Erebus 25 years on

[Brian Abraham]

gsf

Not long after that event I was chatting with a Qantas pilot who was scheduled the fly the same route shortly after the BA flight.

He told me that volcanic dustcloud was notamed, but BA continued on the planned route anyway.
The Qantas pilot said they took on extra fuel and routed round the notamed area.

So, on the assumption my acqaintance was not telling porkies, I would say that the BA captain, would have justifiably copped a fair measure of blame if the flight had ended in tragedy.

The aircrew had no idea of the volcanic activity. The system of notaming volcanic activity was not introduced until after and because of this very incident. The airway was closed following the incident and reopened some days later. A Singapore Airlines 747 was forced to shut down three of its engines while flying through the same area nineteen days later, and Indonesian authorities closed the airspace permanently and re-routed airways to avoid the area. This happened in 1982, you may be referring to Mount Pinatubo, Phillipines eruption in 1991.

[Taildragger67]

May I suggest that with any CFIT episode, the crew is responsible for actually putting the aircraft into the terrain - it is 'controlled', after all.

However simply stopping the analysis there, does not improve flight safety. The correct approach is to then ask, "why did the crew place the aircraft in danger? Were they a) being reckless, or b) negligent, or c) did they have a false (but reasonable) belief of their situation?"

If a) or b), then the buck stops there (except to say that the carrier may need to tighten its crew selection procedures to weed out those who might act recklessly or negligently).

If c), then the question needs to be asked as to what circumstances allowed the crew to hold their (entirely reasonable) belief. This may include organisational factors.

I submit that we are dealing with a c) situation here.

Nobody can deny that Collins & Cassin let-down ZK-NZP below 16000' and reselected nav track after the descent orbits. I cannot accept that they had a collective death-wish, hence I can only accept that they considered it reasonable to take this action. Reselecting nav track then put them back onto the path into Erebus; as I cannot accept that they had a collective death-wish, I can only accept that they thought that they were then proceeding in clear air.

The analysis, therefore, must lie in determining why the crew thought it reasonable to descend below 16000'. As I posited above, I do not believe the crew had a collective death-wish, hence we can only conclude that they did not think that they would be flying straight towards terrain.

As for the F/E's attributed "I don't like this" - my recollection of the transcript (having not read it for a while) is that as soon as this was said, the crew started to take action to remove themselves from the situation (clearly then made more urgent by the GPWS going off after they crossed the cliffs). If my recollection is correct, that leads me to conclude that some pretty decent CRM was taking place - certainly not a case of press-on-itis and Collins trying to impose his will on everyone else.

Those who ignore history are condemned to repeat it. If we stop the analysis with the immediate cause, we risk allowing another crew to find themselves in unfamiliar territory and potentially a similar outcome to ZK-NZP. If upstream factors are given weight - which may be great in all the circumstances - then hopefully this will not happen again.

[ampan]

I’m in the (b) camp. Certainly not (a).

Another lesson to be drawn, or reinforced, is that you don’t change the plan unless you have to. I don’t know what the plan was at Cape Hallett, but we know that 130 miles out it was to descend with radar. It appears that at about 40 miles out, when the radar fix still hadn’t come through, the plan changed, quite suddenly. (I still don’t understand why there was any need for the change. Why not just continue on for 40 miles at 18000ft?)

[Taildragger67]

Ampan,

What would Jim Collins say? (ref. your post #311)

Well, after he said 'Go round power, please', if he had been able to climb out, I suspect he would've said something like 'Where the f**k are we (actually) and how did we end up on a track with Erebus in front of us? I thought we were going straight down McMurdo Sound. Let's get up to FL 200-odd, get a vector to overhead Mac Center, figure out where we really are and head straight home from there because there is a discrepancy between our nav track and what we were briefed on.'

[ampan]

Point taken (but he would have had the opportunity to say all that, and more, he he'd stuck to the plan).

[Taildragger67]

Thanks

But I think that's the point as well - he thought he was sticking to the plan...

It is great that this is still being debated, guys, after 28 years and we must make sure it doesn't get personal or nasty. We all have something to contribute - and something to learn.

[ampan]

Agreed.

While I'm obviously anti-Mahon, I certainly don't want to be seen as criticising Jim Collins. As far as I am aware, everything Mahon wrote about him was was absolutely correct.

The problem, I think, was that the Royal Commission hearing turned into a full-on brawl between the airline and the union. Maybe that's another lesson to be learned.

[ampan]

Given that the latest Erebus eruption appears to have come to end, I just want to slip in a quote from Mahon’s book, because despite his alleged failings, the man could certainly string a sentence together. At pages 83 and 84, Mahon gives his impression of the Chief Pilot’s evidence. The quote might also provide a good indication as to the group of persons who were responsible for the hearing degenerating into a pitched battle:

“Captain Gemmell was then cross-examined, at considerable length, by counsel for other parties. Many criticisms of the flight planning were advanced and it was interesting to see how the witness responded to the detailed and challenging questions which were addressed to him. The answers which he gave were unhesitating and positive. When possible, his answers were monosyllabic, and he seemed to treat the various counsel with thinly veiled contempt.”

