Erebus 25 years on

[nick charles]

Desert Dingo,

Thanks for that info re the changes to the flight plan. Although I've read Impact Erebus and Verdict on Erebus, I was unaware of the details leading up to the change of waypoints.

By the way, I've got the original "Today" program on the accident with live footage of the Royal Commission on DVD if any one is interested. It was taken from an old CVR tape so some of it is a wee bit strained but generally okay.

[prospector]

Desert Dingo

"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."

Please read and inwardly digest.

Also look at the finding of Judge H Greene, District Court USA. when the blame was tried to be foisted on the Controllers at McMurdo.

" The Court concluded that the disaster was the fault of both Air New Zealand and the FLIGHT CREW, and that the US Navy controllers bore no responsibility. The case was dismissed and, being delivered entirely on facts was not appealed."

How many of Mahons peers have to disagree with his findings before it is accepted he stuffed up.

In some parts of his findings.

[Taildragger67]

1. Did ZK-NZP crash? - Yes

2. Was it CFIT or mech failure? - CFIT

3. Did the flight crew take an action which placed the aircraft in a situation where it suffered CFIT? - Yes

4. Did the flight crew recklessly take that action without due regard to any briefing, or were they operating in accordance with what they had been briefed on? - The latter

5. Were the crew aware of earlier flights which had descended to low level? - Yes

6. Did the carrier discipline any pilot who had descended to low level on earlier flights? - No

7. Did the carrier indeed seek to cover up the fact that earlier flights had descended to low level? - No, they used it in marketing the flights

8. Was it therefore reasonable for the flight crew to assume that it was ok to descend to low level? - Yes, in VMC conditions

9 - Are VMC conditions determined visually? - Yes - if you look out and see it's clear (or do not see that it is not clear), then usually (and in Jim Collins's long experience) chances are it's clear

10. Did some outside party do something to change the route from what the flight crew were led to expect? - Yes

11. Would it be reasonable to think that this outside party should tell the flight crew of such a change? - Yes

12. Did they so tell the flight crew? - No

13. Was the outside party therefore negligent in not informing the flight crew of that action? - Yes

14. Can we assume that, if the flight crew knew their actual position relative to Mt Erebus, they would have descended the aircraft to 1600'?

So... yes, the flight crew were responsible for descending the aircraft over the sea to the north of Ross Island. Aliens did not do it and the aircraft did not do it of its own accord or under radio control from Auckland; Collins and Cassin did it.

So Collins and Cassin must take responsibility for doing that. Indeed I don't think anyone has ever denied that fact.

However, they did so, as we know, based on briefings that made them believe that they would be taking such action 20-odd miles off Ross Island. That this reality changed is not their fault. It was a combination of their training, meticulous following of that training, and the change made to the nav inputs, which put them into the 'wrong' place at the wrong time.

It was also entirely reasonable for them to assume that conditions were VMC.

In summary:
IF THE WAYPOINT CHANGE HAD NOT BEEN MADE, OR IF THE FLIGHT CREW HAD BEEN INFORMED OF THE CHANGE, THE FLIGHT CREW WOULD NOT HAVE ASSUMED THAT THEY WERE SEVERAL MILES AWAY AND WOULD NOT HAVE DESCENDED THE AIRCRAFT WHERE THEY DID SO.

The flight crew's actions were the last links in the chain of causation, which started with the nav waypoint change. At any point, the chain could have been broken - eg. not making the change, telling the crew, crew not descending below 16,000', or even selecting G/A power and nose-up just a few seconds earlier. But it wasn't.

So the carrier is (at least vicariously) to a very large extent, liable.

To draw a parallel with VH-OJH at Bangkok - it was the hands-on actions of the flight crew, operating the aircraft's systems, which caused it to overshoot the runway; it didn't do so by itself. But the crew were 100% exonerated, as it could be proven that they were acting 100% as per their training for such conditions. It was the training which was at fault.

