Pilots - what caused Erebus?
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Pilots - what caused Erebus?
Hi there,
I have been a lurker here for a long time and have learnt a lot about the industry here, for which I'm grateful.
Having read widely about the tragedy of TE901, I would like to hear the opinion of people on this forum regarding the true underlying cause of the disaster.
For a long time I thought it was an open and shut case - the disaster was fully caused by the actions of NZ in changing the flight plan. However, awhile ago, I was interested to see a thread on pprune about this subject, and a number of responses that indicated even airline pilots themselves are divided as to whether Captain Collins was ultimately responsible.
I realise this is a touchy topic and truly hope this doesn't devolve into a flame war or other such forms of abuse. While not wishing to appear a thread Nazi, I would prefer responses from airline pilots only and other qualified observers.
A couple of specific questions I would like to ask.
1) In your view, was the Flight Engineer concerned about the operation of the flight immediately prior to the crash?
2) What are your comments on this quote from the accident report?
"..the decision of the pilot in command ... to descend below MSA was in contravention of company restrictions and basic good airmanship "
3) Would you say that Captain Collins was guilty of being too relaxed or too complacent, when compared to the rest of the technical crew, who appeared to be concerned about the operation of the flight and decision to descend?
To all those who respond to this thread, thank you for allowing me to expand my knowledge on this tragic accident.
I have been a lurker here for a long time and have learnt a lot about the industry here, for which I'm grateful.
Having read widely about the tragedy of TE901, I would like to hear the opinion of people on this forum regarding the true underlying cause of the disaster.
For a long time I thought it was an open and shut case - the disaster was fully caused by the actions of NZ in changing the flight plan. However, awhile ago, I was interested to see a thread on pprune about this subject, and a number of responses that indicated even airline pilots themselves are divided as to whether Captain Collins was ultimately responsible.
I realise this is a touchy topic and truly hope this doesn't devolve into a flame war or other such forms of abuse. While not wishing to appear a thread Nazi, I would prefer responses from airline pilots only and other qualified observers.
A couple of specific questions I would like to ask.
1) In your view, was the Flight Engineer concerned about the operation of the flight immediately prior to the crash?
2) What are your comments on this quote from the accident report?
"..the decision of the pilot in command ... to descend below MSA was in contravention of company restrictions and basic good airmanship "
3) Would you say that Captain Collins was guilty of being too relaxed or too complacent, when compared to the rest of the technical crew, who appeared to be concerned about the operation of the flight and decision to descend?
To all those who respond to this thread, thank you for allowing me to expand my knowledge on this tragic accident.
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Kid
I do not know the answers to your questions as I was not there. I certainly remember the day it happened and then watching the events around the original investigation and finally the Royal Commission unfold.
As nobody from those investigations were there either, the resultant reports are nothing more than educated guess's based on what facts were known.
Dredging over old news is a good academic excercise but I believe this one has been done to death and has been superceded by more relevant later accident/incident investigations.
Certainly get the book on the Royal Commission or the report itself and have a good read. Beware of applying todays cockpit or corporate processes to the way things were done 25+ years ago, they do not often stand up to scrutiny through todays eyes were as they were the norm at that time.
Good luck with the research, I was lucky enough to pick up Justice Mahons book at a second hand bookshop for $5 earlier this year.
Sorry, but I will make no comment on any of the crews activities
Disco Stu
I do not know the answers to your questions as I was not there. I certainly remember the day it happened and then watching the events around the original investigation and finally the Royal Commission unfold.
As nobody from those investigations were there either, the resultant reports are nothing more than educated guess's based on what facts were known.
Dredging over old news is a good academic excercise but I believe this one has been done to death and has been superceded by more relevant later accident/incident investigations.
Certainly get the book on the Royal Commission or the report itself and have a good read. Beware of applying todays cockpit or corporate processes to the way things were done 25+ years ago, they do not often stand up to scrutiny through todays eyes were as they were the norm at that time.
Good luck with the research, I was lucky enough to pick up Justice Mahons book at a second hand bookshop for $5 earlier this year.
Sorry, but I will make no comment on any of the crews activities
Disco Stu
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Another thing to look out for is the video/doco I think called also verdict on Erebus.
