got dealt better cards. Maybe why some - not all - avoid using the word blame: it's not fair?

[ampan]

" 'visibility' means the ability, as determined by atmospheric conditions and expressed in units of measurement, to see and identify prominent unlighted objects by day and prominent lighted objects by night"

So what am I missing? Cloud above, ice below, and "very difficult to tell the difference". Is the genius legal argument advanced by Brian A and Compressor Stall that Erebus was not a "prominent object"? It must have been reasonably prominent, because it didn't move an inche after having 200 tonnes of metal slammed into it at 240 knots.

The other allegedly brilliant point these two seem to be making is that the reference to the "ability ... to see" is "determined by atmospheric conditions". So a pilot can fly VMC in gin clear conditions with his eyes shut? No, because all the definitions are qualified by the words "unless the context otherwise requires".

[compressor stall]

"Visibility for aeronautical purposes is the greater of:

a) the greatest distance at which a black object of suitable dimensions, situated near the ground, can be seen and recognised when observed against a bright background

b) the greatest distance at which lights in the vicinity of 1000 candelas can be seen and identified against an unlit background."

ICAO Annex 2, Rules of the Air. Size of the object has nought to do with it.

Ampman - At night, in clear air, is a pilot VMC?

Of course he bloody well will be. If you take off over water on a dark night with 10k + visibility on the ATIS, no moon and a 20,000' foot overcast and no boats, you don't magically turn into IMC because you can't see anything outside.

Yes, you are flying on instruments and can (technically) log IF - but you are NOT IMC. You may be (N)VFR or IFR - it makes no difference.

Ornis - yes, experience (or instruction) tells you to treat whiteout as you would a black night. That is stick to a LSALT. And if you have to land in it treat it and the approach and the circuit area as it was a dark night in the desert landing by some car headlights.

It's my opinion that the whiteout experienced by Capt Collins was of the more insidious kind, but I'll get to that in Prospectors request from last page.

[Ornis]

ampan. Visibility in terms of the definition of VMC means the air is clear so you can see something prominent if there is sufficient contrast. Say a black car against the snow or a lamp in the dark. It doesn't mean you will see something prominent if there is no contrast. That is, it must be conspicuous.

compressor stall. VFR below 3000ft stipulate: (visibility 5km) in sight of the surface, no explanation or elaboration. Perhaps it is presumed this is better covered in GAP (good aviation practice) booklets, not rules.
_______________

I would like to thank all those who answered me, I have learnt a great deal. I'm going to finish up by saying: Collins didn't have his mind on the job.

[Brian Abraham]

With respect, I don't feel your stance of no blame for pilot error is logically tenableOrnis, when a pilot stuffs up we need to ask the question why. A war story of how a bystanders non actions didn't save the day.

We launched at 0600 with a command & control aircraft, two gunships and a flight of five slicks (troop carriers) for a day of supporting the ARVN. I was tail end charlie of the slicks. Having hot refueled, shutdown and received the brief at the airfield of operations, we found only four slicks were needed. As #5, that meant my crew and I got the day off. One of the other slick crews was complaining that their aircraft was a "dog" performance wise. I spent some time trying to talk the crew into letting mine take their place, but to no avail. Being the senior person, I could have pulled rank, but that's not how the unit did things. The crew were very experienced in combat, and we had been among the survivors of a particularly bad ambush, so for my part I saw no need to question the crews judgement.

The flight duely departed on their task while we sunbaked. Some time later the C & C aircraft came in and landed at the POL point to refuel. Strange that the C & C should return before the slicks and gunships. We were at the other end of the runway and I saw a figure walking down the runway towards us. I walked to meet him and recognised it as the XO from his gait. As we closed I could see tears streaming down his cheeks. An aircraft had gone down with the loss of all crew and troops on board. Guess which one.

The wreckage was winched into the back of a Chinook and deposited at battalion headquarters. The aircraft had suffered a mast bumping event, causing the rotor to seperate and chop off the tail boom. The fuselage impacted the ground in a normal landing attitude, and the top of the aircraft was about waist high, and looked for all intense purposes that someone had stepped on it with a size 500 boot. No longer was the cockpit and cabin the usual light grey military paint, but blood red. It was a moment of reflecting what could have been while I stood alongside the crew chiefs position and picked small remnants of nomex flight suit embedded with flesh from various bolt heads.