Let us consider the following scenario:
- I am in a foreign city, out for dinner and trying to get back to my hotel.
- I look on the map and see a street which runs directly from the restaurant, to my hotel front door.
- Unknown to me, a water-main has burst half-way down that road, not visible from the surface but undermining and weakening the road. Local authorities know about it - but I am unaware of it and there are no warning signs.
- I therefore assume I know where I am and head down the road.
- Halfway down, I fall through the tarmac and into a hole.

Prospector, according to your logic, I am mostly, if not totally, to blame. Yes, I put myself in danger by walking down the road. But is it my fault that the road was weakened, and no-one bothered to tell me?

Your logic would also support arguments that women who wear attractive clothes or go to pubs are to blame if they get raped; one hears of very few nuns getting so attacked.

One day, lying on their death-bed, someone will 'fess up and tell those assembled that it was they who changed a couple of digits on the printout of waypoints given to the crew of of ZK-NZP prior to its last trip. If they are still alive, they are living with a terrible burden.

As for Mahon's 'peers' agreeing or disagreeing with his findings of fact, the Judicial Committee of the Privy Council (sorry for dragging them back in here) - who were Mahon's judicial superiors (ie. better than peers) not only did not disagree with Mahon's findings of fact but went on to praise his meticulousness. So his direct superiors (NZ at the time having recourse to the Privy Council but not to any US court) did not, as you assert, disagree with his findings to do with the crash.

What they could not agree with, was his opinion as to whether there was a conspiracy to cover something up. Indeed they did not even say there was not a cover-up; they simply could not agree that there was an organised conspiracy to cover up. It's a fine point, but an important one.

It's not too long a judgment; if you read it from the point of view of the conspiracy aspect, rather than as to whether the Committee is assessing the findings as to the crash, you'll see the difference. I would agree that it's a difference which someone without legal training may easily miss, given the time apparently spent discussing the crash. The Committee's discussion is not actually as to the crash; it is as to whether or not there is evidence of a conspiracy.

The Committee went on to say that it was time to put it all to rest. I suggest we agree with that opinion.

[prospector]

" It was also entirely reasonable for them to assume that conditions were VMC."

IF THE WAYPOINT CHANGE HAD NOT BEEN MADE, OR IF THE FLIGHT CREW HAD BEEN INFORMED OF THE CHANGE, THE FLIGHT CREW WOULD NOT HAVE ASSUMED THAT THEY WERE SEVERAL MILES AWAY AND WOULD NOT HAVE DESCENDED THE AIRCRAFT WHERE THEY DID SO.

Lot of assumptions there, one of the first things I was taught when I was doing my training was not to make assumptions.you must know. Also a major no no was to go down sucker holes, especially when I had only an assumption of my position.


"So Collins and Cassin must take responsibility for doing that. Indeed I don't think anyone has ever denied that fact."

Yes indeed, and yet they are blameless???


"Your logic would also support arguments that women who wear attractive clothes or go to pubs are to blame if they get raped; one hears of very few nuns getting so attacked."

Garbage, another assumption.

"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."

As has been stated before, that statement from Ron Chippendale holds more water that all the legal clap trap that has been printed.

The Committee went on to say that it was time to put it all to rest. I suggest we agree with that opinion.

Agreed.

[Desert Dingo]

Prospector

Also look at the finding of Judge H Greene, District Court USA. when the blame was tried to be foisted on the Controllers at McMurdo.

" The Court concluded that the disaster was the fault of both Air New Zealand and the FLIGHT CREW, and that the US Navy controllers bore no responsibility. The case was dismissed and, being delivered entirely on facts was not appealed."

Can you give me some more details about this case? I have tracked down a Judge Harold H. Greene of the US District Court in Washington DC but can’t find the case you mention.
Can you give me any info on the case number, date plaintiffs/respondents etc.?
Did this judge conduct a separate accident investigation, or did he rely on Chippindale’s report?
He obviously was not referring to Mahon’s report, which did not blame the flight crew.
If he was relying on Chippindale’s report, then I give your argument no points at all.
Chippindale produced a good report, based on what was known at the time and using what are now outdated methods of investigation.
However, when you consider all the extra details brought to light in Mahon’s investigation, when Chippindale writes …

2.5 The flight plan was printed for each flight from a computer stored record which, until the night before the flight, had the longitude for the McMurdo destination point incorrectly entered ………….
……… In the case of this crew no evidence was found to suggest that they had been misled by this error in the flight plan shown to them at the briefing.

