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Erebus 25 years on

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Old 29th Jan 2008, 09:41
  #201 (permalink)  
 
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deadhead,

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

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

I am waiting for Prospector to claim that this is invalid because it is "I was only following orders" Nuremburg defence.
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Old 29th Jan 2008, 10:36
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I am waiting for Prospector to claim that this is invalid because it is "I was only following orders" Nuremburg defence.
Desert Dingo

Why were there no pages left in Captain Collins’ otherwise undamaged ring-binder notebook?
Found this very interesting item in an article written in 1984 by Maurice Shadbolt. "After the Royal Commission was over, Sergeant Greg Gilpin, a member of the police search team in Antarctica, but who was never called as a witness, watched a TV documentary of the inquiries. The camera closed in on Judge Mahon as he examined Captain Collins's empty ringbinder notebook. "I was puzzled", says Gilpin. "It looked just like the notebook I saw at the crash site, where it was handed to me by a colleague. On the cover was Collins's name. All the pages in it were intact and the first few full of technical writing that appeared to be flight data. My colleague and I considered it an important find, so I placed it carefully in a plastic bag and left it with other articles at the campsite." Why then was Collins's widow given only the cover of the notebook? Why was she told that the inner pages were damaged? Would these pages have helped to make it clear how Collins was misled and why 257 people died? These questions will still be asked, though the full answers will never be known"

How very very interesting.........no cover up huh??!
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Old 29th Jan 2008, 19:15
  #203 (permalink)  
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Front Pit,
Read post 86 this thread re Collins folder.

Certainly this is becoming a waste of time.

Desert Dingo,

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

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

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

This from New Zealand Aviation Tragedies by John King

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

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

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

Look at the very first post of the thread.

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

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

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

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

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

Last edited by prospector; 29th Jan 2008 at 20:08.
 
Old 29th Jan 2008, 20:48
  #204 (permalink)  
 
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Prospector,
Your post #86 refers to Captain Collins flight bag and not the ring binder folder allegedly found intact but with no pages. Need to get your facts right old chap.
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Old 29th Jan 2008, 21:16
  #205 (permalink)  
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Front pit,

My apologies, of course I should not have made that error, the state of the ring binder is crucial to the cause of the accident.
 
Old 29th Jan 2008, 22:26
  #206 (permalink)  
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Desert Dingo,
It is obvious, as it always has been, that there will be no agreement as to who compiled the more accurate report on this tragedy, how about a little exercise, I will compile a list of those who disagreed with Mahons report, and went public with their findings, their interest in the findings, and their qualifications and experience to back their views, and you compile a list of those who have gone public with their agreement on Mahons findings, the reasons why, their qualifications and experience, and any interest they have in the situation.

And anyone that has knowledge of publications we miss may add to the list.
 
Old 30th Jan 2008, 00:47
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Prospector, it's appalling that you can be so sarcastic about the deaths of 257 people. It's what was in the folder which may have provided crucial evidence, but appears to have mysteriously vanished. How very convenient.

Your post #147
And if that is your supposition, there is no point in continuing this discussion.
On such a note it is time to rest logical discussion.
You've lost the plot prospector, time to move on.
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Old 30th Jan 2008, 03:55
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My apologies, of course I should not have made that error, the state of the ring binder is crucial to the cause of the accident.
----------------------------------------------------------------
The lack of pages from the ring binder which were present when found and the illegal break-in of the pilots' homes certainly indicate that the company was out to hide something and that something just may have provided some clues as to some factors that may have contributed to the crash.

I agree with the others, Prospector, you seem to have lost it.
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Old 30th Jan 2008, 09:57
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Can we please move past the Privy Council judgment?

The PC did not examine Mahon's findings as to cause as they were not put before it. The judgment makes that explicit in a section headed "The limits on the matters decided on the appeal to this Board" (at p.836).