To make up for a lack of performance I'm guessing that the pilot made a zoom climb after take off. It was something we did usually for tactical reasons, getting as much altitude as possible as quickly as possible. Accelerate to Vne on the tree tops then zoom. You needed to be careful at the top of the zoom though and not allow the aircraft to unload too much. Doing so you could lose control of the rotor disc, which then brought about mast bumping.

So the direct cause was pilot error. But I had my bit part in the outcome, however slight or tenuous.

http://i101.photobucket.com/albums/m56/babraham227/n0006.jpghttp://i101.photobucket.com/albums/m56/babraham227/n0005.jpghttp://i101.photobucket.com/albums/m56/babraham227/n0004.jpghttp://i101.photobucket.com/albums/m56/babraham227/n0003.jpg

I could further relate the story of a young man by the name of Jeremy McNess, who I had a brief chance to meet when he was a secondary school boy. He and his nav died in a F-111 CFIT. Pilot error, but the whys would make any grown military fast jet aviator of experience weep.

Re yourCollins didn't have his mind on the job. and am bound to say, based on his failure to pick up on other clues, he didn't seem very sharp on the day.I put that observation down to the completely inadequate training. You don't expect a crew to carry out a autoland ILS if not trained, and it's no surprise a crew inadequately trained for arctic flight should meet their end.Is the genius legal argument advanced by Brian A and Compressor Stall that Erebus was not a "prominent object"? It must have been reasonably prominent, because it didn't move an inche after having 200 tonnes of metal slammed into it at 240 knots.Well might you carry on about Collins "C". Thus far you you are carrying an Fminus in comprehension. A "prominent object" is one that can be seen, under the circumstances of "whiteout" Erebus could not be seen from the position it was being viewed.
If Brian A and Compressor Stall think anything different, then it's a good thing that they're retired. I hope to God you were never an aviator, your arrogance is overwhelming.

Lying on your back gazing to the heavens under a blue sky and a cloud floats over. What is the visibility? Looking directly at the cloud the visibility will be the height of the cloud, which is the prominent object. Once the cloud floats by, the visibility becomes unlimited.Capt Collins was influenced more by the indiscretions of previous crews rather than Company SOP's and CAA regs???prospector, no one can say, since the only person who could answer is unable. But don't underestimate the power of corporate culture in influencing a persons actions. Certainly none of the other pilots were unduely influenced by either SOPs or CAA regs. Neither did they have any idea where the final waypoint lay. I worked for some time in an organisation where compliance was not observed. New pilots were aghast on joining, but soon fell into the company way of doing things. Not a rag tag outfit either.

[prospector]

Certainly none of the other pilots were unduely influenced by either SOPs or CAA regs.

The first flights down to the ice were limited to no lower than 16,000ft, this was a CAA requirement, it was complied with.

Mayne Hawkins, the pilot of the first company flight to the Antarctic. flatly denied going below 6,000ft. (Previous flights had been flown for a travel agency)

The one piece of evidence that he had done so was a tape recording of Peter Mulgrew's commentary when he said the DC10 was "going to a lower altitude" which proved absolutely nothing when no mention of its previous height was made, and the case was quietly dropped.

You could perhaps say some, or perhaps most of the pilots, but you cannot say "none of the other pilots were unduly influenced by either SOPs or CAA regs.". Very obviously some were.

Neither did they have any idea where the final waypoint lay.Is that statement for real??? All those senior captains blasting off to the Antarctic without knowing where the final waypoint was located??.

[3 Holer]

Mayne Hawkins - ah yes, I believe his evidence was, (amongst other testimony) as the Honourable Justice Mahon coined, a "litany of lies".

[Ornis]

Forget Chippindale, Mahon, AirNZ nav and SOP, CAA, NZALPA, TACAN, radar, VHF, whiteout.