….. that is obviously absurd.
Similarly when you say

…….Office of Air Accident investigation report, which remains the sole official account---and has never been officially challenged."

… are you suggesting that Chippindale’s report is the definitive report on the accident?
It may not have been “officially challenged”, but you cannot deny that Mahon’s investigation showed Chippindale came to a lot of incorrect conclusions.
You can’t blame Chippindale too much; he was working with what was available at the time. However, if you are trying to argue that Chippindale’s report is the sole correct version then, once again, … that is obviously absurd.

[prospector]

Desert Dingo,

This from New Zealand Aviation Tragedies by John King.

"And then came to Court battles, spread over several years and resulting in judgements that went against the OPINION of the Royal Commissioner. The last of these came towards the end of 1987 when representatives of the families of the dead crew members sued the United States Government for alleged failure of the U.S. Navy air traffic controllers at McMurdo to warn flight TE901 that it was in danger. Relatives of the 237 passengers had received substantial compensation, but because the 20 crew members were working for a New Zealand company they were eligible for only the standard accident compensation, and proving negligence against an outside agency was their one opportunity to receive a higher payout.

Following the U.S. District Court hearing in Washington DC, Judge Harold H. Greene wrote in his ruling,

"It is clearly established that, when the pilot told Mac Centre he wished to descend VMC, he effectively informed the controllers that he could see where he was going. In so doing he took SOLE RESPONSIBILITY for separating THE AIRPLANE FROM OTHER AIRCRAFT and the TERRAIN and he was on his own,
There also was much credible testimony to the effect that, and the Court finds that, air traffic controllers are not in a position to challenge, or second guess, the representation of a pilot that he can see where he is going and. indeed, that controllers are trained not to question such a representation".
----------------------------------------------------------------------
To get away from all the legal jargon, the pilot asked for descent, he said he could see where he was going, even on the track that they thought they were on, at no time did they see a 12,000ft mountain, in an area that has brilliant visibility, over 100 miles at times, they would have been no more than 20 miles from Erebus, even on the so called wrong track, they did not see it at any time, even from 16,000ft, before they commenced the descent, and this in an area that they must have known can play some funny tricks weather/visibility wise. and this was their first time down there. one would think extreme caution would be the order of the day.
--------------------------------------------------------------------------
A bit more from Judge Greene,

" Judge Greene said the operational crew of Flight TE901 acted unreasonably in several respects, including not plotting their ACTUAL POSITION from the AINS and descending below "below 16,000ft, contrary to both prudent airmanship and Air New Zealand policy, without ascertaining what was there or following the other requirements for such descent. The crew also missed the obvious landmark of Beaufort Island being on the wrong side of the flightpath and pressed on in the face of deteriorating weather, with five or six extra people milling around the cockpit causing some distraction during the critical period."

Nowhere is Mahon's findings, or Chippendales accident report mentioned, it is not known to me if these in any way influenced Judge Greene, but I would guess not.

Just to get the facts straight on a previous statement you made,

Captain Hawkins (and others) may have been telling fibs.
In the Auckland Star of 22 October 1977 an article appears with “At the controls Captain Hawkins brings the DC10 down to 200m over Scott and McMurdo Bases – well below the towering volcano Erebus belching smoke only 40 km. away.”

The police tried to make a case of this, and as is reported in the same book by John King,

"My lawyer approached the police to ask why nothing had happened, why there was no talking to me, and they asked him what I had to hide. They didn't believe the evidence the other members of my crew, saying it was a bit like a wife giving evidence for her husband.

In the end the one piece of evidence "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.

… are you suggesting that Chippindale’s report is the definitive report on the accident?

Yes I am, because it is.

