Erebus 25 years on
Whispering "T" Jet
IRREFUTABLE FACT:
Mahon observed that ‘the occurrence of any accident was normally due to the existence of a variety of factors’. He asserted that in this case there were 10 factors; the disaster would not have occurred had any one of them not been present. But he then went on to describe a single cause of the disaster:
In my opinion therefore, the single dominant and effective cause of the disaster was the mistake made by those airline officials who programmed the aircraft to fly directly at Mt Erebus and omitted to tell the aircrew. That mistake is directly attributable, not so much to the persons who made it, but to the incompetent administrative airline procedures which made the mistake possible.
He disagreed with Chippindale’s ‘probable cause’ that the pilot was at fault, and cleared the crew of any responsibility for the accident. The blame lay squarely with Air New Zealand.
Mahon observed that ‘the occurrence of any accident was normally due to the existence of a variety of factors’. He asserted that in this case there were 10 factors; the disaster would not have occurred had any one of them not been present. But he then went on to describe a single cause of the disaster:
In my opinion therefore, the single dominant and effective cause of the disaster was the mistake made by those airline officials who programmed the aircraft to fly directly at Mt Erebus and omitted to tell the aircrew. That mistake is directly attributable, not so much to the persons who made it, but to the incompetent administrative airline procedures which made the mistake possible.
He disagreed with Chippindale’s ‘probable cause’ that the pilot was at fault, and cleared the crew of any responsibility for the accident. The blame lay squarely with Air New Zealand.
Thanks for being brave enough to answer the question Megan.
The fact that you think that no matter which Air NZ crew were assigned to that duty the outcome would " quite possibly" have been the same suggests to me that you and I are so far apart in our thinking and experience that we will never see eye to eye and that there is probably no gain from continuing to debate the subject.
I believe that very few Air NZ Captains of the time would have felt comfortable descending to 1500ft, clean, at 260kts, with no VHF reception, no UHF reception, and the weather that was reported at the time. You on the other hand believe that "quite possibly" all of the Air NZ Captains would have chosen to do this. To me, your position is preposterous. I'm glad you answered the question though as now it is clear to me just how differently we view the situation.
I'll now browse the report on the accident you invited me to comment on, and answer it as best I can.
Cheers.
The fact that you think that no matter which Air NZ crew were assigned to that duty the outcome would " quite possibly" have been the same suggests to me that you and I are so far apart in our thinking and experience that we will never see eye to eye and that there is probably no gain from continuing to debate the subject.
I believe that very few Air NZ Captains of the time would have felt comfortable descending to 1500ft, clean, at 260kts, with no VHF reception, no UHF reception, and the weather that was reported at the time. You on the other hand believe that "quite possibly" all of the Air NZ Captains would have chosen to do this. To me, your position is preposterous. I'm glad you answered the question though as now it is clear to me just how differently we view the situation.
I'll now browse the report on the accident you invited me to comment on, and answer it as best I can.
Cheers.
Whispering "T" Jet
framer says:
Forecast at McMurdo prior to descent. Cloud base 4000 feet and viz 40 miles.
From CVR:
1.Aircraft 6000 descending to 2000 and in VMC.
2.There are no less than 13 references made by one pilot to the other confirming that the aircraft was flying VMC.
I knew a few Captains in my outfit that would prefer to do ILS approaches in CAVOK conditions rather than a visual approach. Fair enough, whatever you are comfortable with. No problem descending to 1500 feet with those conditions forecast from my point of view, but yourself and those "very few Air NZ Captains of the time" that wouldn't, no problems. We should all know our limitations and respect them.
and the weather that was reported at the time.
From CVR:
1.Aircraft 6000 descending to 2000 and in VMC.
2.There are no less than 13 references made by one pilot to the other confirming that the aircraft was flying VMC.
I knew a few Captains in my outfit that would prefer to do ILS approaches in CAVOK conditions rather than a visual approach. Fair enough, whatever you are comfortable with. No problem descending to 1500 feet with those conditions forecast from my point of view, but yourself and those "very few Air NZ Captains of the time" that wouldn't, no problems. We should all know our limitations and respect them.
