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Erebus 25 years on

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Old 26th Jun 2016, 16:15
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Where the aircraft went was determined by the captain, not by the AINS, so if any captain shared your concerns, then don't go there, or punch in an offset, moving the track west. The AINS was not like a ground aid. it's purpose was to get from one side of the Pacific to the other, and it did a great job of that. It was not to be used for landings or other descents below MSA, because it could be wrong. Apart from the usual drift, it required human inputs at various stages, leaving room for mistakes, and that's exactly what happened. Captain Collins knew all of this. When he got the bad weather report, there was no talk of going down anyway using the AINS - he was going to go elsewhere. Then he got the offer of the radar-assist - a ground aid, independent of the AINS - and he gratefully accepts the offer and announces it to the passengers. The minutes pass and they are unable to make contact with the radar operator on VHF, so the obvious response was to go elsewhere, but instead, we get this unannounced inexplicable figure of eight descent while pretending to be VMC. I don't see any point in 3 Holer trotting out quotes from Mahon, because Mahon was an idiot.
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Old 26th Jun 2016, 19:09
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Ampan's post above is almost completely composed of facts, not summation, or opinion, and it describes precisely why the prime cause of this accident was pilot error. Collins also made other errors which ampman doesn't mention - such as descending from 2000' to 1500'.

The only assumption ampan makes above is that they were "pretending to be VMC". Lets look at that for a moment.

There was a hell of a lot of cloud around. Ross island to the south was a wall of cloud from high altitude - we know this from the reports, and also because Erebus wasn't seen at any time during the descent. We also know Collins rearmed the INS several times during the descent. Never did he mention Mt. Bird (which should have been very close to where he thought he was) - either because he had zero awareness of the surrounding topography; or because he did not expect to see it - which can only be because there was cloud around. I don't think I've *ever* been in conditions like this where I could somehow have descended from 16,000' to 1,500' and been VMC the whole way.

Is it possible Collins had true VMC conditions at all times during the descent? Yes. Is it likely? I don't think so. I think all the evidence is against it - including the fact the words "VMC" were repeatedly mentioned.

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Old 27th Jun 2016, 01:41
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Here's a good example of Mahon's sheer pig-headedness: He was not thrown in the deep end re aviation. The taxpayer paid for an aviation expert to assist Mahon: Sir Rochford Hughes. Sir Rochford identified the descent without a radar fix as a clear-cut error requiring that the crew receive some, but not most, of the blame. Mahon completely ignored what Sir Rochford had to say and never even referred to the subject - which is what people tend to do with something to which they have no answer.
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Old 27th Jun 2016, 05:59
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Mahon was an idiot
I don't agree, there were elements he didn't understand, certainly. The first class idiots, who stood head and shoulders above any others, resided in the airline executive.
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Old 27th Jun 2016, 07:18
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PapaHotel6 and ampan. You two should hook up together as a comedy act, your last couple of posts could beat anything Dean Martin and Jerry Lewis ever put together. Those posts were really funny in a pathetic sort of way.

When you both stop being silly, I'll re-enter the debate.
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Old 27th Jun 2016, 10:23
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Originally Posted by 3 Holer
PapaHotel6 and ampan. You two should hook up together as a comedy act, your last couple of posts could beat anything Dean Martin and Jerry Lewis ever put together. Those posts were really funny in a pathetic sort of way.

When you both stop being silly, I'll re-enter the debate.
That sounds like the too cool for school version of 'taking my bat and ball and going home'.

The difference between your side of the argument and the general consensus, 3 Holer, is that whilst the consensus admits that other parties were just as responsible for placing some holes in the Swiss cheese that led to that accident as the crew were; you argue that the crew were responsible for no holes at all!