It may not have been “officially challenged”, but you cannot deny that Mahon’s investigation showed Chippindale came to a lot of incorrect conclusions.

Garbage, it did no such thing, Mahons report was an enquiry, and only his opinion came out at the end.

As you obviously believe that the Commissioners report is Gospel, I see nothing to be gained going over the same ground again and again, you obviously have chosen to only read any statement that support Mahons theories and nothing is to be gained from any further discussion.

Thank you,

[ampan]

A very interesting discussion. I suspect the main reason why this debate still rages is that Justice Mahon completely exonerated the crew. In apportioning blame, it wasn't "90% Airline / 10% Crew". It was "100% Airline / 0% Crew". And as has already been pointed out, that finding was not affected by the subsequent litigation, which focused on other unrelated issues. So history will record that the crew was completely blameless, and this is difficult to accept. The airline, obviously, must shoulder most of the responsibility. But Mahon's complete exoneration of the crew, and the methods he used to get there, are very difficult to understand.

It should be noted Mahon was a lawyer, not an aviator - and he was not above the twisting of a word or two. The end result sounds good on the first reading, but makes less sense on subsequent readings. The classic example is the way he dealt with Chippendale's finding that the crew descended below Minimum Safe Altitude when "unsure" of their position. Mahon seized on the word "unsure", and found that the crew were, in fact, sure of their position: they believed they were in McMurdo Sound. But how can this form any basis for exonerating the crew? If they believed they were in McMurdo Sound, they were wrong. And the surer they were, the wronger they were.

As to the crew's certainty of their position, there is one piece of evidence that is never referred to. Just before the Ground Proximity Warning System sounded, the captain said "We're 26 miles north. We'll have to climb out of this." The first officer, seated in the right-hand seat, says "It's clear to the right and ahead. You're clear to turn right. There's no high ground if you do a 180." The captain responds "No. Negative." At this point, the GPWS sounds, the captain calls for go-around power and there is a sudden manual application of LEFT rudder.

No-one, including Mahon (who never referred to this evidence), has explained why a pilot who is certain he is in the centre of McMurdo Sound would decide to turn left to climb out, because Erebus and Mount Bird would be to the left. The obvious manouvre was the right turn that had been expressly suggested by the first officer. The first officer, of course, was wrong. A right turn would have produced a collision with the cloud-covered Mount Bird - and the captain, in the final seconds of the flight, appeared to have some appreciation of there being danger to the right. And when the GPWS sounds, there is an immediate attempt to climb out, rather than any reference the possibility of a false alarm. None of this is consistent with the crew being certain that they were in McMurdo Sound.


Beaufort Island

Judge Harold Greene commented that the crew "missed the obvious landmark of Beaufort Island being on the wrong side of the flightpath."

Mahon attempted to explain that failure, but I did not find his explanation particularly convincing. Of more significance, in my mind, is a photograph of Beaufort Island that was included in Mahon's report. The photograph was taken by a passenger on the flight, and was included for the purpose of demonstrating that the aircraft was flying in clear air. But the photograph also demonstrates that Beaufort Island was almost impossible to miss. The photograph shows an island of significant size, with high cliffs. It is difficult to accept that the crew did not see the island, especially given that they flew past it on three occasions, two of which were below the cloud base. And it appears from the transcript that Beaufort Island was, in fact, sighted from the flightdeck. The Chippendale Report contains a diagram with the track plotted in 3D against the terrain. Also included are comments from the transcript, which are plotted on the track. As the aircraft is half-way through the second of its descending orbits, and just at the point when Beaufort Island is dead ahead, the flight commentatator says "There you go. There's some land ahead."

The flight commentator was not part of the crew, but given that he had just identified some land ahead, wouldn't the next question be "What land is that?" The aircraft had been relying on instruments alone since leaving Auckland, was approaching Antarctica, was flying VMC, below MSA, and the flight commentator had identified land ahead. I would have thought that at least one member of the crew would have attempted to cross-check the assumed poisition against this topographic feature. Had that been done, it would have been obvious that the assumed position was wrong. The map would have shown that there were no other islands in the vicinity. The island ahead could not have been any island other than Beaufort Island and the track allegedly plotted on the atlas would have showbn that the aircraft was on the wrong side of Beaufort Island, on a collision course with Erebus.