A senior airline pilot is going to an unfamiliar and strange place. He is trained to descend south of a mountain. After the briefing he found the waypoint McMurdo was not at McMurdo but somewhere near Byrd. One route takes him over Erebus, the other down the sound.

On the day of the flight he enters the coordinates for McMurdo into the AINS. He doesn't chart it or check it. He flies south, no en route charting or checking.

He arrives at the coast. McMurdo reports low overcast. There is a mountain somewhere close that he cannot see. He finds a hole in the cloud cover and descends to 2000ft. He still cannot see the mountain, or anything that anyone recognises. He doesn't get a readout of his position from the AINS.

So he descends to 1500ft and flies into the mountain. NZALPA opines he is blameless and names its safety award after him.

Soon I will fly to Europe. Should I check that the commander won't decide to have a quick look at Everest, and if he can't see it, fly into it? Am I to understand that if he does, it will be due to lack of training?

[remoak]

Dear oh dear, this one really has grown legs...

Ampan says... As to what was going on inside the head of Captain Collins, the answer is: Very little.That's pretty unfair.

My guess is that Collins had been given his first trip to the ice, which was considered a bit of an honour at the time, and had prepared meticulously for the flight - or as meticulously as he could in the circumstances.

He knew full well that the only point in making the long flight to ice was to give the pax a good view and some happy memories. He would have known that failure to see the sights, while completely excusable from a safety point of view, was not at all what the company was looking for. He would also have known that, under the Air NZ culture at the time, not getting the job done might have consequences at a later date.

He was therefore under pressure on two fronts: commercial pressure from the company (no matter how well it was downplayed); and technical or skill pressure, as it was his first time and he really didn't know what to expect - the briefings might have been good, but until you see it for yourself, you don't really know what's coming.

So he gets down there, and, b#gger, the picture is not great. However, he thinks he should be safe carrying out the descent, after all he can see the water and if he is where he is SUPPOSED to be, he should be safe... In other words, he makes a judgement call. I'm guessing a lot of us would have made a similar call in the circumstances. Airline pilots do it all the time, as do recreational pilots. Mostly, we get away with it... no, I'm pretty sure there was a LOT going on inside his head.

To me, this is the crux of the matter. Definitions of visibility are utterly redundant... you can either see of you can't. If you can't make out any details in your "picture", then you don't have visual reference and it's off to MSA we go. I haven't seen it for a while, but from memory the film taken inside the aircraft seconds before the crash showed people pointing at ground features and filming the view - why would that happening if there was no visibility? Erebus itself was not completely covered by snow so should have been visible to some extent.

I think Collins was a careful guy who made one poor judgement call that would never have been a problem if his world was as he thought it was. Swiss cheese all over the place.

I have experienced whiteout at the other end of the globe (operating into snow runways in the winter in Northern Europe), and it is truly nasty, not least because it takes a few seconds (sometimes quite a few seconds!) to work out that you actually have no depth perception and no actual definition in your "picture".

So I reckon this is what happened:

- Collins, under substantial pressure, made a judgement call based on where he THOUGHT he was. If his navigational picture had been accurate, it wouldn't have been a problem (other than breaking company SOPs which appeared to be somewhat flexible in the existing culture).
- He probably did establish visual reference under the cloud, but as he flew towards Erebus, almost certainly experienced whiteout conditions. However, his mental "picture" was such that he clearly didn't believe that he was placing his aircraft in harm's way. When the GPWS does eventually go off, there is a significant hesitation before he initiates the go-around - easily explainable if Collins was having a "WTF, that can't be right" moment.

Ornis:

On the day of the flight he enters the coordinates for McMurdo into the AINS. He doesn't chart it or check it. He flies south, no en route charting or checking.I remember watching an interview with his widow where she states that he spent quite a few hours charting the flight at home, and making copious notes in his (subsequently stolen) diary. I'm sure that, given the information he had, he was 99% sure where he was... the fact that he wasn't where he thought he was had nothing to do with him or his preparation.

I still think he was wrong to descend below MSA in VMC without clearly identified visual references, particularly given his unfamiliarity with the area. Having said that, he was royally screwed by his company... if they had not made the errors that they did, the crash would almost certainly not have happened.