What have you learned from that accident? To always crosscheck your indicated position against a chart when descending below the height of a mountain nearby that you should be able to see but you can't? Or that if you find yourself in a position where you are required to descend below the height of a mountain that is nearby that you can't see, you should follow the approved procedures and stay at a safe altitude until your position is fixed by a ground based navigation aid located on the 'safe side' of the nearby mountain, that you can't see..?
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Old 27th Jun 2016, 19:55
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the consensus admits that other parties were just as responsible for placing some holes in the Swiss cheese that led to that accident
I hate the Swiss Cheese model of accident causation. It's rattled off as though it explains everything, as if it's some cunning piece of insight when in actual fact it's pretty trite. It also doesn't differentiate between relative degrees of causation, or the relevance of the individual 'slices. Wikipedia says " it has been subject to criticism that it is used over broadly". And how.

The AINS was a "slice of cheese" with a hole in it - the "hole" being the vagueness and confusion surrounding the destination waypoint. But this was a slice of cheese that should never have been in the deck in the first place. Collins placed it in there by not independently verifying his position prior to descent then subsequently using the AINS during the descent in a way it was never intended.
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Old 28th Jun 2016, 00:43
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I hate the Swiss Cheese model of accident causation. It's rattled off as though it explains everything, as if it's some cunning piece of insight when in actual fact it's pretty trite. It also doesn't differentiate between relative degrees of causation, or the relevance of the individual 'slices
The swiss cheese model is a very good one, and not at all trite. You are quite correct though in that it doesn't differentiate between the relative elements, because removing any one of the elements might presumably remove an opening for the accident occurrence.

Imagine if the nav dept had gone to the trouble of plotting the waypoint on a map. Collins is castigated for not plotting his position, but we have a gentleman sitting in an office, with presumably all the time in the world, and he does nothing to check the data that he is entering/typing. What might have been the outcome if he had entered the correct co-ordinates?

What might have been the outcome if the "Ops Flash" at the top of the flight plan had the message "McMurdo co-ordinates changed"? Would the crew have said to themselves, "I wonder where the new McMurdo is?", and then gone to the trouble of plotting the position?

Then again, when the 27 mile discrepancy was reported, no one had the intellectual curiosity of resolving the issue. Not helped by the fact that the airline was run on the basis of phone calls, and not documentation. It would seem that there might not have been a safety reporting system in place, and if there was, it certainly was not used to report the discrepancy.

For what purpose does the nav dept exist, if not to provide information crews can supposedly rely upon? Had the flight planning been left to the crew, they would have got out the RNC chart, followed the relevant tracks to Byrd, thence the real McMurdo, for the company proscribed cloud break procedure. The real question is, why didn't the airline follow the route that had been surveyed by experts, and published for industry use? And why the stupid cloud break procedure, which had half (grid north east sector) of the designated area at 16,000 positioned in the radar cone of silence (the reason the controllers called the procedure "absurd"), when an NDB approach was available (prior to it be taken down)? Hells bells, had the airline actually talked to the Americans (which they never did), the radar might have been organised to actually monitor a descent inbound from Byrd to McMurdo, to whatever altitude the airline/authorities desired to set as a limit - 6,000?.

But I forgot, the airline invented aviation.
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Old 28th Jun 2016, 01:05
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The swiss cheese model is a very good one, and not at all trite. You are quite correct though in that it doesn't differentiate between the relative elements, because removing any one of the elements might presumably remove an opening for the accident occurrence.
A debate on the relevance of the "Swiss Cheese" model is probably outside the scope of this thread. Let's just say I disagree, and it predisposes to "hindsight bias" - which involves placing undue significance on factors that prior to the event should not have been relevant (like the high altitude NAV track being different to what the crew expected).

What might have been the outcome if the "Ops Flash" at the top of the flight plan had the message "McMurdo co-ordinates changed"? Would the crew have said to themselves, "I wonder where the new McMurdo is?", and then gone to the trouble of plotting the position?
Maybe. Maybe not. But provided they stayed above MSA, the worst case scenario should have been what happened on Capt. Simpson's flight.