Change of the Waypoint

I note the explanation of "Desert Dingo" for the change to the waypoint. This appears to follow Mahon's theory, which was that the Navigation Section of the airline was attempting to conceal something from the US authorities or/and the Department of Civil Aviation. But what were they supposed to be trying to cover up? Mahon seemed to believe that the staff at the Navigation Section devoted large amounts of time towards some bizarre conspiracy, when all they had to do was simply change the route to what they wanted and then have it appoved by the US authorities and by Civil Aviation. I much prefer the evidence of the Navigation Section, who frankly admitted that they made a series of errors.

Putting the conspiracy theory to one side, it is not disputed that the nav track for the initial flights was over Erebus. It is not disputed that nav truck for later flights was down McMurdo Sound. And it is not disputed that on the morning of the fatal flight, the nav track was changed, back to one going over Erebus. Desert Dingo does not discuss the circumstances that led up to this final change. Mahon goes into the issue is some depth, but in doing so, he raises an important question which he never answers.

Approximately two weeks before the fatal flight, another flight had visited Antarctica. Shortly after this flight, the captain spoke with the airline executive pilot responsible for navigation on the Antartic flights. The discussion concerned the final waypoint. (It should be noted that on this flight, unlike the fatal flight, the final waypoint was in the centre of McMurdo Sound, which produced a nav track down the sound, rather than over Erebus.) Conflicting evidence was given about the discussion. The executive pilot said that the captain told him that the waypoint was in the wrong position. The executive pilot, assuming the correct track to be over Erebus, instructed the Navigation Section to correct the error, which they did on the morning of the fatal flight. The executive pilot's evidence was hotly contested. The captain said that he never told the executive pilot that the waypoint was in the wrong position. All that was said, according to the captain, was that when he overflew the waypoint in McMurdo Sound, he was about 20km from where he thought he would be and that he believed that future crews should be told of this.

Mahon accepted the captain's evidence, and rejected that of the executive pilot. In doing so, Mahon refused to accept that an airline would "program" an aircraft to fly over an active volcanoe. Again, this sounds good on the first reading, but makes less sense the more you think about it. The purpose of the nav track was to get the aircraft to the vicinity. It seems perfectly reasonable to align the nav track with the most conspicuous topographical feature, specifying a minimum safe altitude. Once in the vicinity, the aircraft was not committed to its nav track.

Even if the captain's evidence is accepted, it is very difficult to understand. The reason is that the captain attended the same briefing as Captain Collins. The briefing officer gave evidence and said that he told the pilots that the nav track went over Erebus. At that time, the nav track did not go over Erebus, but the significance of the briefing officer's evidence is that the pilots at the briefing were told that it did, and that one of those pilots was the captain on the fatal flight. The briefing officer's evidence was disputed by the captain, who was admanant that there was no reference to the nav track going over Erebus.

The important question that arises from that evidence is this: If the captain believed that the nav track was down McMurdo Sound, rather than over Erebus, why, when he overflew the waypoint in McMurdo Sound, did he note anything unusual? Why, in fact, did he note anything at all? If his evidence about the briefing was correct, the waypoint was exactly where it was supposed to be. If, on the other hand, the briefing officer had told the captain that the nav track went over Erebus, then there would be something unusual to note when the captain overflew the waypoint.

There may be an explanation for this, but Mahon never gave it. Instead, he labelled the executive pilot and the briefing officer as perjurers. This apparent contradiction goes right to the heart of the matter, because if the briefing officer told the pilots that the nav track went over Erebus, it is no answer to say that a sheet of paper was handed out with co-ordinates which, when plotted on a domestic atlas, showed a track down McMurdo Sound. In that situation, the pilots attending the briefing were obliged to clarify the situation.

[Taildragger67]

Ampan,

Good first post, which I will re-read and consider. Certainly some food for thought in there.