[SR71]

In case anyone cares, the answer to my question about the two flight-plans in post #283 can be found in the Privvy Council Ruling on Pg 22 onwards.

(I still have not got access to Chippendale's actual report or Mahon's Royal Commission document, nor have I fully digested the Court of Appeal document, so I'm playing catch-up here and, no doubt, the answer is in these documents too...)

[ampan]

The links posted in Desert Dingo’s #249 are still working. Maybe you need to update your Adobe reader?

I haven’t managed to get hold of a copy of the Privy Council case yet, but thought that the answer might have something to do with the convergence of the lines of longitude. Started writing a reply in order to prove how smart I was, and ended up getting hopelessly confused.

[gsf]

Brian Abraham: thanks for that explanation.

Your last sentence might well be correct and my memory is at fault.

[Brian Abraham]

No sweat gsf. I can't remember what I had for breakfast.

Taildragger, if we are taking a vote I'm with you in the (c) camp.

Have found the discussion interesting and see nothing wrong that some of us agree (I hope with respect) to disagree. Although I believe some posters are some what one eyed in their approach and unaccepting of other view points, no matter how well put, I believe the following holds true in any discourse.

The peculiar evil of silencing the expression of an opinion is, that it is robbing the human race; posterity as well as the existing generation; those who dissent from the opinion, still more than those who hold it. If the opinion is right, they are deprived of the opportunity of exchanging error for truth: if wrong, they lose, what is almost as great a benefit, the clearer perception and livelier impression of truth, produced by its collision with error…….We can never be sure that the opinion we are endeavouring to stifle is a false opinion; and if we were sure, stifling it would be an evil still.

To deprecate the value of intellectual freedom because it will never mean for everybody the same possibility of independent thought is completely to miss the reasons which give intellectual freedom its value. What is essential to make it serve its function as the prime mover of intellectual progress is not that everybody may be able to think or write anything, but that any cause or idea may be argued by somebody. So long as dissent is not suppressed, there will always be some who will query the ideas ruling their contemporaries and put new ideas to the test of argument and propaganda.
This interaction of individuals, possessing different knowledge and different views, is what constitutes the life of thought. The growth of reason is a social process based on the existence of such differences.

Not original work as you no doubt guessed.

[ampan]

Well said. I reckon you should print off 30 copies and insert them into Jim Anderton's most-private of places.

It would be polite to roll them up first.

[SR71]

ampan,

Sorry...didn't say that very well.

What I meant was I still haven't accessed them, in order to read them.

Thanks for reposting the links in Dingo's post.

[prospector]

Brian Abraham,
"
"Have found the discussion interesting and see nothing wrong that some of us agree (I hope with respect) to disagree. Although I believe some posters are some what one eyed in their approach and unaccepting of other view points, no matter how well put, I believe the following holds true in any discourse."

I also think that some of the posters are one eyed. Although probably not the same ones as you.

The argument that one is not responsible for ones decision when the result of that decision turns to custard will no doubt be of value in the future to the bean counters when they are trying to get rid of the sharp end crew.

"This interaction of individuals, possessing different knowledge and different views, is what constitutes the life of thought. The growth of reason is a social process based on the existence of such differences."

Brilliant, wish I could come up with such wisdom.

[ampan]

Minimum Altitude

Prospector / Desert Dingo:

Are you able to confirm that I’ve got the facts straight re the altitude limit? I’ve got two documents.

The first is quoted at page 125 of MacFarlane’s book (which itself is a quote from pages 200 to 201 of Vette’s book). The quote is described as an extract from a “briefing document” and is dated 23 October 1979:

“Descent to 6,000 feet for Cloud Penetration at McMurdo


Permission has been given to descend to 6,000 feet QNH in VMC conditions, or using the approved NDB procedure in IMC conditions, provided that:
(a) cloud base reported to be 7,000 feet or better.
(b) visibility reported to be 20 kms or better.
(c) ASR is available and used to monitor Flight Level 160.
(d) No snow showers in the area.

Pilots will have received a comprehensive briefing and completed a simulator detail involving a let-down and climb-out procedure, particular emphasis is being placed [on] the use of grid navigation procedures.

Flight in the McMurdo area below FL160 will be restricted to an arc corresponding to a bearing of 120 degress grid through 360 degrees grid to 270 degrees grid from NDB within 20 nms to keep well clear of the Erebus region.”


The second document is quoted at pages 38 and 39 of the Chippendale Report. It is described as “an amendment DAA:14/13/28 of 8 November 1979”:


“McMurdo NDB not available


Delete all reference in briefing dated 23/10/79
Note that the only letdown procedure available is VMC
Below FL160 to 6000’ as follows;
1. Vis 20 km plus.
2. No snow shower in area.
3. Avoid MT EREBUS area by operating in an arc from 120 [degrees] Grid through 360G to 270G from McMurdo Field, within 20 nm of TACAN CH29.
4. Descent to be co-ordinated with local radar control as they may have other traffic in the area.”



