Erebus 25 years on

[prospector]

From where does all this knowledge come from????

So our crew break out, see the dark buildings of the McMurdo base but SFA of anything else. How long do they bumble about before taking decisive action and get the hell out of there? And in which direction? No guidance on the approach plate. Once again a demonstration of an ill considered operation.

What approach plate are you referring to? There was never any approach plate because the only procedure was a cloud break procedure, there was never any intention that the flights would ever be landing at McMurdo.

The actual weather at McMurdo has been posted a number of times, the weather people advised the conditions were no good for sightseeing, so what was the point of carrying out a homegrown descent procedure to get to Scott Base anyway???

knowing from his previous plotting

Could you advise where you found anywhere that any plotting was done? if any plotting had been done then surely they would have realised they were not on the track they thought they were.

For those who castigate the man for not plotting his position, it wasn't SOP as far as I can tell, so why is it a black mark?

You need to be told to keep an accurate plot of your position????, especially before descending below MSA?

[PapaHotel6]

Megan said

Who checks the oil levels? Who does the water drains? The maintenance? Who designs the ILS approach? The crew have to accept that the people within all departments are professionals doing their tasks in a professional manner. Not to say they don't make mistakes like all of us, but they all play a role in the safe operation of our air transportation system. To expect the front seats to be the goal keepers for everybody elses mistakes is to expect far too much.

I agree, and this is where I have a problem with those who try and clinch the argument with "buck stops with the Captain" statements. Of course there are aspects of the commercial aviation infrastructure that are outside the Captain's control and quite capable of bringing down the aircraft. But here's the thing. No one ever expects the high altitude Nav track to be one of those. If they had, to the extent that a single mistyped digit could crash an aircraft, do you think the crew would have been permitted to enter the INS data manually, as was the case with TE901? No, it would've been entered with reference to a chart and triple checked as it was entered.

There's good evidence that Air New Zealand's navigation section was sloppy, and that the expected level of professionalism wasn't lived up to. Vagueness surrounding destination waypoints and arse'ing around with them isn't good. But never would it be expected to cause an accident. Slight surprise prior to commencing descent perhaps (as was the case with Capt. Simpson's flight), problems with fuel management at the absolute worst. Hitting a mountain, no.

[3 Holer]

But never would it be expected to cause an accident.

After the accident, that was also the sentiment of Air New Zealand’s navigation section, the NZ government and Ron Chippendale.

How wrong they were.

Mind you, it took no less than four extensions of the Mahon inquiry, sitting through hours and hours of sometimes, unbelievable evidence and a determined Justice Peter Mahon to prove how wrong that assumption was.

[prospector]

3 Holer,

Your slavish adherence to the Mahon report, even after it has been shown to be incorrect in many important details, by many of his peers in the legal world, and definitely by many people who have a great deal of aeronautical experience, leads me to the conclusion you must have the same amount of Aviation experience as Justice Mahon.

. Your refusal to accept what is indisputable fact is beyond belief.

This from PH6 earlier post.

I was an avid proponent of Mahon until I became a private pilot myself, studied more about the differences between high and low altitude navigation, IFR flying and more about Aviation in general and I now believe that the factors leading directly to this disaster were the fault of Capt. Collins. Other factors which have been well described were all secondary.

Perhaps the video's produced by NZALPA , and the Mahon report, influenced many people until they actually have first hand knowledge of how the system works.

[3 Holer]

NZALPA's video...............influenced many people until they actually have first hand knowledge of how the system works.

Would that include shredding documents in the navigation department, coercing people to have memory lapses, tow the company line testimony whilst under oath and altering CVR content to suit the establishment? Just to name a few. Is that “how the system works” in your world prospector?

As for your reference about Mahon’s aviation experience. As with most of your arguments on this thread, you seem to think the more aviation experience a person has, the more he is qualified to speak on this subject. Wrong, wrong, wrong again. Using your logic, if that was true, they would have appointed an aviation expert to head the Erebus Inquiry. Muldoon thought Mahon would know “how the system works” and would find in Air NZ and his government’s favour. Alas, they miscalculated Justice Mahon’s integrity (staying true to his moral and ethical principles), initiative (his proactive, resourceful and persistent approach to the accident) and his inclusion (by embracing and valuing the perspectives and contributions of all during the testimonies and investigations).
Mahon never needed any aviation experience, he knew very well how the system worked.