That said, taking things as they stand, I would like to make one small point by way of comparison to show that it is possible for pilots do do things which, had they acted differently, may have caused a different outcome; but fo rth epilots to be exonerated as they were acting reasonably with the information they had and the situation as they reasonably believed it to be.

That comparison is a DC10 crash in May 1979 (AA191) at O'Hare. An engine separated, causing loss of power and assymmetry, but importantly, loss of systems and hydraulics. The crew had been trained to reduce to V2 (around 140kts) after an engine loss; however this crew did not know the engine had separated and certainly did not know they were losing hydraulic fluid, causing the left slats to retract (so raising that wing's stall speed to 160kts). Hence in reducing speed, the crew (by a very literal interpretation) made the aircraft uncontrollable.

However they could be exonerated as they were doing what they thought was reasonable, according to their training.

I will re-read Ampan's post and chew it over.

[prospector]

Taildragger67,
Don't think your comparison to the DC10 at O'Hare is really relevant in as much as TE901 was a perfectly serviceable aircraft, and there was no urgency to do anything when the decision to descend was made.

[ampan]

All agreed. The crew never gets the benefit of hindsight.

On reflection, my point about the captain's decision to turn left to climb out is not a good one. It seems reasonably obvious that he was not, at that time, certain that he was in McMurdo Sound. However, shortly beforehand, after completing two descending orbits that took the aircraft through a hole in the cloud cover, the nav mode was deliberately re-engaged, so that the aircraft would again lock onto the nav track. As Mahon points out, the captain, at that point, must have believed that he was in McMurdo Sound. It is possible that he became slightly less certain after he levelled out at 1500 feet and after the flight engineer said "I don't like this", and then rapidly reassessed the situation after the GPWS sounded. (Some criticism had been made of the slight delay in attempting to climb out after the GPWS sounded, but it should be noted that the first officer had just recommended climbing out to the right, which the captain was starting to have doubts about. The GPWS sounded and then the captain had to decide between the left and the right, which he does in a remarkably short time, and manages to get it right.)

So it's difficult to argue with Mahon's finding that the crew believed they were in McMurdo Sound. If that belief changed, it only changed during the final few seconds, by which time it was too late to recover.

Whether the crew were entitled to believe they were in McMurdo Sound is a different issue.

[ampan]

I think the point that Taildragger67 is making when referring to the O'Hare accident is that the crew can be completely exonerated (ie, 0% fault) even when there was something they could have done to avoid the accident. The fact that something could have been done does not necessarily mean that the crew must get "a little bit" of the blame. For example, the fact that the O'Hare accident would not have occurred if the crew had not throttled back does not make it "Airline 99.9% / Crew 0.01%".

(The O'Hare accident was the airline's fault, wasn't it? I'm aware that the manufacturer was blamed initially, for a defective bolt, with the result that all AirNZs DC10s were grounded for several weeks. But I seem to recall that the bolt was found to have nothing to with it.)

[grummanavenger]