Has a very good demonstration of the visual effects caused by whiteout and the expected and actual visual cues experienced by the crew.
Has a very good demonstration of the visual effects caused by whiteout and the expected and actual visual cues experienced by the crew.
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Dear Koru;
I am not a pilot but the Senior Editor of Air Transport World and like many, have followed this tragedy closely. Allow me to pick up on your point 2 and 3 as under;
2) What are your comments on this quote from the accident report?
"..the decision of the pilot in command ... to descend below MSA was in contravention of company restrictions and basic good airmanship "
This point from the accident report was found to be seriously flawed as while company instructions were for a certain safe altitude the reality was that even check and training captains were flying well below company minimums on these flights and its was even written up in an article and circulated to every New Zealand household.
3) Would you say that Captain Collins was guilty of being too relaxed or too complacent, when compared to the rest of the technical crew, who appeared to be concerned about the operation of the flight and decision to descend?
I feel it was well established at the Royal Commission that Captain Collins was an excellent pilot.
Strongly suggest that you get the late Royal Commissioner's report which has now been accepted as one of the finest pieces of investigative work into an air accident
Best
Geoffrey Thomas
I am not a pilot but the Senior Editor of Air Transport World and like many, have followed this tragedy closely. Allow me to pick up on your point 2 and 3 as under;
2) What are your comments on this quote from the accident report?
"..the decision of the pilot in command ... to descend below MSA was in contravention of company restrictions and basic good airmanship "
This point from the accident report was found to be seriously flawed as while company instructions were for a certain safe altitude the reality was that even check and training captains were flying well below company minimums on these flights and its was even written up in an article and circulated to every New Zealand household.
3) Would you say that Captain Collins was guilty of being too relaxed or too complacent, when compared to the rest of the technical crew, who appeared to be concerned about the operation of the flight and decision to descend?
I feel it was well established at the Royal Commission that Captain Collins was an excellent pilot.
Strongly suggest that you get the late Royal Commissioner's report which has now been accepted as one of the finest pieces of investigative work into an air accident
Best
Geoffrey Thomas
I don't want to be the best pilot in the world - Just the oldest
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Geoffrey,
Congrats on your aviation reporting award.
BTW is the book referred to by Justice Mahon titled "Impact Erebus"? I remember reading it many years ago. Very sobering stuff.
Congrats on your aviation reporting award.
BTW is the book referred to by Justice Mahon titled "Impact Erebus"? I remember reading it many years ago. Very sobering stuff.
Last edited by Islander Jock; 7th Dec 2003 at 23:02.
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Much like, where were you when Kennedy died, I remember exactly where I was when ANZ reported ‘loss of contact’ with their DC-10.
For those not au fait with the accident, CVR transcripts etc at
http://www.taic.org.nz/aviation/79-139_annex_a-c.pdf
For those not au fait with the accident, CVR transcripts etc at
http://www.taic.org.nz/aviation/79-139_annex_a-c.pdf
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Koro Kid,
You are correct, it is still a very touchy subject. However there was, and still is, many people who disagreed with the findings of Mr Mahon. One question you can ask yourself,"would you be flying a DC10 at 1500ft, not below 250 kts, in an area that you had never been and in questionable weather conditions??". In your research you may have read a book by Capt Maurice McGreal who was Deputy Director of Civil Aviation at the time. The book is titled "A Noble Chance" and the relevant page is 186. He states that the Dept's DC10 inspector was rostered to fly on the accident flight, but due to a family illness his flight was postponed till the next flight a week later. The relevance of this is explained by the staement "that if the inspector was on board the disaster would not have taken place, why? because no pilot would have displayed before a Civil Aviation Inspector such a poor level of airmanship". It was stated that some pilots did go below the stated altitude minimums on previous flights, the difference was they did not hit the ground, if you break the rules you must be very sure no mistakes are made. In my opinion, the answers to your questions,
