Erebus 25 years on

[56P]

Justice Mahon had a brilliant mind. Not only was he able to understand the causes of the disaster, he was also able to identify misleading and false testimony.

I still have the original video that includes live performance in the Royal Commission. If one forgets all about the causes of the crash, just ask a few simple questions.

Why was it necessary to break into the homes of the pilots?

Why was the folder of Captain Collins' diary recovered with all the pages missing?

Some outright lies were told under oath at that commission. Why was it necessary to lie? Of course, there was a cover-up!

[Kaptin M]

Thanks for a very succint summation, from a PROFESSIONAL point of view, Desert Dingo, vs ramblings of one obviously swayed by titles and types!

The tragedy of TE901 was made only worse by the actions of Air New Zealand management's attempts to shirk their responsibility.
You, prospector appear to STILL be acting in collaboration with the proven guilty party of that disgraceful, orchestrated, pack of vultures........the same people responsible for:-
(i)attempting to hide their actions of changing the waypoint co-ordinates,
(ii)stealing and secreting evidence from the crash site,
(iii)breaking and entering into the homes of the (deceased) crew members to remove evidence,
(iv)falsely testifying, under oath, in court
Air New Zealand - no-one does it better

Proud of yourself, prospector?

Thanks for the compliment - the vitamin tablets and Grecian 2000 (along with a little exercise) do wonders for one, don't they
But for the record..16,000 + hrs
B grade Oz Instructor rating
F27
DC9
B737 1/2/3/4/500
B767
B747
..and I've SEEN Concorde taking off at LHR

[Thump & Go]

Prospector, correct me if I'm wrong (all my literature on this subject is in storage - AKA at mum & dad's ) but were Justice Mahon's findings[ overturned by the Privy council or did they suggest he had stepped outside his mandate with regard to the "litany of lies" statement and the aspersions he cast on the company's evidence?

WRT to Judge Greene's findings on the subject of Mac Centre, I would suggest they came about for the same reason GE and McDonnell Douglas had "experts" on site to "assist" the investigation - good old fashioned ar$e covering in litigation-mad US of A.

For the record, I believe the accident occurred for the same reason any major crash occurs - them old swiss cheese holes lining up.
Don't descend below MSA - don't crash
Don't programme A/C to fly at hill - don't crash
Adequately prepare crew for Sth Pole - don't crash
etc, etc
In other words, no one was at fault but all these things contibuted to the cause.

Surely this is apparent to everyone here????

[deadhead]

Here is one of my replies to an earlier post on this topic:

The Captain’s decision to descend below the route MSA of FL160 was probably flawed, since under an IFR flight plan the only two ways you can do that is by descent under radar (or DME step or similar) OR by conducting a visual approach. (Of course you could cancel IFR as well). None of these things actually occurred, since a descent “VMC” is clearly not the same thing as cancelling IFR and proceeding VFR, and neither is it the same as conducting a visual approach. A descent maintaining own terrain visually still, as I understand it, requires a radar service. You cannot do that in a non-radar environment – you have to formally cancel IFR OR fly a visual approach.

Analysis of the captain’s probable thought processes reveals two fundamental pathways:

Either he decided to descend knowing that such a decision was an improper course of action, or:

He decided to descend knowing that such a decision was a valid and proper course of action.

If the first is true, then the captain was reckless and incompetent. End of story. Most, if not all of the “pilot error and nothing else” theories assume this (in many cases quite unknowingly!). It is now a natural and easy progression to apply the “command responsibility” excuse and go no further.

If the second is true, then a study of all information the captain may have based his decision on is required.

My belief is that the Captain of TE901 elected to make a descent because he knew that such an act was proper. That he was tragically mistaken is history. That this decision was neither challenged nor even queried by the other crew members shows that this misconception was shared by them all. The famous unease expressed by the operating F/E “I don’t like this” did not occur until much later.

Despite the amount of technical support available to him, (far more than what poor Ron Chippindale had) Mahon was probably out of his depth (despite producing a report that was well ahead of its time) and the fault here lies squarely with the then Attorney-General, who was foolish enough to appoint him as a one man band. Tragically the politicians of the time did not see it as "expedient" to use Ron Chippindale to assist the Commission. The political climate that prevailed required blame to be found quickly, in response to so-called "public pressure." Thus what should have been a formality turned out to be a nightmare for Chippindale, whom I recall was cross-examined continuously for seven days, and through little fault of his own, what should have been a report of "substance" has been relegated, in the eyes of many, to the back benches. That is a real tragedy, too. There is no doubt, though, that the Report of the Royal Commission set a precedent for examining systemic causal factors, a line that was taken up by ICAO in the eighties and nineties. Had this state of the art been available prior to 1979, there would have been no pathways available leading to this tragedy and therefore it would have been avoided. Both the operator and the regulatory authority would have had procedures in place back then, as they do today, to see and avoid these pathways.