Latest today

Tuesday, 12 February 2008200802121010
Erebus air investigator killed by car

LATEST: Retired chief air accident investigator Ronald Chippendale, who wrote a controversial report of the Erebus disaster, was hit and killed by a car this morning.
Mr Chippendale, 75, was struck by a car which went out of control in Porirua, north of Wellington, at 7.25am.
As chief inspector of air accidents, Mr Chippendale wrote a report on the 1979 Air New Zealand DC10 crash at Mt Erebus, Antarctica.
However Mr Chippendale's report, which blamed the crash on pilot error, was contested by a subsequent report by Justice Mahon.
In this morning's crash, an 18-year-old Porirua man allegedly lost control of his car while driving up Whitford Brown Avenue and ploughed into Mr Chippendale as he was walking on the footpath.
Mr Chippendale, who was returning to his Aotea home from his usual early morning walk, was killed instantly.
Air New Zealand Flight TE901 ploughed into the northern slopes of Mt Erebus on November 28, 1979. It killed all 237 passengers and a crew of 20, working under Captain Jim Collins.
Mr Chippendale, after a six-month inquiry as Chief Inspector of Air Accidents, blamed the aircrew.
He said Collins had erred by flying at low altitude in conditions which made it hard to define the ground and the horizon, and when the crew was not certain of their position.
However, a Royal Commission chaired by Justice Mahon, which reported a year later, fingered the airline.
On the night before the flight the flight track was changed in the plane's navigation system without the crew being told; the route went across Erebus and not over the flat sea ice of McMurdo Sound, the flight path for the earlier trips.
Mahon was also critical of the Civil Aviation Division. He caused a huge furore when he accused Air New Zealand of "a pre-determined plan of deception" and "an orchestrated litany of lies".
The Appeal Court later said these findings of Justice Mahon went beyond his jurisdiction and didn't comply with natural justice.
Almost 30 years later, debate over the primary cause of the crash continued.
Kapiti Mana Area police commander Inspector John Spence said today that the driver involved in the crash was shaken but uninjured.
He has been interviewed and it is likely that serious charges will follow once the investigation has been completed.
"Mr Chippendale was a keen walker and could be seen most days striding out in the Aotea and Papakowhai areas," Mr Spence said. "The circumstances of his death are a real tragedy."
Porirua Police are appealing for witnesses to the crash. Officers would also like to talk with a man and woman who stopped and helped the driver out of his car.

Y

[walschaert valve]

That's terrible news. I knew his brother Alan well, he died early from cancer.

Walking down the street, really sad.

[hoggsnortrupert]

T'was a real sad day then:

And a sad day today:

RIP Ron Chippendale:

I still have the original Government copy of the accident findings by Ron Chippendale, together with, Impact Erebus, by Gordon Vette and Justice Peter Mahon.

To read them both collectively is "interesting".

If I could say that things where certainly different then, and with different values.
Ron Chippendale,Morrie Davis,& Sir Robert Muldoon, where of an OLD BOY era.

I mention this because of the political influence and I guess the some what “interferrence” by Morrie Davis & Sir Rob.

It is only my opinion that to some degree ,Ron was played by messer's Davis & Muldoon.

Yes the crew went below FL 160: but so had others.

This whole debate hinges around Captain Jim Collins and F/O Greg Casin "knowingly" operating VFR:

1/ They had not been trained in sector white out, Hence they thought they had clear air, and at some point something became apparent that they needed to get out of the position they were facing, I believe from reading both “reports” that from a totally “benign” & “ignorant” white out situation, that it was with some rapidness that conditions changed to the point that they wanted to get out of the conditions.

2/ They had no reason to doubt their INS system that was functioning perfectly.

3/ They had not operated the machine any different this day, to what other senior company pilots had previously.

4/ Jim Collins had drawn his intended track on a map the night before with his daughter, he had no reason to doubt the actual track, from track in his MINDS EYE from the night before:

5/ Jim Collins and Greg Casin did not know that FLt ops Dep had changed the Lat & long of a waypoint , with the result being a shift of the "MINDS EYE" route, to that of their actual flt path.

6/ The need for a topographical map in sector white out would have been pointless.

Tis indeed an interesting debate, and there has been an awful lot of good come out off this over the years, by way of "HUMAN FACTOR TRAINING".

As I said in a post last year, BRAVO GORDON VETTE!

Chr's
H/Snort

[ampan]

A couple of points:

I agree with (1), concerning sector whiteout. It is interesting to note the despite the lack of any training, the captain was aware of the problem: At the beginning of the transcript (ie, about 30 minutes from impact), after getting the weather from McMurdo, he says "Clouds come down a bit ... May not be able to ... McMurdo. Very hard to tell the difference between the cloud and the ice."

Re (3) - I don't think it's completely accurate to say that the crew operated their flight to Antarctica in the same way as previous crews. In total, there were about 12 flights, over 3 years. They were timed to get the best weather, and they did. Of the previous flights, nearly all arrived to find perfect 'blue sky' conditions - so the crews did not pay a great deal of attention to the nav track or to the minimum safe altitude, because they didn't need to. I far as I am aware, there was only one previous flight where the McMurdo was covered in cloud, and that flight did not descend. It went to a different area.