1. Yes
2. Yes
3. No, all appeared to be in agreement with the decisions till very late in the sequence of events.
Prospector
You are correct, it is still a very touchy subject. However there was, and still is, many people who disagreed with the findings of Mr Mahon. One question you can ask yourself,"would you be flying a DC10 at 1500ft, not below 250 kts, in an area that you had never been and in questionable weather conditions??". In your research you may have read a book by Capt Maurice McGreal who was Deputy Director of Civil Aviation at the time. The book is titled "A Noble Chance" and the relevant page is 186. He states that the Dept's DC10 inspector was rostered to fly on the accident flight, but due to a family illness his flight was postponed till the next flight a week later. The relevance of this is explained by the staement "that if the inspector was on board the disaster would not have taken place, why? because no pilot would have displayed before a Civil Aviation Inspector such a poor level of airmanship". It was stated that some pilots did go below the stated altitude minimums on previous flights, the difference was they did not hit the ground, if you break the rules you must be very sure no mistakes are made. In my opinion, the answers to your questions,
1. Yes
2. Yes
3. No, all appeared to be in agreement with the decisions till very late in the sequence of events.
Prospector
Last edited by prospector; 8th Dec 2003 at 04:13.
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I seem to remember a TV program that was about a friend of the said ANZ captain (another ANZ captain) doing his own investigation about the 'poor airmanship' conclusion and trying to clear his friends'name.
Unfortunately, I can't remember the name of the program nor the name of the captain - maybe others could shed some more light.
I do remember that it was quite interesting.
Unfortunately, I can't remember the name of the program nor the name of the captain - maybe others could shed some more light.
I do remember that it was quite interesting.
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I seem to remember a TV program that was about a friend of the said ANZ captain (another ANZ captain) doing his own investigation about the 'poor airmanship' conclusion and trying to clear his friends'name.
His book is called "Impact Erebus"
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I read justice Mahon's book and one impression I got from it was that although he thought he understood everything that was presented to him, there were a number of pieces of evidence and witness statements which clearly showed he did not.
Hi Guys, 3 books that are very good;
1) "Impact Erebus" by Gordon Vette with John Macdonald 1983 ISBN 0 340 320249.
2) "The Erebus Papers" by Stuart Macfarlane 1991 ISBN 0-473-00844-0 and
3) "Verdict on Erebus" by Peter Mahon 1984 ISBN 0 00 636976 6
The video is also titled "Impact Erebus"
All extremely sobering!
1) "Impact Erebus" by Gordon Vette with John Macdonald 1983 ISBN 0 340 320249.
2) "The Erebus Papers" by Stuart Macfarlane 1991 ISBN 0-473-00844-0 and
3) "Verdict on Erebus" by Peter Mahon 1984 ISBN 0 00 636976 6
The video is also titled "Impact Erebus"
All extremely sobering!
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The posts so far highlight all the pertinent factors. I am a consultant and researcher who works in part in the area of human error in aviation. This paper:
http://www.webresearch.co.nz/docs_pu...CreekPaper.pdf
compares Erebus with the (Canadian) Dryden accident and a significant non aviation disaster in New Zealand.
Since writing that paper I would want to add an analysis of what it was that Captain Collins actually saw. The problem is that he was in sector whiteout - that is the whiteout only applied when looking forward. Landmarks on either side of the aircraft were clearly visible. Thus Captain Collins did not know that the weather conditions were as they were because he had not been trained in whiteout flying. the flight crew were suffering from the visual illusion that they were flying in clear air.
This initial problem was compounded by the fact that the changes to the navigation track in the INS that were done without his knowledge encouraged the crew to believe that the landmarks they could see were those they were expecting to see along the track they thought they were flying.
For the three reasons above a cognitive illusions was created in the minds of the flight crew. Perception research suggests that almost anyone not specifically trained in whiteout flying would be likely to have been deceived by the same illusion.
It is my personal view that Captain Collins ALSO contributed (contributed to - not 'was solely responsible for') the accident because the crew descended below 15,000' not having positively sighted Erebus (that they believed to be off their port side).
The low flying part is contentious. The whole point of those flights was to give passengers a good view of Antarctica. Flying at that height had become a normal expectation and there was considerable company pressure on flight crew that had taken on the dimensions of a cultural norm. I still get irritated at the hypocrisy of the aviation authorities in New Zealand who to this day say that if they had known about the low level flying they would have stopped it, when just four weeks before Erebus they published an edition of their house magazine with a cover photograph of an Air New Zealand DC10 flying obver Scott Base at about 5000 feet.
http://www.webresearch.co.nz/docs_pu...CreekPaper.pdf
compares Erebus with the (Canadian) Dryden accident and a significant non aviation disaster in New Zealand.