The Captain of flight TE901 clearly thought he could achieve the productivity goal without compromising the safety goal. That does not necessarily mean he put the productivity goal ahead of the safety goal - it may merely show he was mistaken in his beliefs. And if so, we need to find out why.

There was only one way the captain could have prevented this accident - by electing not to descend - but there were a multitude of things the operator could have done to ensure the pathways to the tragedy weren’t available. They didn’t do any of them, mainly because they, and the regulatory authority were totally ignorant of them at the time. None of this was explored by the official accident report but this is attributable to the fact that there was simply no requirement to do so, under the then version of ICAO Annex 13 (Accident Investigation).

Now the “pilot error” pundits will point out that the Captain’s “command responsibility” means that he failed in his command role. Fair enough. It is a great pity, though, that in order to have “succeeded” in his command role he would have been required to outwit a seriously flawed system.

And no human should ever be put in that position.

dh, on a very sad day for me if the worst is true re the probable accident on Mt Egmont today. Bloody mountains.

[prospector]

Thump and Go,
Justice Mahon and the Privy Council: My reference states:

"In their judgement, delivered on 20 Oct 1983, the five Law Lords of the Privy Council dismissed the Commissioners appeal and upheld the decision of the Court of Appeal decision, which set aside the costs order against the airline, on the grounds that Mahon had committed clear breaches of natural justice. They demolished his case item by item, including exhibit 164 which they said could not 'be understood by any experienced pilot to be intended to be used for purposes of navigation'.and went even further, saying there was no clear proof on which to base a finding that a plan of deception, led by the company's chief executive, had ever existed.

Judge Greene: This case was brought by people from NZ, hardly arse covering by anybody in the USA.

"Surely this is apparent to everyone here???"

One would think so, but read Kaptin M last posting and some of the others and the only conclusion they can see as correct was that of Mahon. My postings have endeavoured to show that the company were not the only ones at fault.

Prospector

[Thump & Go]

You'll have to help me out with Exhibit 164 'cause I don't think it's fair to ask Mum to go look it up for me

I'm still unclear about the Appeal court/Privy Council - are they bagging his findings? (ie multiple factors - sector whiteout/company safety culture/flightplan alteration/lack of adequate preflight briefing etc) or; Are they not suggesting he had no proof that a cover-up existed,that if it did there is no proof it started with Morrie Davis and "thats not what you're here for anyway son" so leave it out?

Surely the only controversy with the Mahon report was his totalexoneration of the crew - otherwise, as someone said earlier it was ahead of it's time-the embryo of modern crash investigation.(ahh... so quotable )

Mac Centre = US ATC no?

[Vampire 91]

Erebus revisited

It's interesting to note the level of angst that still exists regarding this accident and its aftermath. I recall watching TV that night when the program was interrupted by an announcement, and a still photo of an ANZ DC10, that an ANZ DC10 was overdue on a flight to the Antarctic and there was no possibility that the aircraft was still airborne. Chilling news. The following day I was on an ANZ domestic flight where, according to a friend on the crew, some passengers requested 'no ice in the drink today' as if it was some sort of joke.

Like many others I had some association with people on board the aircraft. I played a bit of rugby with Brick Lucas (I think that he was a nav prior to retraining as a pilot in the RNZAF), and a former school mate was a passenger on the flight. Some years later I was a passenger on an ANZ flight which had Judge Mahon on board. It was interesting to observe the warmth with which he was received by the crew.

It would provide some satisfaction to believe that the lessons learned from this accident have been incorporated into aircraft operations and investigation processes. Sadly, CFIT remains a major cause of accidents.

[prospector]

Thump and Go,
Exhibit 164:

The original chart (164) was photocopied from a Dept of Defence chart and evidence was given that this chart was discontinued in July 1976

"Exhibit 164 had no significance at all in the operations to McMurdo," says Keith Amies.

" However it was the only piece of evidence that could support the Commissioner's contention that the DC.10 was intentionally flight planned to anywhere other than McMurdo."