Guest
Posts: n/a
Why I ask that question
:
Surely the written orders after the verbal briefing has precedence??
As has been posted many times, the crew knew of this requirement, a copy was found in the cockpit wreckage.
Nobody has yet explained why it was that trained, experienced Met observers, and crews of other aircraft operating in the same area, reported that Ross Island was completely obscured by cloud, and that the weather for sightseeing was completely unsuitable, well below the minimums required for the approved descent, so why was it even attempted? commercial pressure has been forwarded, but since when has commercial pressure overruled good sense?
And after all this well known, indisputable fact, can anyone say this crew made no errors?
I know many people who have never sat in the sharp end of an aeroplane digest Mahon report as gospel, but it has many holes in his reasoning, one that stands out is the use of the WX radar in mapping mode. Other pilots doing this flight have stated that Ross Island showed up very well. Mahon comes up with some theory of dry ice giving no returns. But as is shown in the photo's of the land that the crew failed to identify correctly, the ice was surrounded on the seaward side by many large patches of bare rock. . These would certainly have shown up if the radar had of been used in mapping mode.
The Approach radar at 6,000ft. The radar could be switched to surveillance mode and that would have picked them up within a few minutes if they had of maintained MSA for a few more miles, even on the track over Mt Erebus.
6,000ft minimum descent was a strict CAA rule when approving these flights. I very much doubt anyone could say an invitation to descend to 1,500ft by an Air Traffic Controller could in anyway overrule this CAA requirement.
Captain Wilson confirmed that during his briefings given in 1978 and 1979 crews were told that they could descend to any height authorised by the USN Air Traffic Controller.
Delete all reference to briefing dated 23/10/79. Note that the only let down procedure available is VMC below FL160(16,000ft) to 6,000ft as follows
Surely the written orders after the verbal briefing has precedence??
As has been posted many times, the crew knew of this requirement, a copy was found in the cockpit wreckage.
Nobody has yet explained why it was that trained, experienced Met observers, and crews of other aircraft operating in the same area, reported that Ross Island was completely obscured by cloud, and that the weather for sightseeing was completely unsuitable, well below the minimums required for the approved descent, so why was it even attempted? commercial pressure has been forwarded, but since when has commercial pressure overruled good sense?
And after all this well known, indisputable fact, can anyone say this crew made no errors?
I know many people who have never sat in the sharp end of an aeroplane digest Mahon report as gospel, but it has many holes in his reasoning, one that stands out is the use of the WX radar in mapping mode. Other pilots doing this flight have stated that Ross Island showed up very well. Mahon comes up with some theory of dry ice giving no returns. But as is shown in the photo's of the land that the crew failed to identify correctly, the ice was surrounded on the seaward side by many large patches of bare rock. . These would certainly have shown up if the radar had of been used in mapping mode.
that the approach radar would be unable to pick them up above 6000 feet. On previous flights the approach had been largely clear of cloud and, as a sure aid, the feed in had been attained by using McMurdo’s NDB (Non-Directional Beacon) to bring them into the orbit of the precision approach radar, at 6000 feet.
6,000ft minimum descent was a strict CAA rule when approving these flights. I very much doubt anyone could say an invitation to descend to 1,500ft by an Air Traffic Controller could in anyway overrule this CAA requirement.
Capt Mayne Hawkins who stated "I was in no doubt at the briefing that the lower limit was 6,000ft. The weather on my flight was perfect, with clear skies and 100 miles of visibility. Ice tower asked me for a low run, but I kept to 6,000ft.
If there'd been the slightest doubt in my mind I would have been down there with the best of them. I was a ground attack pilot for five years flying Vampires, Venoms and Meteors in Cyprus, the Middle East and Singapore, so I knew what I was doing.
If there'd been the slightest doubt in my mind I would have been down there with the best of them. I was a ground attack pilot for five years flying Vampires, Venoms and Meteors in Cyprus, the Middle East and Singapore, so I knew what I was doing.