Finally, prospector, if as you attest,” the Mahon report has been shown to be incorrect in many important details, by many of his peers in the legal world, and definitely by many people who have a great deal of aeronautical experience”.

Why did the following occur:

In 1999 the Minister of Transport, Maurice Williamson, who worked at Air New Zealand as a corporate planner at the time of the crash, tabled the Mahon report in Parliament. Williamson argued that the time for apportioning blame was over and that he was tabling it because 'of the lessons it taught'.
On 23 October 2009 Air New Zealand CEO Rob Fyfe apologised to those affected by the tragedy for Air New Zealand's failures and for its treatment of families of the victims.

The controversy of Justice Mahon’s opinions aside, his report is most notable for its groundbreaking allocation of culpability to organisational failure. (Paragraph 393. Mahon report) This kind of conclusion was somewhat revolutionary in 1981, as identified in the chapter entitled “Erebus and Beyond” in the book Beyond Aviation Human Factors.

[PapaHotel6]

Prospector said

Perhaps the video's produced by NZALPA , and the Mahon report, influenced many people until they actually have first hand knowledge of how the system works.

It certainly did in my case. There was so much about the Mahon the report that was believable to the general public with little or no aviation knowledge.

His writings about the computer track being changed, descriptions of whiteout and romanticised writings of Collins and his infallabilty made us all feel like aviation experts. And the big company trying to shaft the little guy, the government guy (Chippindale) being a ponderous, ex- military buffoon with no appreciation of how modern aircraft functioned....... enter Vette with his *brilliant* psychological insights......Collins's lovely family..... you couldn't write better stuff.

The truth however, which has been very well described in this thread - was quite a bit more complex, and nowhere near as romantic. And, as patronising as it sounds, you do actually need a fair bit of aviation knowledge - even experience - to appreciate it, and put all the factors into the correct perspective.

[Fantome]

If ever a writer is so inspired and tackles a return to IMPACT EREBUS
then it is to be hoped he gives attention to this thread from its beginning and other forums where many conflicting views are canvassed. The unimpeachable integrity of men such as the late Justice Peter Mahon and the late Captain Gordon Vette should
be reacknowledged in any thorough appraisal of the whole disaster (and the whole saga of conflicting verdicts on Erebus which make a reappraisal all
the more fascinating.)

For instance the views of posters such as 3-holer and others of like mind seem eminently balanced and knowledgeable.

[framer]

To expect the front seats to be the goal keepers for everybody elses mistakes is to expect far too much.

I disagree. To me ( on a daily basis) it seems that is the primary role.

The crew have to accept that the people within all departments are professionals doing their tasks in a professional manner.

Again I disagree. Maybe accepting that most within all departments will do their jobs in a professional manner I could agree with. The crew have to accept, and be comfortable with, the fact that some people will not do their jobs in a proffessional manner and as a result during their career the crew will see rags left in undercarriage uplocks, cowlings left unlatched, out of date data bases loaded, correct data bases loaded with waypoint errors, poorly designed stars and approaches, ATC clearances that create traffic conflicts, banned dangerous goods loaded for flight, incorrect fuel loads uplifted, important ground handling procedures not followed etc etc.
The role of the flight crew ( among other things) is to recognise these things and deal with them in an appropriate manner, this is happening all day every day all around the world and is why Airlines won't give jet commands to people who have 500 hours. Most 19 year olds could quickly learn the stick and rudder stuff, it is this fandangled airmanship thing that can't be taught at university.

[megan]

I disagree. To me ( on a daily basis) it seems that is the primary role.

I want to fly with you framer, being so omnipotent and all. Then again, perhaps not, you thinking that you’re so good.

^^^ wtf? Don't drink and post!
p.s are you aware of what controlled airspace actually is below 60" south?

Hempy, get off the sauce man. What has controlled airspace south of 60” got to do with anything. Think you mean 60°, not that it makes any difference, but when you’re in the state you’re in I understand.

So if they were cleared to 50' it would have been fine to do so would it?

If you were idiot enough to ask for it, and someone was idiot enough to give you clearance, I guess fill your boots. Flights had flown previously at 1,500 and less, though you will always get the argument that it was OK, despite being against SOP, because it was in really, really good VMC.

But answer, if you can, why Captain Wilson was briefing crews that it was OK to go below 6,000.