Since writing that paper I would want to add an analysis of what it was that Captain Collins actually saw. The problem is that he was in sector whiteout - that is the whiteout only applied when looking forward. Landmarks on either side of the aircraft were clearly visible. Thus Captain Collins did not know that the weather conditions were as they were because he had not been trained in whiteout flying. the flight crew were suffering from the visual illusion that they were flying in clear air.
This initial problem was compounded by the fact that the changes to the navigation track in the INS that were done without his knowledge encouraged the crew to believe that the landmarks they could see were those they were expecting to see along the track they thought they were flying.
For the three reasons above a cognitive illusions was created in the minds of the flight crew. Perception research suggests that almost anyone not specifically trained in whiteout flying would be likely to have been deceived by the same illusion.
It is my personal view that Captain Collins ALSO contributed (contributed to - not 'was solely responsible for') the accident because the crew descended below 15,000' not having positively sighted Erebus (that they believed to be off their port side).
The low flying part is contentious. The whole point of those flights was to give passengers a good view of Antarctica. Flying at that height had become a normal expectation and there was considerable company pressure on flight crew that had taken on the dimensions of a cultural norm. I still get irritated at the hypocrisy of the aviation authorities in New Zealand who to this day say that if they had known about the low level flying they would have stopped it, when just four weeks before Erebus they published an edition of their house magazine with a cover photograph of an Air New Zealand DC10 flying obver Scott Base at about 5000 feet.
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Rongotai,
Yes, the low flying had been carried out prior to the accident flight, there can be no doubt about that. But all previous flights had positively identified their position before indulging in this practice. But why was it necessary? the vis is so good down there that a few thousand feet of altitude was not going to improve the scenic value such that the disregard of CAA regs, company rules was justified surely?. The sector whiteout explains why the crew never saw the mountain granted, but it does not explain why they were at 1500ft. Whiteout problems had not been covered in any briefing because at the altitude that the flights were legally allowed to descend to it would not have been a problem. It is very disturbing if what you say about the blatant disregard of Company and CAA rules can be attributed to "company pressure" and "dimensions of a cultural norm". Especially with the experience level of AntArctic operations that this Captain and First Officer crew had, namely nil, and this was in itself a contravention of requirements laid down by CAA.
Pharknose.
Yes this is the case that generated that statement, but to keep it in context you must also read what Mr Mahons peers in the Appeal Court,(High Court??)and the Privy Council had to say about it.
Prospector
Yes, the low flying had been carried out prior to the accident flight, there can be no doubt about that. But all previous flights had positively identified their position before indulging in this practice. But why was it necessary? the vis is so good down there that a few thousand feet of altitude was not going to improve the scenic value such that the disregard of CAA regs, company rules was justified surely?. The sector whiteout explains why the crew never saw the mountain granted, but it does not explain why they were at 1500ft. Whiteout problems had not been covered in any briefing because at the altitude that the flights were legally allowed to descend to it would not have been a problem. It is very disturbing if what you say about the blatant disregard of Company and CAA rules can be attributed to "company pressure" and "dimensions of a cultural norm". Especially with the experience level of AntArctic operations that this Captain and First Officer crew had, namely nil, and this was in itself a contravention of requirements laid down by CAA.
Pharknose.
Yes this is the case that generated that statement, but to keep it in context you must also read what Mr Mahons peers in the Appeal Court,(High Court??)and the Privy Council had to say about it.
Prospector
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Like others I am loathed to make personal comments about the actions of the crew involved. I have to however make what I believe to be a significant point about one comment above:
I have a couple of hundred hours flying around Sott Base and McMurdo. I have been to the crash site, paid my respects, and have flown the route to impact of flight 901 at 1500ft. I also studied this particular crash investigation at university a dozen years ago.
Rongatai: Very nice, concise comments.
Prospector: Valid points too and I can appreciate your point that ultimately the descent below company MSA was a significant causal factor. (No matter whether is was considered amongst ANZ pilots as standard) but please read #2 below.