" At the Inquiry I demonstrated to those present exactly how this was done. Obviously Mr Mahon could not appreciate the necessity for this check, but anyone conversant with grid navigation would agree that it was prudent to carry out such a check"

"Weighing the evidence presented before him--and the crediblity of the witnesses themselves--Peter Mahon concluded that Exhibit 164 was the track and distance chart supplied to Antarctic crews, and Annex J was something the airline would rather have been found in the cockpit of the wrecked DC.10. That conclusion was one of the many later dismissed at both the Court of Appeal and Privy Council hearings."

Difficult to quote just pieces of this and keep it in context, or get accused of selective memory, but that should give you an idea of Exhibit 164, and the weight Mahon put on it, and the weight Appeal Court, Privy Council decided it was worth.

MAC centre, U.S. Navy air traffic controllers.

This statement by Mr Chippendale after analysing and correcting or refuting more than 70 statements made by the Commissioner.

"I regret the lack of consultation between the Commissioner and the Chief Inspector during this inquiry. It is a radical reversal of the procedure which had always taken place on the earlier public inquiries into aircraft accidents in New Zealand.
This lack of consultation together with the absence of the technical assessors provided for in the Civil Aviation(Accident Investigation)Regulations 1978 resulted in a decision which conflicts with the accepted views of the international aviation fraternity around the world.
The errors in the briefing were serious but not an absolute excuse for the accident when the means were readily available for the pilot in command to make certain he knew where he was."

And as you have seen, you either agree with Mahon or Chippendale.

Prospector

[TAY 611]

I guess Chippendale would say that as he would have felt he had some sort of ownership on the origional report, that if refuted, made him look like he hadn't done his job very well.
Correct me if I am wrong but wasn't Gordon Vette advising Peter Mahon at the time of the commission and he appears not to be a lightweight in DC10 operations either.
Its all the talk of dodgey things like breaking into homes, giving false statments and shredding evidence that adds weight to Mahons Litany of lies remark and is something you seem to avoid comment on there Prospector.

[prospector]

TAY 611,
Why talk about those things??? Did they cause the accident??

Read the last sentence of Chippendales statement in my last post.

Were the briefings seriously in error?? Yes they were.

Were means available for the crew to establish their exact position???? Yes they were.

Prospector

[56P]

A police officer recovered the diary of Capt Collins, complete with all pages. That officer was not required to appear at the commission. When the diary was presented in court, all the pages were missing despite the good condition of the binder. The witness who presented the binder advised that he could not recall removing the pages!

No wonder Justice Mahon had doubts regarding some of the statements from some of the witnesses.

Many factors contributed to this disaster. There was no need to attempt a cover-up. The purpose of any accident investigation is NOT to apportion blame but to identify the cause so that steps may be taken to avoid any recurrence. Any cover-up negates the purpose of any investigation.

[Desert Dingo]

It seems that the apologists for the airline make much of the fact that Captain Collins did not comply with a company requirement to observe the FL160 MSA approaching Mt Erebus (and then a 6000 ft limit when past it to the south).
The airline briefing notes stated “ if VMC cannot be maintained, FL160 is the Minimum Safe Altitude.” Even Chippindale’s report states “He was not violating any local restriction by descending to 1500 feet in VMC”
Anyone care to explain how the NZ regulations require flight above the MSA when operating in VMC? OK, then perhaps are we agreed that it was only a company requirement.?

Justice Mahon observed that in the 2 years prior to the disaster, NOT ONE PREVIOUS FLIGHT HAD COMPLIED WITH THIS RESTRICTION. They all happily flew in VMC below the MSA. Perhaps they were all crazy line pilots breaking the rules, lucky not to be reported, and the company knew nothing about it ?? Who would like to bet that no management pilots ever commanded one of these flights?? Come on! It cannot be disputed that the airline promoted the whole thing as a low level sightseeing flight, and the airline cannot escape the fact that Captain Collins was endeavoring to do what the airline expected him to do.

There is no doubt that Chippindale produced a magnificent report with detailed analysis of thousands of pieces of evidence. However, I think it was a classic case of “not seeing the wood for the trees..” You only need to stand back and metaphorically squint a bit and two monumental facts stand out.
1) The crew thought they were flying in VMC, and they were not.
2) The crew thought they were in McMurdo Sound, and they were not
Change either of these facts and the disaster would not have happened.

Can you blame the crew? I think not. Collins appeared to be meticulous in maintaining VMC.