But I forgot, the airline invented aviation.
They certainly didn't set up a bullet proof infrastructure, that's for sure. But in this whole episode - if any parties can be accused of making up the rules of aviation to suit them; it would be Collins and Mahon.
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Old 28th Jun 2016, 04:02
  #950 (permalink)  
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You disappoint me Hempy. You appear to be siding with the anti Mahon camp who, all through this debate (and the last 40 years), have been trying to insidiously introduce the pilot error card to camouflage and convince the “consensus” to reconsider Mahon’s findings.
There is not one post of mine where I have stated the crew
......were responsible for no holes at all!
The debate has always, in my opinion, been about the Chippindale v Mahon reports. Chippindale (Air NZ &Muldoon government) went too hard on the pilot error theory. Mahon was seen as being too lenient on the pilots in his summary of probable cause. However, to Mahon’s credit, he took the time to collate evidence and present it in an impartial way.
I contend and will continue to believe that, until there is any new evidence, Mahon got it 100% correct. The Air New Zealand flight department and administration section was toxic and Mahon got to the bottom of it. Para. 393 cannot be disputed and has never been proven wrong. This was (and still is) the catalyst for division between the two camps.
The MSA/low flying is rubbish and was shown to be a “smokescreen”
Myths & Facts. Erebus disaster:
The 16,000-foot safety ceiling was soon shown to be a smokescreen. Air New Zealand had claimed flights were not allowed lower than that till south of Ross Island, and that they were not allowed lower than 6000 feet at any stage. But a succession of pilots at the royal commission said they had flown as low as 1500 feet in the area with the full knowledge of the airline. They were, after all, sightseeing flights and there was not much to be seen from 6000 feet or 16,000 feet. Mr Chippindale initially upheld the height restriction claims, but in an interview in 1989, on the 10th anniversary of the disaster, he acknowledged that Air New Zealand had only made the claim to try to avoid insurance liabilities. He accepted that previous flights had also gone down low and that the airline had condoned it.
The AINS tracking argument is just another one.
All parties, please think about this:
In its 1983 decision, the Privy Council expressed the wish that everyone caught up in the Erebus conflagration would move on from it. "The time has now come for all parties to let bygones be bygones so far as the aftermath of the Mt Erebus disaster is concerned. The time for bitter feelings is over."
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Old 28th Jun 2016, 05:38
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if any parties can be accused of making up the rules of aviation to suit them; it would be Collins and Mahon
Beg once again to differ. It was the airline that made up the rules to suit themselves. Their cloud break procedure would not have passed TERPS, which governed McMurdo operations, or any other regulatory authority given to designing such procedures. Absolutely nothing about the operation could, by any stretch of the imagination, be called "professional".

Why Collins may have done what he did would require the insights of a behavioural psychologist, which unfortunately we lack. But given the airlines modus operandi, I have an understanding of why he may have done what he did - back up and see my post re VMC. As for Mahon, any misunderstanding that he may have had would arise with any judge presiding over a technical case, whether it be financial, engineering, etc. I say "would" because different people will read into, and take away their own interpretation, judges after all are human, and subject to all the frailties thereof. The trouble with communication, whether it be oral or written, is the belief that it has taken place. Mahons finding for example, I can understand from where he was coming, others don't agree, ampans trenchant criticism being a case in point. Neither of us will change the others mind.

The following was written in 1995 by David Beaty,
When the Human Factor in Aircraft Accidents first appeared in 1969, it was recognised in the Press worldwide as ‘The first major attempt to pin down the human failings that caused planes to crash.

However such human factor causes were resisted by aircraft manufacturers, airlines and the pilots themselves till the major disaster of Tenerife in 1977 when two 747s collided and 583 people perished. That caused elements of the aviation industry to begin to make tentative moves towards understanding the problem. By 1991, human factors were being researched and taught in psychology departments and airlines in Europe and America. Indeed the study and practice of aviation human factors was beginning to blossom into an industry.

Even so, there had been and still is understandable resistance to that study in that we all tend to deny making mistakes in a society that blames and demands heavy
penalties from those of us who do make them, especially ones with huge financial implications such as those resulting in an aircraft accident.