But please keep in mind:
1. Sector Whiteout was only internationally recognised AFTER this investigation. Yes, whiteout was known and understood but the anomlies of diffuse light sector whiteout were not widely acknowledged and most definitely not understood. (Photographs recovered from the wreckage accurately show Bird Island clearly visible -in approx 20Nm visibilty - only 2 minutes prior to impact]).
2. The aircraft in fact impacts Mt Terror. The summit of Mt Erebus is high and a few miles right of the impact site. As Capt Collins asked for climb power he started a right hand turn. (Consistent with the theory that the crew thought Erebus was to their left.) It has never been proven that the DC10, so close to the summit and turning towards it, could have outclimbed Mt Erebus....EVEN IF IT WAS AT COMPANY MSA when the GPWS sounded. This possibility was not investigated thoroughly.
Lastly I concur wholeheartedly with Disco Stu......please try not to apply modern practise and thought in reliving this tragedy. Times were certainly not the same.
Brgds Felix
I have a couple of hundred hours flying around Sott Base and McMurdo. I have been to the crash site, paid my respects, and have flown the route to impact of flight 901 at 1500ft. I also studied this particular crash investigation at university a dozen years ago.
Rongatai: Very nice, concise comments.
Prospector: Valid points too and I can appreciate your point that ultimately the descent below company MSA was a significant causal factor. (No matter whether is was considered amongst ANZ pilots as standard) but please read #2 below.
But please keep in mind:
1. Sector Whiteout was only internationally recognised AFTER this investigation. Yes, whiteout was known and understood but the anomlies of diffuse light sector whiteout were not widely acknowledged and most definitely not understood. (Photographs recovered from the wreckage accurately show Bird Island clearly visible -in approx 20Nm visibilty - only 2 minutes prior to impact]).
2. The aircraft in fact impacts Mt Terror. The summit of Mt Erebus is high and a few miles right of the impact site. As Capt Collins asked for climb power he started a right hand turn. (Consistent with the theory that the crew thought Erebus was to their left.) It has never been proven that the DC10, so close to the summit and turning towards it, could have outclimbed Mt Erebus....EVEN IF IT WAS AT COMPANY MSA when the GPWS sounded. This possibility was not investigated thoroughly.
Lastly I concur wholeheartedly with Disco Stu......please try not to apply modern practise and thought in reliving this tragedy. Times were certainly not the same.
Brgds Felix
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Amos - Continued discussion Erebus is still valuable - see below.
Prospector - your points are valid, but........
For me the issue of Erebus - still unresolved in attitudes to attribution of cause in aviation accidents - is that a simple 'pilot error' conclusion is frequently used to let everybody else of the hook despite a false premise.
For me the false assumption in blaming Collins (and many crews since) is that all that is required to avoid human error accidents is for pilots to follow standard operating procedures as documented in their manuals and instilled in their training. This is a false premise for three reasons:
(a) real life situations are invariably more complex than those predicted in manuals and training:
(b) manuals and training never predict every possible situation; and
(c) pilots, just like everybody else, are human beings who can occasionally be put under pressure by contradictory requirements between technical performance and social, cultural and business expectations.
In this case, as in many others, all three were operating at some level. If we want someone to blame then we can choose the crew (Kippenberger) or the company (Mahon) and there is a defensible position in either case. But if we want to reduce accidents then we must recognise that there is a correlation between cultural and business practices of airlines and errors committed by aircrew. If, in such situations, we simply attribute blame to the aircrew without addressing any underlying corporate behaviours or practices that contributed to that error, then we may have cause some sort of emotional catharsis but we have done absolutely nothing to reduce the frequency of critical incidents in that company.
Erebus is one of the first, and still one of the most striking, case studies about such matters. That is why it still merits study and discussion. Everybody acknowledges that Collins was a top class pilot. Everybody recognises that in strict procedural terms he should not have been where he was. If we consider how a pilot of such quality could nevertheless place himself in that situation, we have the possibility of drawing lessons that might make commercial aviation safer in the future. If we simply blame the pilot, we deny ourselves that possibility.
Prospector - your points are valid, but........
For me the issue of Erebus - still unresolved in attitudes to attribution of cause in aviation accidents - is that a simple 'pilot error' conclusion is frequently used to let everybody else of the hook despite a false premise.