I believe that very few Air NZ Captains of the time would have felt comfortable descending to 1500ft, clean, at 260kts, with no VHF reception, no UHF reception, and the weather that was reported at the time. You on the other hand believe that "quite possibly" all of the Air NZ Captains would have chosen to do this.
We all know why they were not where they thought they were. There can be no doubt whatever that Justice Mahon and Captain Gordon Vette spent many many hours and days and nights agonising is not too strong a word, over a reconstruction of events based on hard evidence. Nobody had a better handle on the facts. Yet thirty-seven years later the revisionists and the knockers are thick at the door. Mahon, Vette, Chippendale, Davis all are now deceased. And yet in some ways it seems the ashes still are warm. Perhaps a little R.I.P. would not be out of place. And for all those souls lost that fateful day no expression of empathy for their families will ever begin to touch the surface.
Last edited by Fantome; 20th Jun 2016 at 13:04.
Guest
Posts: n/a
We all know why they were not where they thought they were.
Surely that is all the debate is about, that this crew should shoulder some of the responsibily for the disaster? If as Mahon says they made no error, then surely that puts all the error on other people. They also made mistakes, but those mistakes could have been corrected if astute airmanship had of been exhibited by the crew.
COMPLETE HONESTY
Hand on heart, with total honesty, and after 20,000 plus hours, 14000 hours as PIC on heavy jets, 4000 plus hours as a simulator/line/base/ground instructor, TRE TRI etc bits-of-paper in my Navbag, almost 40 years as an AIRLINE PILOT, .......I HAVE NEVER EVER MADE A SINGLE MISTAKE, NEVER EVER!......
Hand on heart, with total honesty, and after 20,000 plus hours, 14000 hours as PIC on heavy jets, 4000 plus hours as a simulator/line/base/ground instructor, TRE TRI etc bits-of-paper in my Navbag, almost 40 years as an AIRLINE PILOT, .......I HAVE NEVER EVER MADE A SINGLE MISTAKE, NEVER EVER!......
Impressive pedigree, but would you not have reprimanded any body who commenced a descent below MSA, as this crew did, just because they thought they knew where they were??
Fantome, that was a very big edit, just as well I copied that pedigree first.
.
Last edited by prospector; 20th Jun 2016 at 09:31.
Join Date: Feb 2008
Location: New Zealand
Age: 64
Posts: 523
Likes: 0
Received 0 Likes
on
0 Posts
megan's #839 continues with another irrelevant reference to something Chippendale says, but continues on to misquote the evidence. It is said that the audio contained a reference "to McMurdo", the suggestion being that that phrase could include a location 20 miles to the west of McMurdo Station. Let's look at the precise wording. If Megan can be bothered, it's in Exhibit 12: " A standard route definition will be used employing the From-Via-To Format. Enter NZAA 79S/167E this being the approximate co-ordinates of McMurdo Station."
They then went into the simulator, which was programed by F/O Cassin using an old flight plan. After the simulator was used to practise the change to grid navigation, it was then repositioned to overhead the final waypoint to practise a cloud-break procedure. So where did it end up? Overhead McMurdo Station, or 20 miles west. Answer: Overhead McMurdo Station.
There is absolutely no doubt that every pilot who attended the briefing believed that the final waypoint was at McMurdo Station, hence Captain Simpson's surprise when he found that it wasn't.
What about all the evidence from other pilots saying that they didn't think the route went over Erebus and thought it would be to their left? There is nothing inconsistent in that. Note that the only map they had was a photocopy of the inset to NZMS135, which didn't include Cape Hallett - so they could not picture a line from Cape Hallett to McMurdo Station. They all believed the waypoint was at McMurdo Station, but thought that a route to that point would take them down the Sound with Erebus to the left.
They then went into the simulator, which was programed by F/O Cassin using an old flight plan. After the simulator was used to practise the change to grid navigation, it was then repositioned to overhead the final waypoint to practise a cloud-break procedure. So where did it end up? Overhead McMurdo Station, or 20 miles west. Answer: Overhead McMurdo Station.
There is absolutely no doubt that every pilot who attended the briefing believed that the final waypoint was at McMurdo Station, hence Captain Simpson's surprise when he found that it wasn't.