That section contains the passage:

The Royal Commission Report convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged. The judge was able to displace Mr. Chippindale's attribution of the accident to pilot error,
(my emphasis)

and also (at p.837):

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

These appalling blunders and deficiencies, the existence of which emerged piecemeal in the course of the 75 days of hearings, had caused the loss of 257 lives
(my emphasis)

It is clear from these passages that the PC in no way questioned, challenged or otherwise threw any doubt on Mahon's findings of fact as to the cause of the crash itself. Further, the PC makes it clear that no other party sought to do so (or indeed has ever sought to do so, except perhaps on PPRuNe... ).

The appeal was simply over what Mahon said in his paras 376 and 377 about actions which were purported to have taken place well after the crash and which can be separated from it. He had no right to make such a finding. It was outside his terms of reference and, under NZ case law, he was not (could not) enquiring into a crime (Cock v A-G (1909) 28 NZLR 405). If someone called me a criminal when they had no right to do so and could not substantiate their claim (and the PC points out (at p.839) that the claims were investigated by police), then I would challenge that claim. That is all the PC looked at, because that is all that they were asked to look at.

Had any of the individuals fingered by Mahon have had an argument with his findings as to the cause of the crash, they had, and still have, plenty of opportunity to challenge them. They have never done so.

So can we please now move on and leave the Judicial Committee of the Privy Council out of it?

Last edited by Taildragger67; 30th Jan 2008 at 12:31.
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Old 30th Jan 2008, 12:27
  #210 (permalink)  
 
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Captain Collins and First Officer Cassin were briefed on a flight path that took the aircraft over the ice-covered waters of McMurdo Sound well to the west of Mt. Erebus but were issued, for use in the aircraft's computer, as the nav track a flight path which went directly over Mt. Erebus itself, without the aircrew being told of the change, involved admissions of a whole succession of inexcusable blunders by individual members of the executive staff.
The absolute root of this disaster!

My seven year old son can comprehend this what else seems to be the problem?
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Old 30th Jan 2008, 19:23
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Taildragger and jack red,

Your posts SHOULD put to bed any debate over the PC's involvement with the case. No one from TE or anywhere else has seen fit to challenge the PC or Mahon's findings as to the root cause of the crash.

Prospector may yet try again but it would appear that he has dropped the Air NZ ball.
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Old 30th Jan 2008, 21:16
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Just the facts, please.

Prospector:
…. how about a little exercise, I will compile a list of those who disagreed with Mahons report, and went public with their findings, their interest in the findings, and their qualifications and experience to back their views, and you compile a list of those who have gone public with their agreement on Mahons findings,
Do you think that will prove anything? Counting heads does not show if something is true or false.
A majority of people once believed the sun revolves around the earth, or that the earth is flat. They probably wrote lots of books about it too. It did not make either belief into a fact.
I prefer to look at just the facts, so I will decline your kind offer to make lists.

