Erebus 25 years on

[PLovett]

Oh boy......sit back........snack at hand and drink ready and watch the fireworks.

[3 Holer]

Fireworks over what?

Moderators don't take long to sort out who the trolls are

[PapaHotel6]

Moderators don't take long to sort out who the trolls are

Nor should they. But if that comment is directed at myself, I resent it.

To exonerate Collins from responsibility, as Mahon did, it is necessary to believe:

- that his descent from high altitude through a hole in the cloud in a region known to contain a 13,000' mountain, using only the (assumed) high altitude flight plan to verify his position was justifiable;

- that he was truly in VMC conditions all the way down to and including 1500';

- that the requirement not to descend below 16000' MSA until south of Erebus was in fact not real;

- that he was psychologically tricked by whiteout and "saw" a clear, normal horizon stretching out in front of him all the time up until impact;

- that he maintained appropriate situational awareness in the last stages of flight, in spite of failing to establish VHF comms and several comments from other crew members about High ground/Erebus/don't like this etc.;

- that it was appropriate to descend from 2000' to 1500' when good conditions were not apparent at 2000'.

I personally reject every one of the above points.

[zkdli]

Hmm, situational awareness is such a mine field. Perhaps it is time for a human factors specialist to provide a definition... one that all human factors specialists can agree with

[PapaHotel6]

I think most of us would agree that "situational awareness" refers to the ability to assimilate the wider factors of a situation that might not be individually related, and act accordingly.

Quantifying situational awareness and agreeing whether it was present is of course always going to be a matter of opinion. However in the case of Collins:

- he'd commenced a descent that was unorthodox relying only on the supposed integrity of the flight plan;

- conditions during the descent were marginal VFR at best;

- He had been unable to establish VHF comms;

- Others on the flight deck had expressed concern;

- Finding himself at 2000' (and subsequently 1500') in a DC-10 loaded with 257 people, in a region known to contain a 13,000' mountain he still found poor visual conditons.

I would feel confident in saying that most of the professional body of airline pilots would argue that Jim Collins did not display the situational awareness expected of a captain.

[ampan]

It was a simple case of pilot error. The reason for the continued argument is that Mahon was duped by the union and botched things up, and the union then sought to enshrine its victory.

[zkdli]

now we have human error and situational awareness. PH6 your thoughts on the pilot's situational awareness are based on hindsight, unfortunately we will never know what the factors involved in Capt Collins situational awareness were, we will only know the results of his decisions not his awareness of the environment that he was operating in.
As for "pilot" or Human error, again that is a construct of Hindsight. We also know that several times in past flights, pilots were doing similar actions as Capt Collins. I know that every flight was different however, they were doing similar things and it would be interesting to discuss what they based their environmental awareness on. By the thought process on pilot error, they must also have been committing pilot error but did not come to grief.

[PapaHotel6]

The fact that other pilots may have broken the rules also and got away with it neither exonerates Collins nor invalidates the rules. The comparisons are also invalid, as Collins's descent was in a league all of its own. No other Antarctic pilot descended through a hole in the cloud in marginal (at best!) VFR conditions down to 2000' then 1500' all the while neglecting to identify the known high ground in the region.

[framer]

I normally like to see some of the responsibility of the crash go to the PinC when discussing Erebus for all the oft discussed reasons, but to completely exclude the operating culture of the time is as bad as to try to completely exonerate the Captain of his responsibility. There will never be agreement on where the responsibility lies because people naturally like to lump it all in one place ( like you are doing PH6) when that is not how life works. There were serious decision making errors yes, but he wasn't operating in a vacuum, he was operating inan era and as a part of a particular culture when those errors were made. Peoples views will change with time as well. As a young turbo prop Captain I put the blame 90/10 on Collins. Now as a more experienced and older jet Captain I put it at about 70/30 on Collins......when I retire will it be 50/50? I doubt it but I wouldn't rule it out.

[ampan]

It’s a bit difficult to discern whose side you’re on.Various silly w*nkers will say that there are no “sides” – but there are. Mahongot this completely wrong, probably because he had a brain tumour.
Read the CVR transcript: Bad weather at McMurdo Station - probablyhave to go somewhere else. Fine.
Radar let –down to McMurdo offered. Fine.
Can’t get VHF communications for radar let-down. Go downanyway? So obviously not fine that it beggars belief that this is still a topicfor any argument.
Can any of you stupid twits out there justify that?

[PapaHotel6]

I normally like to see some of the responsibility of the crash go to the PinC when discussing Erebus for all the oft discussed reasons, but to completely exclude the operating culture of the time is as bad as to try to completely exonerate the Captain of his responsibility. There will never be agreement on where the responsibility lies because people naturally like to lump it all in one place ( like you are doing PH6) when that is not how life works. There were serious decision making errors yes, but he wasn't operating in a vacuum, he was operating inan era and as a part of a particular culture when those errors were made. Peoples views will change with time as well. As a young turbo prop Captain I put the blame 90/10 on Collins. Now as a more experienced and older jet Captain I put it at about 70/30 on Collins......when I retire will it be 50/50? I doubt it but I wouldn't rule it out.

Thanks framer. Yes, the company and culture were far from perfect either. But where people become confused is in failing to differentiate between direct causal errors and those that were only significant in the presence of a unique set of circumstances.