Denial is a defence mechanism that is used by our society and frequently by ourselves as individuals to ensure its and our survival. It is dangerous to go against the grain of public opinion and the opinion of our masters. We might lose our jobs. We would certainly lower the esteem in which we are held. Even Darwin hesitated for years before publishing The Origin ofthe Species because of public opinion at that time, and kept a low profile on whether our similarity to the bodily characteristics of animals might in some way and to some degree be matched by a similarity to the ways animals think and feel and react.

The age-old witch hunt to identify a scapegoat — usually the pilot — has begun to give way to the concept of the collective mistake. The practice of Cockpit Resource Management (CRM) has been tvvinned with Line Oriented Flight Training (LOFT), though even as late as 1992, only four airlines in America had integrated CRM/LOFT programmes.

Then human factor education courses have been started in some enlightened airlines. There is a human factor examination requirement in the pilot licence. joint training of flight deck and cabin crews has started, to which one or two enterprising airlines have added despatchers, ATC and maintenance staff In other words, the concept of all being in this together and all being responsible for the outcome has at last caught on. Hopefully management personnel will also be incorporated. ICAO has initiated a sustained campaign to increase awareness of the pervasiveness of human error in aviation amongst the middle and senior managers of the international aviation community particularly in some regions where there is an even lower understanding of human factors than elsewhere in the world.

What is still to be accepted is the commonality of the causes of mistakes that lead to accidents in all areas of human behaviour. Forgetting to switch the lights off
before leaving a car may result in a flat battery. Forgetting a switch on an aircraft may cost dozens of lives. Airliners continue to collide both into each other and into
the ground for similarly universal human factor reasons. There have been at least twelve Controlled Flight Into Terrain (CFIT) accidents with horrific loss of life since the beginning of 1992.

There is need to look at mistakes in a much wider context instead of in constrained and separated specialised enclaves with little communication between them. Too many separate individuals and organisations appear to be pursuing the same rabbit from different directions without realising it. Individual expertise in the different environments of air, sea, road, rail and ground are of course essential, but a connection between them and a cross-fertilisation of information on the pivot of a corporate understanding of human factors needs to be established and maintained if we are to progress deeper into the many different areas of human understanding. One such, which so far has been avoided, is how far personality is a factor in the making of mistakes — but this minefield eventually will have to be addressed.

On the positive side, the aviation industry has now begun to realise the fundamental importance of human factor understanding. Boeing has just published Accident Prevention Strategies which advances the collective mistake theory. It reasseses 232 major accidents over the ten years to 1991 and identifies 37 individual links which could contribute to an accident.

Because of its intensive supervision and testing, its vast network of information exchange, its introspection and present excellent safety record, other industries such as the medical and nuclear are coming to aviation to learn about human factors.

What is needed is the establishment and maintenance of awareness in people of the potential of human factors for both triumph and disaster. Unless there is receptiveness, all instruction will fail to penetrate deaf ears.
It seems from this thread that the last sentence is still applicable.

Amen to your final quote 3Holer.
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Old 28th Jun 2016, 06:35
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So - just so we're absolutely clear. Megan and 3-Holer - you believe Collins was blameless in this accident? That no one, without the benefit of hindsight, could reasonably expect him to have behaved differently?
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Old 28th Jun 2016, 06:59
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Some of you people don’t seem to appreciate how dirty this fight was, particularly by the union. Here is but one example, involving the critical evidence of Captain Simpson. But first, the background re the final waypoint.
The Various Waypoints:
Williams Field - IceRunway – 77’53” South; 166’ 48” East
TACAN – Hangers, Radar Operator on VHS – 77’ 52.7” South; 166’ 58” East
NDB – McMurdo Station, Radio Operator on HF – 77’ 51” South; 166’ 41” East
Dailey Islands – 27 nautical miles west of McMurdo Station –77’ 53” South; 164’ 48” East