What about all the evidence from other pilots saying that they didn't think the route went over Erebus and thought it would be to their left? There is nothing inconsistent in that. Note that the only map they had was a photocopy of the inset to NZMS135, which didn't include Cape Hallett - so they could not picture a line from Cape Hallett to McMurdo Station. They all believed the waypoint was at McMurdo Station, but thought that a route to that point would take them down the Sound with Erebus to the left.
Last edited by ampan; 20th Jun 2016 at 20:26.
ampan, all you need do is look at the flight plan that was included with the briefing. It calls the point down in the bottom of the sound, 27 miles away from the real McMurdo, McMurdo. So the audio mentioning only reinforces the flight plan positioning of "McMurdo", particularly in light of the fact that the maps indicate tracking to the false "McMurdo" position as well.
One wonders why there was no leg on the flight plan from the false McMurdo to the real McMurdo in the event they needed to make an IMC descent in the earlier flights. Could it be because the nav dept had absolutely no idea where the false McMurdo was placed?
So you need to answer why Captain Wilson in his briefings told crews they could go below 6,000. I have no idea of the reason, and I doubt you do either.
One wonders why there was no leg on the flight plan from the false McMurdo to the real McMurdo in the event they needed to make an IMC descent in the earlier flights. Could it be because the nav dept had absolutely no idea where the false McMurdo was placed?
6,000ft minimum descent was a strict CAA rule when approving these flights. I very much doubt anyone could say an invitation to descend to 1,500ft by an Air Traffic Controller could in anyway overrule this CAA requirement.
Join Date: Feb 2008
Location: New Zealand
Age: 64
Posts: 523
Likes: 0
Received 0 Likes
on
0 Posts
I'm not interested in the altitude issue and the various alleged rules. Let's just say that the captain was subject to the general rules of good airmanship.
The track issue is different. The first correct statement by megan is that the nav section did not know that the final waypoint was 20 miles west of McMurdo Station. Absolutely correct. They though the waypoint was at the NDB at McMurdo Station. Captain Simpson noted the 20 mile difference and told Captain Johnson that the waypoint might be better positioned at the TACAN, which was a couple of miles away from the NDB. The nav section obliged, thinking they were only moving the waypoint from the NDB to the TACAN.
The track diagram you refer to was not in the briefing papers handed out at Captain Collins briefing. It somehow found its way into the briefing papers given to Captain McWilliams a couple of years before, and showed the military route to the Byrd reporting point followed by a left turn towards the runway at Williams Field. But the military route was designed for a landing, The Air NZ route was not. It's a complete red herring of no relevance.
The track issue is different. The first correct statement by megan is that the nav section did not know that the final waypoint was 20 miles west of McMurdo Station. Absolutely correct. They though the waypoint was at the NDB at McMurdo Station. Captain Simpson noted the 20 mile difference and told Captain Johnson that the waypoint might be better positioned at the TACAN, which was a couple of miles away from the NDB. The nav section obliged, thinking they were only moving the waypoint from the NDB to the TACAN.
The track diagram you refer to was not in the briefing papers handed out at Captain Collins briefing. It somehow found its way into the briefing papers given to Captain McWilliams a couple of years before, and showed the military route to the Byrd reporting point followed by a left turn towards the runway at Williams Field. But the military route was designed for a landing, The Air NZ route was not. It's a complete red herring of no relevance.
Join Date: Feb 2008
Location: New Zealand
Age: 64
Posts: 523
Likes: 0
Received 0 Likes
on
0 Posts
I don't think a red herring can ever be relevant, by definition (unless the captain had a dinner of rotten fish the night before, which might explain his performance.)
Whispering "T" Jet
ampanyour last post have raised some prudent points.
– some of the previous operating crews appear to have accepted that culture.
– but they never bothered to check the new track was straight at Mt Erebus.
– how does that happen in a professional airline?
. – I would respectfully suggest that there was a lot of relevance especially to the 257 victims of this terrible tradgedy.