CVR extracts:
35:36 “Presently through FL130. VMC. Intention to descend to 10,000”
38:23 “I’ve got to stay VMC, so I’ll be doing another orbit.”
42:49 “We’re VMC around this way, so I’m going to do another turn.”
45:00 “Now at 6000, descending to 2000, VMC.”
Then when it appears that VMC is becoming marginal…
47:43 “Might have to drop down to 1500 feet here, I think.”
48:46 “Actually these conditions don’t look very good at all”
49:24 “I don’t like this”
49:30 “We are 26 miles north. We’ll have to climb out of this.”

They are hardly the words of someone recklessly ignoring regulations.

Can he be criticized for not climbing at the first indication that conditions were deteriorating?
47:43 “Might have to drop down to 1500 feet here, I think.”
Once again, I think not. It was still a legal altitude, and he believed he was over the flat expanse of McMurdo Sound.

There is one part of Chippindale’s report I find utterly incredible.

2.5 The flight plan was printed for each flight from a computer stored record which, until the night before the flight, had the longitude for the McMurdo destination point incorrectly entered ………….
……… In the case of this crew no evidence was found to suggest that they had been misled by this error in the flight plan shown to them at the briefing.

No evidence to suggest that they had been misled by this error ????
They flew into a mountain they thought was 25 miles away fercrissake !!!

CVR:
46:39 “Where is Erebus in relation to us at the moment?” “Left. About 20 or 25 miles…about 11 o’clock.”

And also this little conversation in the cockpit.
Alt Cap
Ross Island there
Yes
Alt Hold
Erebus should be here
Right
fifteen hundred
Capture
Alt hold
Hold on both, nav track

Anyone happen to notice that NAV TRACK callout? As far as the crew were concerned, they were locked onto the planned track they had been briefed on and they were in the middle of McMurdo Sound.


Our airline apologists try to tell us that Justice Mahons findings were “overturned.” They were not. Justice Mahon's finding that the crew was blameless was not overturned. What happened was that Air NZ challenged Justice Mahon’s findings of a cover-up on the grounds that if such an accusation was to be made it should have been put to it at the inquiry.
The Court of Appeal agreed, and set aside the costs order against the Airline, on the grounds that Mahon had committed clear breaches of natural justice. The Privy Council subsequently found that Justice Mahon, as Royal Commissioner, had acted in excess of his jurisdiction and contrary to natural justice regarding those allegations.

It appears to me that once again nit-picking lawyers let criminals go free. There was still the cover-up of course, but the poor darlings were not told at the correct time that it was going to be made public.

Here is some of John Roughan’s column in the New Zealand Herald

Erebus eventually became the story of a cover-up. That was the conclusion of the inquiry conducted by Justice Peter Mahon and his story received eager treatment in the news then and ever after. It will be widely rehearsed again this weekend, the 25th anniversary of the crash.
Mahon decided the root cause of the disaster was the airline's navigational computer in which the pilots had absolute faith but which had been unwittingly programmed to fly into the mountain. Further, he believed Air New Zealand had realised it was at fault and had tried to pull the wool over his eyes.

It was a great story and Mahon was a great writer. I was back here and covering the High Court by the time his Erebus report became contentious. Justice Mahon was well-regarded by his peers. His decisions were written with crystal clarity and wry elegance. His report was a work of dedicated investigation, human insight and controlled fury.

Then it turned into a personal disaster. Air NZ challenged the fairness of his findings of a cover-up on the grounds that if such an accusation was to be made it should have been put to it at the inquiry. Mahon's peers at the Court of Appeal agreed.

When they found his report to be a breach of natural justice, he resigned from the judiciary and died some years later, said to be broken in spirit.

Most people's sympathies, including mine, were with Justice Mahon, particularly since the agent of his downfall was suspected to be the ever-domineering Prime Minister, Sir Robert Muldoon.

Prime Minister?
Airline?
Shonky dealings?
Why am I not surprised?
It’s Deja-vu ..all over again.

[TAY 611]

Prospector
When 257 people paid a hefty price in this accident why not talk about these things? It may not have directly caused the accident but it sure exposed a corporate culture that allowed it to happen then tried to whitewash their own involvement.
3 issues to look at here
(1) Chippendales report (you give it a glowing report)
(2) Mahon aided by Gordon Vette commission result (condemned by you and you prefer to acknowledge a concorde pilot's opinion before even acknowledging Vette's view)
(3) Mahon's suspicions and exposure of a cover up (the only comment you have here is why talk about it)
Which eye have you got closed there and which tunnel are you looking through?
TAY

[prospector]

Dessert Dingo,
I for one am certainly not an apologist for ANZ, in fact over the years, and particularly about the time of the crash had very little time for them.