You can see the fallout from Erebus in modern airline training practices. In one of the airlines I served in as a trainer, we always took new captains on famil trips to all Cat C and some Cat B airports. Any particularly tricky place, like Innsbruck or Calvi, involved six hours in the sim followed by a famil trip in the jumpseat.

When you look back at it now, the way Air NZ conducted the Antarctic flights was pretty arrogant... but hey, it was the '70s... remember the advertising for Air NZ at the time? "Nobody does it better", with Alan Whicker? I remember watching the advertising displays coming down in the Wellington Air NZ offices, as the radio broadcasts were becoming increasingly dreadful. A little part of New Zealand died that day.

[Ornis]

remoak. Fair comment. Nobody could tell Air NZ anything: complete shambles. Line pilots off on an adventure. Nevertheless, Collins could have done more; Lucas was a former RNZAF navigator (and pilot).

Thank you for: Positive visual reference, definitions of visibility are redundant. This is surely the essence of safe visual flying.

Brian Abraham. Thanks. I have resolved the issues in my own mind. Circumstances, failures and human frailty do conspire against us. I have developed a few personal maxims, for example, if go around enters my mind I go around, no thinking about it. Another is, I don't have to go there, I can go somewhere else. (Luxury of a recreational pilot.) This sounds awfully trite, but it counters what Teresa Green meant I think, with: the bastards are out to get you.

[compressor stall]

The reason the VMC discussion came about at length recently here was because various parties have said earlier the the aircraft was not in VMC when it is almost certain that it was, except for possibly the last second or two in the go around.

If you can't make out any details in your picture the it's off to the MSA you go.

Nice sentiment and wise words and I'm sure the capt thought the same. The difference here is that he was expecting nothing straight ahead. And saw nothing. This fitted his "picture".

[prospector]

The reason the VMC discussion came about at length recently here was because various parties have said earlier the the aircraft was not in VMC when it is almost certain that it was

Are we talking about the company requirement for 20km vis or the legal requirement for flight below 3,000ft???

[compressor stall]

Definitely the latter, and almost certainly the former. It's hard to retrospectively prove the 20km vis straight ahead (2.5 mins flying) as there is no photographic evidence but IIRC the fact that the dry valleys were clearly visible tens of miles to the west shows that the vis was certainly in excess of 20km in that direction. It is likely that it was clear towards the mount.

As an aside, one of the incredible things about Antarctica is the general clarity of the air. Things look much closer than they really are. It is possible (and I have not reread the evidence to prove this likelihood) that the capt did not get suspicious that the mountains were an extra 30nm away due to this.

[Ornis]

compressor stall. The discussion on VMC has been invaluable. It made me think about what VFR means; more than the CAA's 5km vis and in sight of the surface.

Can you face one more question? My notion of whiteout: you see everything white, perhaps a (dull) white glow, your eyes focus <10m out (empty field myopia), seeing essentially nothingness. There is no perspective - if you do see something inconspicuous it might be a post close by or a building in the distance. Sector whiteout means this phenomenon is directional.

I do not get the impression you might see what appears to be a flat textured ice sheet under an overcast sky, with a horizon.

[ampan]

I would use the word "nonsense", rather than "invaluable".

The notion that a pilot is entitled to fly visually into a situation where he knows he won't be able to see properly is ridiculous, whatever be one's distorted view of the applicable regs.

Brian A: Am looking forward to two more pages of irrelevant crap.

[Dark Knight]

Am looking forward to two more pages of irrelevant crap

Just a remake of the previous thread again degenerating to similar unsubstantiated depths.

Mods, Time to re-apply the lock again before the excretion of more pages of irrelevant crap!

[Brian Abraham]

Brian A: Am looking forward to two more pages of irrelevant crap. ampan, your most welcome, since you're an expert on irrelevant crap, and unwilling to conceed you know little of what you sprout when confronted by an expert (compressor stall). Time to go. Bye, and good riddance ampan. :D

With you Dark Knight.

[Tidbinbilla]

Perhaps you all best agree to disagree.

Once again we have a circular argument covering no new ground.

Time to let the topic rest.

TID