Are you or were you ever a member of NZALPA???
No, sorry. Your “guilt by association” argument will fail to get off the ground.
However, I did meet Captain Gemmel.
Once. Briefly. I was being cleared to operate an Air New Zealand simulator to train NZ pilots for another airline and he turned up as part of the approval process. Thought he was a nice chap, although I was surprised to find him now working for the department upholding truth, justice and the New Zealand way.
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Old 30th Jan 2008, 22:45
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Taildragger,
Please forgive me for mentioning the Privy Council again, but I think there is value in reading this pretty concise summary of the aftermath of the Royal Commission report as it explains why things turned out the way they did:
Andrew McGregor “Accidents, Failures, Mistakes and Leaky Buildings. (my emphasis)
Mahon also blamed the airline for deliberately conspiring to lie, reflected in his famous ‘litany of lies’ quote. Air New Zealand objected to the Court of Appeal (CA) on the basis of costs. According to historical clauses in the TAIC Act, the CA judged that Mahon overstepped his brief in judging that the Air New Zealand witnesses committed perjury, because it was a crime and could only be judged so in a court of law, not a Royal Commission of Inquiry (Beck 1987). However the Court of Appeal stopped short of faulting Mahon’s technical determinations including the predominant cause of the crash.
Mahon appealed to the Privy Council as a private citizen but the Privy Council not only supported the Court of Appeal, it also cleared the airline of blame without the corresponding rigour of Mahon’s enquiry. This effectively undid much of Mahon’s work and to a layperson, confused the findings. The logic of the Privy Council in clearing the airline of blame remains unclear. The judgement of the Court of Appeal and Privy Council is criticised by Stuart MacFarlane, a retired senior law lecturer, in his book titled The Erebus Papers (1991). According to MacFarlane (1991) and Beck (1987), in order for Mahon to judge between conflicting witnesses, he had to judge that several of them had lied and could not fulfill his mandate without judging so. In their view, this would have been obvious to the alleged liars and the warning that the Court of Appeal and the Privy Council judged should have been given, was unnecessary.
Beck (1987) cites that the main reason to go to appeal was in order to vindicate Air New Zealand of its reputation. Therefore without Mahon’s mandate to apportion blame, Air New Zealand may not have appealed and the investigation process may have concluded with a clearer outcome. It is interesting to note that during the course of Air New Zealand’s final submissions, when it was convenient for them to do so, counsel for the airline invited Mahon to stop short of attributing blame and merely identify the contributing factors. In response, Mahon acknowledged that “the prime purpose of aircraft accident investigation is to secure avoidance of similar accidents in the future, not to identify and apportion culpability or blame for what occurred” and that citing the ten factors was sufficient to achieve this (Mahon, 1981, p. 158). However he advised that his mandate also included the need to “answer the question whether this disaster was caused or contributed to by blameworthy acts or omissions by any person or persons” (Mahon, 1981, p. 158).
The cost of a clouded inquiry and the need to apportion blame was enormous. Following the inquiry, Captain Gordon Vette and Peter Mahon, both leaders and highly respected professionals in their respective fields resigned from their jobs, thus ending their careers. Although Captain Vette continued to implement improvements in international air safety, regrettably Mahon died a few years later. In the minds of many professionals, the judgement of the Privy Council confused the conclusions that Mahon so painstakingly derived and made it difficult for safety professionals to openly promulgate the lessons learnt from the Erebus crash, which ICAO later admitted carried a profound message in preventing organisational accidents in the future.
This is from a well written analysis of how the incremental results of the actions well-meaning people doing what they thought was the right thing at the time, can eventually result in a disaster. Well worth reading
http://www.prosolve.co.nz/accidents.pdf
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Old 31st Jan 2008, 05:55
  #214 (permalink)  
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"A majority of people once believed the sun revolves around the earth, or that the earth is flat. They probably wrote lots of books about it too. It did not make either belief into a fact"

And by the same token it does not make Mahons beliefs fact.

"although I was surprised to find him now working for the department upholding truth, justice and the New Zealand way."

Which Dept would that be, or has it completely gone along with the dinosaurs??
 
Old 31st Jan 2008, 08:42
  #215 (permalink)  
 
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the contents of the notebook were not relevent to the event.
Big call. Bloody big call CI300. Tell us more. What did it contain - no one else knows. The very fact that the airline (who else pray tell) saw fit to destroy the evidence says something about what the pages contained.

Last edited by Brian Abraham; 31st Jan 2008 at 08:53.
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Old 31st Jan 2008, 10:52
  #216 (permalink)  

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I've been lurking...

Those who espouse that, because Collins was PIC, he should bear ultimate responsibility for the tragedy, have surely failed to appreciate the most crucial tenant of the New View of Human Error which Dekker's books/papers so thoroughly elucidate.

Was the PIC of JL 123, who fought valiantly with his a/c for 32 mins, ultimately responsible for the loss of 520 lives because he failed to appreciate a pressure bulkhead was repaired incorrectly?

Was the PIC of AA 191 reponsible for the loss of 271 lives because AA mechanics had invented their own procedure for replacing self-aligning bearings on the pylon in compliance with a Douglas service bulletin?