If the company requirement for descent was complied with then there would have been no crash, it was as simple as that.

If you wish to quote from the CVR go back a little further,
"We're maintaining 10,000 presently 34 miles to the north of McMurdo"

34 miles North, 10000ft, no DME lock on, no VHF contact, no radar contact. what would that tell you???

From Peter Mulgrew, the expert ice man, the only one who had been down there.

"I still can't see very much at the moment-- as soon as I see something that gives me a clue as to where we are I'll let you know"

That statement descending between 10000ft and 6000ft.

As you say there was a lot of "They thought"

If you consider the crew blameless, as apparently Mahon did, after flying a perfectly serviceable aeroplane into a mountain carrying out a procedure that was against a Company Standing order then so be it.

TAY 611,
Mahon made all his own decisions unassisted by any ANZ crew in any official capacity, there was I believe an RNZAF officer meant to be assisting him in a technical capacity, but his name was not mentioned once in the report I dont believe.



Prospector

[56P]

34 miles North, 10000ft, no DME lock on, no VHF contact, no radar contact. what would that tell you??
--------------------------------------------------------------------------
Prospector

They "thought" that they were 34 miles north because, so far as they were aware, the NAV system indicated it. They thought that they were 34 miles north in the centre of McMurdo Sound because that was where they expected the nav system to take them. I do not beleive that was an unreasonable assumption. And remember that they thought that they were in VMC.

Trying to remain objective, I see errors on all sides. The error in the coordinates inserted into the nav system without advice to the crew was a major one. Likewise, it is difficult to understand the time elapsed between a hard GPWS warning and the request for go-around thrust. Again, maybe the crew had difficulty to understand the warning because, in their opinion, they were no where near high terrain.

[Kaptin M]

Your continuing defence of the undefencable - that Air New Zealand management KNEW that THEY would be viewed as the primary causal factor, as proven by their many and various underhanded tactics - has me wondering why you doggedly persist in trying to shift the blame AWAY from them, prospector.
Your posts indicate a good knowledge of the reports written about this accident, but very little PRACTICAL aviation operational knowledge, from a pilot's point of view.
Your comment, "I still can't see very much at the moment-- as soon as I see something that gives me a clue as to where we are I'll let you know"

That statement descending between 10000ft and 6000ft." indicates your inability, or unwillingness to concede that Capt Collins was in VMC conditions - the "I can't see very much at the moment", indicates to me that due to the flat, icy, featureless terrain, he was merely commenting that he couldn't see any positively identifiable landmarks to confirm their position - however he could see that they had terrain clearance, and (mistakenly) knew that as long as the aircraft continued tracking on the Company supplied flight plan route, they would remain well clear of high ground.
Obviously, had whiteout conditions not existed, the crew would have seen the mountain, and their proximity to it.

Just to clarify some previous comments of some contributors - the crew didn't THINK that they were visual - they WERE visual, prior to encountering the whiteout phenomenom.

I give Desert Dingo's account 2 thumbs up for a well-written, well thought out expose

[prospector]

Kaptin M, Dessert Dingo, 56P,

If you consider it acceptable to conduct a flight with so many "thoughts" "assumptions" and "mistakes" please advise which airlines employ you so I can ensure that I dont "mistakenly" get on your aircraft that I "thought " was to be operated in accordance with SOP's and not by "assumptions" that you know better than the people that make the rules.

Prospector

[Kaptin M]

Visual approaches have been included in the SOP's of all (5) major airlines for which I've worked, prospector.
In your case, a little knowledge is a dangerous thing - how's the adage go..."It is better to appear a fool and say nothing, than to open one's mouth and remove all doubt!"
Why the "vested interest" though?
Was it YOU who was responsible for changing the co-ordinates?

[HANOI]

That is probably the most disgusting thing you have ever said on this forum.

[prospector]

Kaptin M,.
Well you have certainly done that.

The SOP for McMurdo stated the only descent available and the reason for that has been stated many times, the fact that the weather was below the minimums required for that descent does not authorize a crew to invent their own visual descent.

I willingly accept the fact that I am not a GOOD pilot, I lasted 45 years without hurting me or any of my passengers. From Agricultural to Airline, and with a break as an Air Traffic Controller, and some 5,000hrs Single Pilot IFR ops.

In that time I have read many many many accident reports, and one thing they all appear to have in common is how good the pilot was.

Prospector