Re (4) - I take your point about the atlas. Although the captain might have plotted the nav track on his atlas, it does not necessarily mean that he took the atlas with him - which would explain why the atlas was not found at the crash site. (But it wasn't found at the captain's house either.) If the atlas wasn't available on the flight deck, then the crew's failure to identify Beaufort Island is explained.

[Taildragger67]

Prospector,

I suggest Ampan has understood me. I am not drawing parallels between actual cause or type etc. but more that it is possible to exonerate people who actually have their hands on the tiller at the time of the incident, where they quite reasonably think one set of circumstances exist when, in fact, another does; the real fault then lies with what prevented them from being in possession of the full set of actual facts.

This is important because if, for instance, blame for the O'Hare DC10 had been laid with the pilots' mistaken reduction of power - "it was recoverable, if they had not reduced speed below 159KIAS, so the fact that they did so, makes them to blame" - then a host of other issues would not have been looked at - AA's maintenance, the fallibility of the DC10 engine attachment, FAA oversight, etc.

So to with Erebus - whilst it is undeniable that TE901's crew flew below 16000', to then say they are fully to blame would have meant other human and organisational factors would not have been fixed.

This is a learning process. Aviation learnt many things from TE901 and that is the legacy of Collins, Cassin and all the others who perished that day.

[hoggsnortrupert]

White Out:

Re (4) - I take your point about the atlas. Although the captain might have plotted the nav track on his atlas, it does not necessarily mean that he took the atlas with him - which would explain why the atlas was not found at the crash site. (But it wasn't found at the captain's house either.) If the atlas wasn't available on the flight deck, then the crew's failure to identify Beaufort Island is explained.

Ampan: I think you perhaps miss my point!

In White out what you THINK YOU SEE, IS NOT WHAT YOU SHOULD BE SEEING, rather like a simulator, its all an ILLUSION OF NATURE! what good would have been an ATLAS or MAP:

Also: ONE of the Pilots, I can't remember which: their family home was broken into within days of the accident and records where taken!

There is indeed I feel some substance to the rumor over the years that ANZ and Morrie Davis, knew within a very short space of time, from the FLT not reporting in that they had flown into Erebus:

Why: The shift of the waypoints it is RUMORED to have been known about almost immediately:

I am willing to stand corrected here: but the chap that shifted the Lat & Long ( Waypoints) I heard committed suicide shortly afterwards.

I stand corrected if I am wrong:

Chr's
H/Snort

[prospector]

Taildragger67,
"So to with Erebus - whilst it is undeniable that TE901's crew flew below 16000', to then say they are fully to blame would have meant other human and organisational factors would not have been fixed."

My argument has been, and still is, that the Mahon enquiry was wrong in stating that no blame should be placed on the crew. No where have I stated that they were fully to blame.

As you say it is a learning process, but if the lessons learnt are not correct where is the value??

The following statement from Ron Chippendale would be what I find sums up the situation best, but it would appear I am in a minority with this belief, but hopefully it has made people rethink Mahons findings.

"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."

[ampan]

Maps

I don't think I missed H'snort's point re a map. Yes, a map won't help if the sector whiteout prevents you seeing anything. But this wasn't the case. Although the crew couldn't see Erebus, they could see Beaufort Island. If you knew where you were in relation to Beaufort Island, then you would know where you were are in relation to Erebus - if you've got a decent map. If you haven't got a decent map, then that island down there in the sea is just an island down there in the sea.

Does anyone know what maps they had on the flightdeck?

[bushy]

Nav systems

I believe they had triple inertial nav systems, and one captain said he had never had an error in the inertial nav system in ten years of DC10 flying.
I have great respect for the head of the navigation section who stood up in court and explained that the co-ordinates had been changed.
The crew were, I believe navigating by reference to the inertial nav system. Not visually.
Of course they were discussing what they could see. That was the purpose of the flight.