Surely, the safe conclusion of a commercial flight is, quite literally, the end result of hundreds of people doing the jobs expected of them with due diligence?

How is this situation different?

I fly an EFIS FMC equipped aircraft and have no knowledge of how the DC-10 nav system works....

Every time I go flying I upload a company route designator into my FMC. It may change from day to day but as long as the waypoints agree with my flight plan, I'm happy. Because we fly to less than 30 destinations, my familiarity with the various routes will probably allow me to pick up any outrageous changes that might likely kill me.

But name me a single commercial pilot of this/my generation who will then cross check an unfamiliar route against his enroute chart(s) to see if all the previous safety nets have failed, and he has now uploaded a route which will take him straight into a mountain...

I've yet to come across such a pilot...

Surely as PIC I have a right to expect to expect the route is not going to kill me just like I have a right to expect a pressure bulkhead's integrity?

It is a question that puzzles me regards this incident, but how/who changed the route? Who changed the coordinates and why was the route changed?

Yeah, but what about the VMC let down....

I have to say that my reading of the CVR transcripts don't suggest a cavalier crew to me...

Let me ask another rhetorical question...

Is there a commercial pilot out there, who hasn't at some time, been temporarily unsure of his position?

Happened to me a few weeks ago, 4000 ft below MSA, nav-aids disagreeing with each other, false FMA indications, suspect radar control coverage, and, therefore, only FMC filtered IRS information to rely on....temporarily. I was able to resolve the situation within seconds.

Seems to me the crew of ZK-NZP (PIC and others) resolved their course of action within seconds. It just wasn't quite enough.
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Old 31st Jan 2008, 18:29
  #217 (permalink)  
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SR71,

I am, for one, not suggesting that the blame is entirely with the crew.

Neither do I believe they are completely blameless, as Justice Mahon found, and so many believe.

This from Ron Chippendale, the Air Accidents Inspector.

"The errors in the briefing were serious but not an absolute excuse for the accident when the means were readily available for the pilot in command to make certain he knew where he was."

This covers what many experienced aviation people believe, and is a fair statement of events.

Last edited by prospector; 1st Feb 2008 at 00:07.
 
Old 1st Feb 2008, 00:43
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SR71,
It is a question that puzzles me regards this incident, but how/who changed the route? Who changed the coordinates and why was the route changed?
The initial route approval was directly over Mt Erebus and required severe limitations on descent.
The military route down the middle of McMurdo Sound was a far better idea, so the track was altered to conform with the military route.
Then in September 1978 steps were taken to print a flight plan for each Antarctic journey from a record stored in the Air New Zealand ground based planning computer. And it is at this stage that the longitude co-ordinate for the southernmost waypoint was fed into the ground computer as 164° 48' E.
"So as I say, I think it likely that the change of the McMurdo destination point was intended and was designed by the Navigation Section to give aircraft a nav track for the final leg of the journey which would keep the aircraft well clear of high ground."
Then the next revision of charts became due, but official approval for the change had never been sought from CAD, although it would have been granted.
.
.. the next edition of the Ross Sea chart NZ-RNC4 would contain the official Air New Zealand flight path to McMurdo, and that the safest course would be to put the destination point back to the approximate location at which Civil Aviation Division had thought it had always been."
Small problem, though. The flight plans were now being transmitted to McMurdo ATC and showed the lat/long of the waypoints, and the changed waypoint would be obvious and they might not be happy with the change. Easily fixed. By typing in a special character the lat/long is replaced by just the waypoint name.
As usual a signal was sent to the United States base at McMurdo with advice that the aircraft was to fly to the Antarctic on 28th November and the flight plan for the journey. And in the list of waypoints appears the word "McMurdo" in lieu of the geographical co-ordinates which had appeared in the equivalent signal for the flight three weeks earlier
"In my opinion, the introduction of the word 'McMurdo' into the Air Traffic Control flight plan for the fatal flight was deliberately designed to conceal from the United States authorities that the flight path had been changed, and probably because it was known that the United States Air Traffic Control would lodge an objection to the new flight path."
So the waypoint was changed, and you know the rest.
The subsequent Court of Appeal after Mahon’s report came out successfully quashed Mahon’s attributing blame to the company, although his findings on the cause of the disaster were never challenged. The minority report of CA totally exonerated the company of any blame.
This kinda pissed off Justice Mahon, so he took his marbles and left the game.
His Way: A Biography of Robert Muldoon by Barry Gustafson p292