You would have thought that someone who had little experience operating in this area

And there’s the rub, the crews had zip, zero, narda experience in polar operations.

Could you advise where you found anywhere that any plotting was done?

You need a little comprehension prospector. My post was quite plain, the plotting he had done the previous night. Perhaps I was not clear enough.

What approach plate are you referring to?

Ok, cloudbreak. They were never able to fly the cloudbreak procedure in IMC when the NDB was available, for the simple reason they wouldn’t have the RADAR monitoring that was demanded. As the US said, being able to provide radar monitoring was “absurd”.

Had they been able to fly the IMC cloudbreak, which they couldn’t, there was absolutely no guidance given should they find themselves in whiteout conditions ie able to see the base buildings, aircraft and vehicles on the runway, but nothing else. Scramble back to the MSA, after spending whatever time it would take to realise the predicament they were in, of which they have zero experience, and what escape route to take?

By a poster on another thread.

Descent below the LSALT of FL160 had to be made in VMC as you say. What advantages accrue from specifying the VMC descent to be made in the stipulated sector overhead McMurdo? Assuming the descent was made in the sector and did not go below 6,000 what weather parameters ruled operations from that point on? 7,000 foot overcast permissible? At no time were the operations immune from whiteout, the point of impact would just be 4,500 feet higher, that’s all. It matters not in the scheme of things (to my mind) where the descent is made if being made in VMC conditions. And there is no evidence that the aircraft was in anything but VMC from FL160 right up to the point of collision. The argument that the other aircraft had gin clear conditions is moot, VMC is VMC, you either are or you aren’t. The only problem being the crews had no business to be tooling around in VMC due to a complete lack of both experience and training. Had the flights continued in the manner in which they were being conducted it was just a matter of time before someone stubbed their toe. And it would not have been the crews fault, however much the apologists for management duck and weave.

With VMC flight we can imagine the aircraft as being at the centre of a bubble or sterile area, that is, a minimum height above ground or cloud, a minimum height below cloud, and a minimum distance horizontally from cloud or ground. All of that is achieved by estimation with the Mk. 1 Mod. 0 eyeball (the V in VMC). That pre-supposes that you do not need to know where you are, since any obstacle, it is assumed, will be seen. Normal obscuration’s to our vision are caused by such phenomena as smoke, dust, mist, fog, cloud or precipitation. Both the cause and degree of obscuration is easily discernible. That is a pilots real world experience, but there are always exceptions and caveats. The exception and caveat in this case is EXCEPT IN POLAR REGIONS. Mention has been made that other flights were made on gin clear days. Maybe so, but even in such conditions you may still very well fall afoul of the tricks of light and depth perception unique to polar operations. There is good reason the US military, in their wisdom, required crewmembers to have made three familiarisation flights to the ice before embarking on the adventure themselves.

There is a reason some operators do not permit VMC operations over the ice/snow when an overcast is present.

Collins let corporate pressure influence him and a false sense that his prior experience enabled him to justify the decisions he made on the day. Any commander has the right to operate outside of the SOPs as he sees fit, if and when required for the safety of his passengers and aircraft. In this instance Collins operated well outside the SOP for no justifiable reason and the accident occurred.

Amen to what you say. Except, it was the norm not to follow SOP on the Antarctic flights, and he may very well have been influenced by the actions of those who went before. The “Normalisation of Deviance” part. Couple that with the lack of adequate training, the failures of the nav department, briefings that didn’t comply with the SOP, failure to provide McMurdo with a copy of the now changed flight plan putting the aircraft over the top of Erebus, to which they would have objected. Had they known it was planned over Erebus the inference given is that the aircraft would have been cleared by a route clear of the mountain. What a missed opportunity.

Had the pilots done their own flight planning, and not relied on the nav dept, things may have been different.

All those bloody cheese holes. When applying Prof. Reason’s Swiss Cheese model to this accident there are so many holes as to lead one to believe that insufficient cheese remains to sustain one mouse for one day.
The operation was such a disordered mess that an accident was inevitable. Only three questions need to be asked,

When

Where

To whom

As Chippendale said,

There was no explanation of the horizon and surface definition terms in the operators’ route qualification briefing or pre flight dispatch planning, and only a passing reference to whiteout conditions.

The operator had not ensured that all significant information was included in the route qualification briefing and presented in an unambiguous manner.