Here's what I mean. Air New Zealand
- probably should not have gone into the sightseeing business in the first place
- should have trained and briefed their pilots properly, and unambiguously
- should not have made a series of errors with the high altitude flight plan
- should not have removed the requirement for one person on the flight deck to have flown in Antarctica before.

But here's the thing. While these things may have contributed, not one of these factors on their own would you expect to cause an accident. But flying an aircraft in marginal visual conditions at 1500' in an unfamiliar mountainous area? Absolutely!

[prospector]

-

should have trained and briefed their pilots properly, and unambiguously

should not have removed the requirement for one person on the flight deck to have flown in Antarctica before.

Was it not the ALPA people who insisted that their senior captains all have a "turn" at this perk flight? Here CAA should have been more insistent that the Company use the experience of the people who had been going down there for many years, and no Captain should have gone down there as PIC until a familiarisation flight had been undertaken, as was a mandatory requirement for all the service aircrew carrying out operations down to the ice.

[Anotherday]

Thought the USAF (who'd been operating down there for decades and had lost airframes and crew as a result) at the time wanted nothing to do with AirNZs trips to Erebus as they felt the company was grossly inexperienced in operating to Antartica.

I still don't see the connection between doing AKL-LAX and taking a DC10 way south for some VFR.

[PapaHotel6]

I still don't see the connection between doing AKL-LAX and taking a DC10 way south for some VFR.

There isn't one. Which is why that although the direct cause of this accident was pilot error; not all the blame can go to Collins and some sympathy must be directed his way.

He, like all Air New Zealand pilots was trained for commercial transport ops. Extrapolating this to commercial sightseeing ops in Antarctica with only an afternoon's training defies belief. As does the perception that these flights were so routine, that the requirement for previous Antarctic experience could be done away with.

Simply put, the airline placed their crews in a situation where errors were more likely to occur. They simply weren't trained for what they were being asked to do.

[prospector]

Simply put, the airline placed their crews in a situation where errors were more likely to occur. They simply weren't trained for what they were being asked to do

That statement, whilst correct, is not the whole story.

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 ask advice from elsewhere, such as the RNZAF < USAF< USN or the division, wrote Bob Thomson in his History of New Zealand Antarctic research programme 1965-88

Nor did Air New Zealand take advantage of the experience gained by members of their aircrews who flew earlier flights. Apparently the NZALPA saw the Antarctic flights as a "special perk" for their members and had an agreement with Air New Zealand that flight crews should be spread widely amongst its members,

Therefor aircrews, including aircraft captains, usually had not any previous experience on these flights, an experience which would have avoided the Erebus disaster from ever happening..

Bob Thomson was not a pilot, but probably had done more flights to the Antarctic than anybody, usually in the cockpit, and at times was the commentator for Air New Zealand scenic flights to the ice.

[PapaHotel6]

That statement, whilst correct, is not the whole story.

I think we are probably in agreement here when I say the 'whole story' in relation to the Erebus incident was:

1. Pilot error.
2. Systems failures which by themselves should not have been causative.

Getting point 2 into context is where so many - including Mahon, who should have known better - have come unstuck.

Here's an analogy which I thought of. Aircraft A has some substandard work on an engine done. This causes a reduction in power, and Aircraft A has to fly slower than it otherwise would. An ATC error causes Aircraft A to collide with aircraft B. This would not have occurred had Aircraft A been flying at the normal speed.

The engineer who worked on Aircraft A made an error. Had this error not occurred, the accident would not have occurred. But did this error cause the accident, and should the engineer be responsible for it? In no way, shape or form.

And the same goes for the briefing/NAV track change/"whiteout" etc. in relation to the Erebus incident.

[slice]

PapaHotel, I have to disagree with your example in that in your scenario the failures are completely unrelated to each other (ATC and Engineering), whereas with this disaster the failures (both systemic and human) are related and cumulative. As such the organisation responsible must bear their share of the blame. Air New Zealnd's actions post accident are indicative of an organisation desperate to avoid such blame.

[PapaHotel6]

PapaHotel, I have to disagree with your example in that in your scenario the failures are completely unrelated to each other (ATC and Engineering), whereas with this disaster the failures (both systemic and human) are related and cumulative.

Yes and no. A NAV track change is unrelated (or at least, should be unrelated) to a descent from MSA and subsequent low altitude VFR flight. These errors were not related or cumulative. But persuading the general public (or Mahon, Holmes et al.) who can't see past the emotive "the aircraft was programmed to fly into a mountain" logic, is well nigh impossible.

This is where I have a problem with the oft-quoted "swiss cheese" analogy of accident analysis. It implies that all the factors, and errors (ie. holes in the cheese) are of equal causation and interrelated relevance. Whereas usually nothing could be further from the truth.

[3 Holer]

You are correct slice. Anyone who thinks differently, is either a private pilot with very little experience or has never attended Crew Resource Management/ Human Factors training.

[747-419]

Originally Posted by 3 Holer

You are correct slice. Anyone who thinks differently, is either a private pilot with very little experience or has never attended Crew Resource Management/ Human Factors training.

Agree with you 3 Holer. This accident happened nearly 40 years ago but now we have some instant experts who profess to know exactly what the cause was. Be interesting to know what aviation experience they have that they can make these profound statements.