So it remains, undisputed,Mahon’s profound statement .........................” the incompetent administrative airline procedures which made the mistake possible”
I'm not interested in the altitude issue and the various alleged rules
The nav section obliged, thinking they were only moving the waypoint from the NDB to the TACAN.
somehow found its way into the briefing papers given to Captain McWilliams a couple of years before.
The Air NZ route was not. It's a complete red herring of no relevance
So it remains, undisputed,Mahon’s profound statement .........................” the incompetent administrative airline procedures which made the mistake possible”
Megan: I have had a quick read of the American DC-10 report that you referred to, and since you asked for my take on it I'll give it although I don't see it as being particularly relevant to this thread.
I think there were three causal factors at an Industry level, two at an organisational level, and one at an operational level. None of the causal factors I identified during my amateur assessment involved the flight crew.
My assessment of the causal factors wouldn't be any more valid than the next airline captains but, my opinion on the responsibilities of command is probably as valid as the next guys and this is what I have been offering.
You chaps make quite a show about " those who like to lay blame" and the " knockers" and the " revisionists" etc but you miss the gist of what most here are saying. It is not that Collins is the one to blame, it is that he is not free of responsibility.
The judgement and decision making of the crew who lost the engine on departure isn't in question whereas the judgement and decision making of Collins is.
Anyway, have a good day and don't forget how much responsibility is on your shoulders next time you operate, it helps with making decisions considerate of risk.
I think there were three causal factors at an Industry level, two at an organisational level, and one at an operational level. None of the causal factors I identified during my amateur assessment involved the flight crew.
My assessment of the causal factors wouldn't be any more valid than the next airline captains but, my opinion on the responsibilities of command is probably as valid as the next guys and this is what I have been offering.
You chaps make quite a show about " those who like to lay blame" and the " knockers" and the " revisionists" etc but you miss the gist of what most here are saying. It is not that Collins is the one to blame, it is that he is not free of responsibility.
The judgement and decision making of the crew who lost the engine on departure isn't in question whereas the judgement and decision making of Collins is.
Anyway, have a good day and don't forget how much responsibility is on your shoulders next time you operate, it helps with making decisions considerate of risk.
Join Date: Feb 2008
Location: New Zealand
Age: 64
Posts: 523
Likes: 0
Received 0 Likes
on
0 Posts
Don't include me in the 'measured and reasonable' group. I lay the blame on the captain. Were it not for his appalling series of errors, the co-ordinateswould not have mattered.
Join Date: May 2016
Location: Auckalnd
Posts: 154
Likes: 0
Received 0 Likes
on
0 Posts
A couple of own-goals from 3-Holer from this page alone.
They were amusing at first, but like any oft-repeated jokes, have started to run dry. Please think before you post.
Very succinctly put Framer.
IRREFUTABLE FACT:
Mahon observed
Mahon observed
So it remains, undisputed,Mahon’s profound statement
You chaps make quite a show about " those who like to lay blame" and the " knockers" and the " revisionists" etc but you miss the gist of what most here are saying. It is not that Collins is the one to blame, it is that he is not free of responsibility.
Join Date: May 2016
Location: Auckalnd
Posts: 154
Likes: 0
Received 0 Likes
on
0 Posts
I lay the blame on the captain. Were it not for his appalling series of errors, the co-ordinateswould not have mattered
To which I reply this.
The navigation department does work of crucial operational importance. But it takes a big leap of imagination to connect a professional failure in the promulgation of the high altitude NAV track to collision with terrain at 1500'. But VFR rules, and MSA rules are basic rules of airmanship and flight, and it takes no imagination whatsoever to understand how violation of those would lead to tragedy.
Hence the biggest professional failure was that of Collins.
Join Date: Feb 2015
Location: North Up
Posts: 489
Likes: 0
Received 0 Likes
on
0 Posts
They all believed the waypoint was at McMurdo Station, but thought that a route to that point would take them down the Sound with Erebus to the left.
It is what was in the heads of the crew which led to disaster.
That mental model had been set up by the airline and to a lesser extent by the CAD. That is why the prime responsibility rests with the airline management and its overseer.
The fact that the crew members were hopelessly inexperienced in the task at hand and their training was woefully inadequate compounds the culpability.