As a result of questions put to some of the pilots of earlier Antarctic flights it was obvious that misconceptions were held about the minimum altitude to which the aircraft was permitted to descend in VMC and the actual topography below the flight planned track from Cape Hallett to McMurdo.

You need to be told to keep an accurate plot of your position????, especially before descending below MSA?

Chippendale had a comment about that. No one was plotting topography against INS, it took 14 months to detect the cockup.

The fact that a computer error of over 2° of longitude to the west could exist for 14 months indicates there was no regular valid comparison between the topography and the geographical co-ordinates by flight deck crews.

Last word by a young lady.

Janine Marsden-Brown, January 9th, 2005 at 6:47 am

On a very personal note, I would like to say that I do not believe it was pilot error, I believe it was one bad mistake after another leading to a catastrophe. I think the pilots did exactly what was expected of them and ANZ did pressure pilots to make it a fanastic scenic flight. ANZ tried to whole-heartedly blame the pilots from day 1 until the information about the flight data turned up.

After losing both my parents in the Erebus crash I have complete contempt for the way Air New Zealand handled the situation. Although I was only 16 at the time, I read every piece of information about the crash and every book that was written. Air New Zealand treated my 2 brothers and I with complete disrespect, it took 5 years, a team of lawyers and the NZ victims families had to form a consortium before we got any settlements. Since then several overseas people told me that ANZ settled with them a few months after the crash.

25 years later all I can say is I hope ANZ learned something from their mistakes of the Erebus crash.

[Hempy]

Originally Posted by megan

Hempy, get off the sauce man. What has controlled airspace south of 60” got to do with anything. Think you mean 60°, not that it makes any difference, but when you’re in the state you’re in I understand.
Quote:
So if they were cleared to 50' it would have been fine to do so would it?

Sorry, my phone doesn't give me flash 'degrees' symbols, but regardless...Flights over McMurdo, whilst in the NZ FIR, are the responsibility of the USN. Controlled Airspace ends at FL195, the rest is Class G. So your 'clearance' below A060 signifies your lack of knowledge.

p.s re: framer. Given what you've written, I wouldn't fly with you if you were the 2nd last pilot on the planet (making the massive assumption that you aren't a Walt..)

[Fantome]

MEGAN . . . I for one take hat off as you have shown a fine grasp of the myriad of conflicting and technical elements right across the board.

That last quoted post from Janine Marsden-Brown adds a necessary plaintive voice . .. .one that serves perfectly to remind us never to forget the deep personal toll that marked for so many a grief beyond comprehension.

[megan]

So your 'clearance' below A060 signifies your lack of knowledge.

Really?

For the purpose of flights to the Ross Dependancy civilian operators accept the USN and FAA ATC procedures utilised by military aircraft as mandatory.

Promulgation of radio navigation information at McMurdo was the responsibility of the USN who installed, calibrated and maintained in accordance with TERPS. This manual was standard for the FAA, USAF, USN, US Army and the US Coast Guard. However, because of the special nature of the operations in Antarctica the aids and ATC procedures were installed specifically for the Antarctic Support, Operation Deep Freeze aircraft. Promulgated procedures are intended for use by Operation Deep Freeze aircraft only, others may use at their own risk.

Perhaps you can fill us in with the relevant USN and FAA procedures applying at McMurdo at the time. The airline was not aware of the procedures in place at the time.

[Hempy]

Could someone please remind me again as to what ICAO says the PIC is responsible for? Some people here seem to have forgotten (or never learned....)

[framer]

I want to fly with you framer, being so omnipotent and all. Then again, perhaps not, you thinking that you’re so good.

Address the point of the paragraph Megan rather than trying to deflect with childish insults. I made a good point

left in undercarriage uplocks, cowlings left unlatched, out of date data bases loaded, correct data bases loaded with waypoint errors, poorly designed stars and approaches, ATC clearances that create traffic conflicts, banned dangerous goods loaded for flight, incorrect fuel loads uplifted, important ground handling procedures not followed etc etc.
The role of the flight crew ( among other things) is to recognise these things and deal with them in an appropriate manner,

and your reaction is to deflect.

[prospector]

Megan,

You need a little comprehension prospector. My post was quite plain, the plotting he had done the previous night. Perhaps I was not clear enough.