[Date]
[Final Waypoint]
15 Feb 1977
Williams Field


22 Feb 1977
Williams Field


3 Oct 1977
NDB


1 Nov 1977
NDB


8 Nov 1977
NDB


15 Nov 1977
NDB


7 Nov 1978
Dailey Islands


14 Nov 1978
Dailey Islands


21 Nov 1978
Dailey Islands


28 Nov 1978
Dailey Islands


7 Nov 1979
Dailey Islands


14 Nov 1979
Dailey Islands


21 Nov 1979
Dailey Islands


28 Nov 1979
TACAN

On 14 November 1979 Captain Simpson attended a briefing,along with Captain Collins. One of the briefing officers, Captain John Wilson(retired), brought along four flight plans from a flight he had been on a week before. They were the flight plan for the route to McMurdo, the plan for the alternate route to the South Magnetic Pole, and the “as flown” versions of both. Of the two flight plans showing a route to McMurdo, the final waypoint was at the Dailey Islands, at 164’ East.
On 18 March 1980 Captain Simpson was interviewed byChippindale, and said this: “[Captain Wilson] had some old Flight Plans from previous years flights which he handedout for us to just look at – he didn’t have enough to give away.”
The phrase “previous years” excluded the flight plans brought to the briefing by Captain Wilson. So were there any other flight plans floating around? There was definitely one, that being the flight plan used to program the simulator, an identical version of which was later found in the wreckage. In that flight plan, from 1977, the final waypoint was the NDB at McMurdo Station.
If you’re the union lawyer, which flight plan do you want Captain Simpson to be looking at during the briefing when he forms his opinions as to the position of the final waypoint? You want him to be looking at one of Captain Wilson’s flight plans, with the waypoint 27 miles west of McMurdo Station – and you certainly don’t want the phrase “previous years”, because that included 1977.
Captain Simpson’s statement was taped, transcribed and sent to him for any corrections to be made. He then sent a photocopy to the union lawyers.They prepared a typewritten statement. When it came to the phrase “previous years flights”, they changed the wording to “a flight of the previous year”. Megan and 3 Holer might have some difficulty getting the point here, so I’ll spell it out: In the previous year, 1978, the waypoint was at the Dailey Islands, so 1978 was fine as far as the union was concerned – but 1977 was not. So this apparently minor change had the effect of locking Captain Simpson in to a position supported the union’s case.
I assume that lawyers have various rules as to how they aresupposed to treat people they call as witnesses and if that sort of behaviour is permitted by those rules then that so-called profession is even more rotten than most people think. (By the way, there are more examples of similar behaviour.)
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Old 28th Jun 2016, 08:16
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On 14 November 1979 Captain Simpson attended a briefing,along with Captain Collins. One of the briefing officers, Captain John Wilson(retired), brought along four flight plans from a flight he had been on a week before. They were the flight plan for the route to McMurdo, the plan for the alternate route to the South Magnetic Pole, and the “as flown” versions of both. Of the two flight plans showing a route to McMurdo, the final waypoint was at the Dailey Islands, at 164’ East.
On 18 March 1980 Captain Simpson was interviewed by Chippindale, and said this: “[Captain Wilson] had some old Flight Plans from previous years flights which he handedout for us to just look at – he didn’t have enough to give away.”

The above is circumstantial hearsay and can't be verified as Captain Collins is no longer with us.