Mahon was shattered by the decision of the Court of Appeal and decided to retire immediately because he took the Court's finding to mean his credibility as a judge had been destroyed and that he was 'incapable of distinguishing truth from falsehood’. A few weeks later he wrote a longer, more formal letter again noting that 'my judicial position has been compromised bythe way in which the Court of Appeal handled this case’

He requested that the Government exercise its discretion and pay him a pension which be would supplement by part-time; university teaching because a convention prevented him returning to the bar. He also asked if the Government would appeal the decision to the Privy Council on the grounds that the Court of Appeal as a whole had 'misconceived the true nature of a Royal. Commission', and that Justices Woodhouse and McMullin should not, because of their family and other connections, have taken part in the appeal.

Woodhouse and McMullin had presented a minority report totally exonerating Air New Zealand of giving false evidence. Mahon had known in advance of the Court of Appeal hearing that Woodhouse and McMullin had children who were employed by Air New Zealand but when given the opportunity to object to their sitting had not done so.

Muldoon and Mclay diverged strongly over the Mahon report on the Erebus disaster and there wereheated exchanges between the two when Muldoon sided with Air New Zealand and Mclay defended Mahon. At one point. indeed. Mclay. who wanted to reject Mahon's offer to resign, nearly resigned himself when Muldoon favoured immediate acceptance. Mahon did resign and subsequently in 1983 the Privy Council also found that there was no evidence to substantiate Mahons charge that Air New Zealand's management had been guilty of a 'litany of lies' and a ‘conspiracy to deceive’. Nevertheless, there were many in the public who felt that Air New Zealand had been too quick to blame pilot error and to minimise other contributing factors to the tragedy and that Muldoon had been too partisan in defending the board and senior management of the airline.
It seems to me that Justice Mahon’s big mistake was to expect the justice system to apply the same high ethical and analytical standards that he had set. Justices Woodhouse and McMullin TOTALLY EXONERATED the airline of giving false evidence, fercrissake! I could understand some quibbling over details, but to me that is just unbelievable!
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Old 1st Feb 2008, 01:22
  #219 (permalink)  
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"The subsequent Court of Appeal after Mahon’s report came out successfully quashed Mahon’s attributing blame to the company, although his findings on the cause of the disaster were never challenged. The minority report of CA totally exonerated the company of any blame.
This kinda pissed off Justice Mahon, so he took his marbles and left the game"
---------------------------------------------------------------------------
"Because the findings of the Royal Commission of Inquiry on the cause of the disaster were limited in scope, being legally an opinion and not a statement of fact, they could not be appealed in legal terms, unlike the Office of Air Accident investigation report, which remains the sole official account---and has never been officially challenged."

It would appear "facts" depend upon where you find them.

"Successfully quashed Mahon's attributing blame to the company, although his findings on the cause of the disaster were never challenged".

Seeing as that he put all the blame of the company, and the Appeal Court said he was wrong, how do you reconcile that with the statement that

"His findings on the cause of the disaster were not challenged"

Last edited by prospector; 1st Feb 2008 at 01:38.
 
Old 1st Feb 2008, 02:45
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Seeing as that he put all the blame of the company, and the Appeal Court said he was wrong, how do you reconcile that with the statement that

"His findings on the cause of the disaster were not challenged"
Quite easily:
When the squabble went to the Privy Council they said
The Royal Commission Report convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged. The judge was able to displace Mr. Chippindale's attribution of the accident to pilot error,
What part of "unchallenged" do you not understand?
Are you able to discriminate between the cause of the disaster and the blame for the disaster?
I think not.
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