For me the false assumption in blaming Collins (and many crews since) is that all that is required to avoid human error accidents is for pilots to follow standard operating procedures as documented in their manuals and instilled in their training. This is a false premise for three reasons:
(a) real life situations are invariably more complex than those predicted in manuals and training:
(b) manuals and training never predict every possible situation; and
(c) pilots, just like everybody else, are human beings who can occasionally be put under pressure by contradictory requirements between technical performance and social, cultural and business expectations.
In this case, as in many others, all three were operating at some level. If we want someone to blame then we can choose the crew (Kippenberger) or the company (Mahon) and there is a defensible position in either case. But if we want to reduce accidents then we must recognise that there is a correlation between cultural and business practices of airlines and errors committed by aircrew. If, in such situations, we simply attribute blame to the aircrew without addressing any underlying corporate behaviours or practices that contributed to that error, then we may have cause some sort of emotional catharsis but we have done absolutely nothing to reduce the frequency of critical incidents in that company.
Erebus is one of the first, and still one of the most striking, case studies about such matters. That is why it still merits study and discussion. Everybody acknowledges that Collins was a top class pilot. Everybody recognises that in strict procedural terms he should not have been where he was. If we consider how a pilot of such quality could nevertheless place himself in that situation, we have the possibility of drawing lessons that might make commercial aviation safer in the future. If we simply blame the pilot, we deny ourselves that possibility.
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Rongotai,
Agreed as to the accident causes and aftermath. But as has been shown during this thread many people accept that Mr Mahons findings were correct and indisputable. However, the findings of Mr Chippindale, the Chief Accident Inspector, is still the official account. Mr Mahon conducted a Royal Commission of Inquiry that was limited in its scope and the findings could not be appealed in legal terms. Much has been written since but the following statements to be found in John Kings publication New Zealand Tragedies, Aviation, Page 62, appertaining to Mr Mahons findings, and the reputations he sullied, should also be known more widely. "The court of appeal addressed several aspects that were brought to the commissioners notice during the enquiry but ignored by him. The five judges unaminously quashed the $150,00 costs order, imposed as a punishment for the alleged conspiracy" and from the Privy Council.
"In their judgement, delivered on 20 Oct 1983, the five Law Lords of the Privy Council dismissed the Commissioners appeal and upheld the decision of the Court of Appeal decision, which set aside the costs order against the Airline, on the grounds that Mahon had committed clear breaches of natural justice. They demolished his case item by item, including Exhibit 164 which they said could not"be understood by any experienced pilot to be intended for the purposes of navigation' and went even further, saying there was no clear proof on which to base a finding that a plan of deception, led by the company's chief executive, had ever existed".
The statement "An orchestrated litany of lies" would appear to live on, even after Mr Mahons reasons for making the statement have well and truly been demolished by both the Appeal Court and the Privy Council.
Prospector
Agreed as to the accident causes and aftermath. But as has been shown during this thread many people accept that Mr Mahons findings were correct and indisputable. However, the findings of Mr Chippindale, the Chief Accident Inspector, is still the official account. Mr Mahon conducted a Royal Commission of Inquiry that was limited in its scope and the findings could not be appealed in legal terms. Much has been written since but the following statements to be found in John Kings publication New Zealand Tragedies, Aviation, Page 62, appertaining to Mr Mahons findings, and the reputations he sullied, should also be known more widely. "The court of appeal addressed several aspects that were brought to the commissioners notice during the enquiry but ignored by him. The five judges unaminously quashed the $150,00 costs order, imposed as a punishment for the alleged conspiracy" and from the Privy Council.
"In their judgement, delivered on 20 Oct 1983, the five Law Lords of the Privy Council dismissed the Commissioners appeal and upheld the decision of the Court of Appeal decision, which set aside the costs order against the Airline, on the grounds that Mahon had committed clear breaches of natural justice. They demolished his case item by item, including Exhibit 164 which they said could not"be understood by any experienced pilot to be intended for the purposes of navigation' and went even further, saying there was no clear proof on which to base a finding that a plan of deception, led by the company's chief executive, had ever existed".
The statement "An orchestrated litany of lies" would appear to live on, even after Mr Mahons reasons for making the statement have well and truly been demolished by both the Appeal Court and the Privy Council.
Prospector