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Old 28th Jun 2016, 11:11
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The absence of Captain Collins is not relevant The issue is what Captain Simpson said, before the union lawyers got their hooks into him. The whole of his original statement is at pages 354 to 362 of MacFarlane's book. The "previous years flight" phrase is at page 354. The subsequent statement prepared by the bent union lawyers is at pages 663 to 669 of MacFarlane's book, and the slight-of-hand re "previous years flight" is to be found at paragraph 5 on page 664. But it actually gets worse. One would think that the union would think that they had Simpson right where thy wanted him, committed to a 1978 flight plan with the Dailey Islands waypoint. But there was no evidence of that there was ever such a flight plan at the briefing, so that might cause an issue to erupt, which would turn the attention back to the original statement and the phrase "previous years flight". So in the final version, zinged to the captain just before he was to give his evidence, the wording was changed again: "During the briefing Captain Wilson produced flight plans from a previous flight to the Antartic for our perusal." The effect was to bring Captain Wilson's four 1979 flight plans back into the mix, but it could also include 1977, so in the unlikely event of Captain Simpson picking up on the various changes to the wording, he could be placated.
Captain Simpson knew nothing of the various flight plans and he probably began to believe that he must have been looking at a flight plan with the Dailey Islands waypoint. But when he came to be cross-examined on that point, he was politely taken to pieces by one of the Queens Counsel. If, however, he was looking at the 1977 flight plan with the NDB waypoint, every single piece of Captain Simpson's statements and evidence makes sense. Of all the witnesses who gave evidence, Captain Simpson received the worst treatment and ended up getting it in the neck from both sides. The process that led to that was begun by NZALPA.
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Old 28th Jun 2016, 13:49
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Some of you people don’t seem to appreciate how dirty this fight was, particularly by the union
Given the criminal behaviour of the airline I don't know why you give the union a kicking. Airline visited the F/Os house and removed documentation which never again saw the light of day, destruction of all original documents on file so only copies were available, break and enter into the Captains house, pages in the Captains notebook which were noted by a police officer on the ice subsequently turned up with all pages missing, the Captains and F/Os nav bags which were noted in the store at McMurdo by police disappeared never to be seen again.

Cry me a river ampan, the dirt came from the airline, not the union.
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Old 28th Jun 2016, 20:13
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Given the criminal behaviour of the airline I don't know why you give the union a kicking.
Cry me a river ampan,
WHAT????!! What credibility you had with me Megan, you've just lost. If the union lawyers manipulated a witness's statement, that is utterly abhorrent. Unethical behaviour should be viewed as such and condemned regardless of whether it supports the "side" you're on.

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Old 28th Jun 2016, 22:09
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I think the union won the dirty stakes, though I'm obviously biased. Look what the did to Captain Dalziel:


Captain Dalziel’c inititial written recollections of his nterview with Chippendale, dated 15 December 1979, before the union lawyers got involved:


“Q – Was I made aware of the terrain existing on track between C. Hallett and McMurdo?”
“A – Yes, without any doubt I was made fully aware particularly location of Erebus.”

Here’s what the union lawyers made of that:


“I do not remember getting any definite idea from the briefing as to the relationship of the route south of Cape Hallett to the topography. I knew that Mt Erebus was quite close to our track and though we would fly south down the Victoria Land coast. I remember that the audio visual presentation contained a slide with the commentary “Mt Erebus ahead” and the slide indicated to me that the aircraft would pass to the right or west of the mountain depicted in the slide. Nothing was said at6 the briefing which indicated to me that the nav track went directly over Ross Island and Mt Erebus.”

Captain Dalziel was then cross-examined by one of Air NZ’s lawyers:


“ Looking at [the initial written recollections] were you made aware of the terrain existing on the track between Cape Hallett andMcMurdo? “


“I was aware there was an area of mountainous terrain.”


“Is the answer to my question ‘yes’? “


“I think it was, wasn’t it?”


“You were made aware of the terrain existing on the track between Cape Hallett and McMurdo in the course of the briefing?”


“Yes”

Captain Dalziel, obviously, should not have read out the statement prepared for him by the union lawyers, because it wasn’t the truth, which the union lawyers knew full well. But if the document was stuck in front of him outside the hearing room just before he was to give his evidence (which is what they did to Captain Simpson) then Captain Dalziel’s behaviour is understandable.
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Old 28th Jun 2016, 22:20
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Would be nice if we could get back to debating the issues here rather than a He said/She said tirade of boring commentary. There was plenty of evidence of "witness tampering" from both sides in this saga and no one (Mahon included) gave a rats***. Stick to the facts or just agree to disagree.

Sorry to hear you have been removed from PapaHotel6's Christmas Card list for this year megan. You'll get over it - trust me.
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Old 28th Jun 2016, 22:28
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3-holer quote..."Sorry to hear you have been removed from PapaHotel6's Christmas Card list for this year megan. You'll get over it - trust me."

Mate,as serious as this debate is,and as interesting ,for those of us watching it unravel,I actually got a good laugh out of that little gem!
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