A copy of the second document was found at the crash site, and I understand from the thread that there is no dispute about this. A copy of the first document was not found at the crash site.

Desert Dingo refers to an authorisation to descend below FL160 VMC with ATC clearance. As I understand things, this authorisation was not recorded in writing. Instead, it was given orally at the briefing. He points out that the briefing officer conceded that the authorisation was given.

There is also correspondence between CAA and AirNZ which records FL160 as the minimum except in the sector behind Ross Island, but is this correspondence relevant? The issue is the rule conveyed to the crew by AirNZ, not the rule conveyed to AirNZ by CAA.

Is there anything else? If not, then persons wanted to make up their own mind can simply read the two documents, in the light of the oral authorisation given at the briefing.

[Desert Dingo]

Those descent restriction memos

ampan: In the light of the bombshell Captain Wilson dropped in giving his evidence at the Royal Commission those memos became obsolete and irrelevant. It is a pity that the administrative procedures were so stuffed up that they were not officially withdrawn.

Allow me to quote:

My (#302)

However the whole descent memo became totally irrelevant when the company briefing specifically authorized the crew to descend to any altitude approved by the United States Navy Air Traffic Controller.

Mahon (Verdict on Erebus p223)

…. Evidence had been given by a number of pilots that they had been specifically briefed to descend to any altitude authorized by American Air Traffic Control and that they had done so. This had been a specific briefing by the senior briefing officer of the airline and this, of course, meant that the 16000 and 6000 feet flight level MSA was a myth.

Mahon (Verdict on Erebus p118)

All this was grossly at variance with the management evidence already given. I had been led to believe up to this time that any descent below 16000 feet on the approach to McMurdo and any descent below 6000 feet at McMurdo would have been in flagrant breach of the airline’s operating procedures.
The airline’s implacable and persistent “altitude defense” had now disintegrated.

There are many other examples I could use, but I think you can get the idea I am trying to convey.

[prospector]

ampan,
" McMurdo NDB not available" was the current requirement at the time of the flight. As you can see it is quite specific, it is written, a copy of it was found in the cockpit after the crash. The crew knew about it and its contents.

Against that, we have a verbal briefing, that people remembered in different ways, and at different times, especially after counsel for you know who became involved.

Also from the chief pilot, "We didn't put anything into the briefing about whiteout, but we discussed it with Operation Deep Freeze and went into in quite some depth. At 6,000ft there was no whiteouts."


"The airline’s implacable and persistent “altitude defense” had now disintegrated"

In Mahons eyes perhaps but as has been shown many disagree with that view, including Capt Dereck Ellis who stated "These included his unprofessional belittling of some very capable senior witnesses, ignoring views contrary to his own preconceived idea's. his introduction of somewhat controversial later evidence that could not be challenged by counsel."

Try also reading the Bolt/ Kennedy report, no doubt you would be aware
of Sir Richard Bolt and his vast qualifications in the aeronautical sphere.

Paragraph 17 of the Bolt/Kennedy report says "After studying carefully the relevant transcripts of evidence and questioning further those officers involved, we simply record that in our view, that (For the Royal Commission) to reject certain propositions as "absurd" or "untenable or "unwarranted was unfortunate and may have been the result of misunderstandings"

Very polite way of saying????

While this report was compiled to answer allegations made against CAA. they refer in the main to the requirements for descent for FLT901.

Also try for The Erebus Enquiry, a Tragic Miscarriage of Justice, written by CHN L'estrange, his background and experience Airline Pilot on North Atlantic services and was recruited to serve as an Operations Officer (airline inspector).

"With his expert knowledge and detailed logic, he has been able to identify and highlight facts that had been smudged by the Commissioner".

[ampan]

The problem is that Capt. Wilson accepted that he gave the oral authorisation. And the crew themselves didn't appear to believe that FL160 was the minimum during the run down McMurdo Sound. Desert Dingo is probably taking it a wee bit too far when he says that the documents became completely irrelevant after Capt. Wilson's evidence, but it still makes it very difficult to establish an error by establishing the breach of a rule.

I'm still trying to figure out why the crew didn't stick to planned radar descent. Maybe it had something to do with the second memo? Correct me if I'm wrong, but on a literal reading, you couldn't break the cloud cover over McMurdo Station, even if you're position had been fixed by radar.

[prospector]

ampan,
Have another look at the weather at McMurdo, it was below the company requirements for any descent, the crew were advised that sightseeing at McMurdo was no good and to go elsewhere, Taylor valley or somewhere from memory.
from John King"s book
"knowing from McMurdo that the weather was well below the minima required for the company approved letdown procedure and so he would have to improvise his own, he saw a break in the clouds which extended to sea level. Collins stated his intention to circle to get below cloud"

To keep on going down to 1480Ft, in those circumstances of weather, area and lack of local knowledge must surely speak for itself.