I initially thought that was what you meant. Then I thought surely not, of what point is plotting your position on a school atlas prior to the flight relative to deciding to go below MSA without knowing precisely your position.

It is not as if it would have been any hardship, there was a readout right above their heads with continually updated Lat and Long. To transfer that to a chart would be a very simple matter.
The lack of any meaningful effort to establish exactly their position prior to descent below MSA means one has to agree with Bob Thomson's comments that this crew thought "they were on a Sunday drive".

for the simple reason they wouldn’t have the RADAR monitoring that was demanded. As the US said, being able to provide radar monitoring was “absurd”.

What rubbish, try to stick to established known reported fact. I quoted in a previous post, from Gordon Vette's "Impact Erebus" that the radar could be switched to surveillance mode, and it was in that mode , it was well capable of monitoring the approved descent as promulgated to this crew prior to departure.

Had they been able to fly the IMC cloudbreak, which they couldn’t, there was absolutely no guidance given should they find themselves in whiteout conditions ie able to see the base buildings, aircraft and vehicles on the runway, but nothing else. Scramble back to the MSA, after spending whatever time it would take to realise the predicament they were in, of which they have zero experience, and what escape route to take?

Once again completely wrong. The weather report they received was well below condition required for any descent, and they were even advised that the area was no good at all for any sightseeing. All this information is available in relevant publications. Would suggest you avail yourself of this information.

As the US said, being able to provide radar monitoring was “absurd”.

From where did you glean that information??

Here again is the actual weather at the relevant time, you will note that Ross Island is reported as being completely obscured by cloud, not sector whiteout, cloud. You will also note, or perhaps not, that the cloud cover at McMurdo was total at 3,500, how could any descent be commenced that was limited to 6,000ft?

Weather at the McMurdo area at the time of the disaster was reported to be completely overcast at 3,500ft with other cloud layers above, and a wind of 10 knots. Mountain tops in the area were covered in cloud and although the surface visibility was good surface definition was poor and horizon definition only fair because the sun was obscured and snow surface features could not be readily identified from close up. Other aircraft in the area reported Ross Island as being completely obscured by cloud, and the crew of a helicopter which landed at Cape Bird Hut, 35 kilometres from the crash site and only an hour later, said it was overcast art 1,500ft with light snow Shortly afterwards they landed on the beach 10 kilometres from the site, in snow flurries and deteriorating conditions which made them cut short their

visit

Now please advise how you think any descent was justified,? yes it was a sightseeing flight, but the pax had been advised if weather conditions were not suitable they would go to an alternate area. The crew's ultimate job was to get the pax back home again, safe and sound, if they missed their sightseeing through weather the company could not be held accountable for that. It was always a possibility, and I would be quite certain they would rather have missed Scott Base and got home again.

[PapaHotel6]

The lack of any meaningful effort to establish exactly their position prior to descent below MSA means one has to agree with Bob Thomson's comments that this crew thought "they were on a Sunday drive".

Nor was the descent procedure discussed amongst the crew in any meaningful way, they didn't discuss terrain clearance and never mentioned Mt Bird that that they easily could have hit if they had been where they thought they were. They simply saw a cloud break and down they went.

[Fantome]

In any open forum discussing the finer points my money's on Megan every time. Not that that means diddly-squat.

if they missed their sightseeing through weather the company could not be held accountable for that. It was always a possibility, and I would be quite certain they would rather have missed Scott Base and got home again.

….. as one of his harsher critics espouses. " rather have missed Scott Base and got home again. " .. . . Yep. . . you're probably right there in your certainty that they'd want to get home again . . .. seems a reasonable proposition as opposed to having your mortal remains strewn across the bleak and lonely face of Erebus.

[3 Holer]

PapaHotel6 states:

Nor was the descent procedure discussed amongst the crew in any meaningful way, they didn't discuss terrain clearance and never mentioned Mt Bird that that they easily could have hit if they had been where they thought they were. They simply saw a cloud break and down they went.

How do you know the descent procedure wasn't discussed?

[PapaHotel6]

How do you know the descent procedure wasn't discussed?

Because of something called the CVR - that stands for "Cockpit Voice Recorder". Of course, it's possible they held said discussion in whispers, or sign language, or by passing notes to each other; but I don't think so.

[3 Holer]

So are you now assuming the descent procedure was only discussed in the 30 minutes prior to impact ?