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Paul Holmes and Erebus

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Old 25th Mar 2012, 22:38
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If one looks at the thread re Pacific Blue and their disputed departure from Queenstown, all because of a minor deviation from SOP's
And there's the rub. Everyone (airline management and regulator) knew from the airlines advertising that SOPs were not being complied with, yet chose to do nothing about it. If they were to claim they didn't know they are being just a tad disingenuous.
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Old 26th Mar 2012, 01:00
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yet chose to do nothing about it.
Granted, but surely the Captain, by also choosing to disregard SOP's, CAA regs, with no apparent discussion with the crew, neither the first officers or the flt engineers, carried out a descent that ended the way it did must surely shoulder a portion of the blame??

If he decided to disregard the SOP's, CAA requirements for descent, the specific instructions that were laid down for descent on these sight seeing trips, then he would have had to have the same weather conditions as the previous flights, he did not have these conditions.

The decision to descend where and when they did was the captains. The disaster was caused by that descent, therefor he must shoulder a major portion of the blame.

If the flight had of returned then no doubt the non conformity with SOP's and regs would not have been an issue.

It is agreed that previous non conformity with the requirements laid down for descent should have been cause for reprimand, but they were completed without any problems, so they were not. This may have had an influence on the decision of Capt Collins but it should not have, he was faced with the conditions they experienced and his safety margin was supposed to be provided by the descent requirements, which he ignored.
 
Old 26th Mar 2012, 03:41
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Brian Abraham

Forget the paperwork for a minute.

Had Collins called on a radio to Auckland, "We are over Cape Hallett", the response might have been, "Thanks, Jim, have a nice day."

Had he called operations later and said, "I've found a bit of a hole in the cloud so I'm going to descend to 2000ft", what do you think the response would have been? Yes, No or be careful?

And then, had he called to say he was on the coast somewhere at 1500ft but couldn't see the mountains; never mind he was going to lock onto the AINS and fly to "McMurdo"? What would the answer have been? "Turn North and climb" or "Come home immediately."
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Old 26th Mar 2012, 06:39
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That unannounced descent was Dambuster's stuff.

Lucas would have asked the question, but he was back in the cabin.

What was the question?: "Why are we going between the cloud and the ice VMC when it's very difficult to tell the difference?"
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Old 26th Mar 2012, 16:23
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The crew has to be ulitmately responsible.....

I follow my company,s SOP,s......not always to the hilt.....

SOP,s, state flaps 3 landings is normal ldg procedure.....sometimes I do flaps full(for obvious reason,s)

SOP,s state...must fly most fuel efficent altitude @ CI 35 on prog page......I deviate from this also(for obvious reasons)....

There are many area,s where SOP,S are stated.....and pilots deviate from these...generally SOP,S are "Recomended"......and some SOPS,there is no deviation(for obvious reasons)............

.......any for evey airline Ive ever flown for ,Mgt/Company/Govt Regulating agency.....Tin-plate their Backsides.....by stateing

The Pilot(PIC) is ULTIMATELY resonsible for the safe operation of that A/C.......and whether or not the above controlling agencies cock it up or not......I dont buy into the argument that(the crew) were not responsible....
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Old 26th Mar 2012, 18:56
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Sooner or later ppruners will reread Chippendale's report and realise he was mostly correct in the first place.
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Old 26th Mar 2012, 20:01
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“The probable cause of this accident was the decision of the captain to continue the flight at low level toward an area of poor surface and horizon definition when the crew was not certain of their position and the subsequent inability to detect the rising terrain which intercepted the aircraft’s flight path. Although the accident would have been avoided if the aircraft had not descended below safety height it was not inevitable until the aircraft reached 1500 feet AMSL on track to McMurdo and maintained a heading toward GRID north. Had the aircraft been turned toward the true north even at that late stage and either climbed to safety altitude or the crew pinpointed their position and headed towards lower terrain the accident could still have been averted. This is not to say that such a manoeuvre is in any way condoned. The pilot probably assumed that he would be able to see any and all obstructions clearly with a 2000 foot cloud base and 40 miles visibility below the cloud. It is not likely that the potential whiteout hazard indicated by the reports of horizon and surface definition was appreciated by the crew.” (Chippindale Report, pages 53 & 54)


The only thing he got wrong was the last two sentences, given that the captain was aware of the visual problem.
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Old 26th Mar 2012, 20:28
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pakeha-boy

You see, your "problem" is you live in the real world. An analogy, and an analogy is only an analogy, is rape. We all know men should not rape women, and the feminists tell us rape is rape and a woman can say NO at any point.

But if a skimpily dressed woman goes back to a hotel room at 2am with some bloke she met in bar at 1am, is that wise if she is not interested in sex? If she is raped, what use was the law to her?

Or if a teacher supervising a group of children barges onto a pedestrian crossing without making sure the car has stopped, is that wise? Yes, we all know cars should stop; equally we know that sometimes they don't. So if a kid is run over, is she blameless? (She won't be prosecuted.)

Good airmanship means making wise decisions, regardless of the law, company policies or pressure from anyone, to keep the aircraft flying and keep it safe.

I can understand the difficulty of attributing a percentage of blame to the crew and to the company. In my view they both failed miserably. The company's failings I can comprehend: shoddy organisation to the point of sheer confusion. The commander's I find more difficult. It be the human factors my old mother called a "brainstorm".

When I fly down to Ohakea this week and Wanaka next week in my little aircraft, I know things could go wrong. I even accept, although I will have my usual "copilot" to help, things might go horribly wrong. But Collins behaved as if nothing could go wrong.

Brian Abraham writes some of us would have liked Collins to have survived so he could be punished. I would have liked him to have given himself such a hell of a fright he never flew again and the company saw sense. To me that would have been the best outcome anyone could have hoped for in this shocking affair.
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Old 26th Mar 2012, 23:33
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Brian Abraham is steering the argument from one he can't win towards one he can. Yes, Reason Model, Swiss Cheese, etc, all good stuff - but what's the relevant issue?

The relevant issue is whether the captain should be "exonerated". No blame at all. So of course there were multiple causes, and of course others in the airline were also to blame, but no-one could reasonably suggest that the captain displayed faultless airmanship.

If I had to select one particular AirNZ employee who has to shoulder most of the blame, it would be Captain Collins. That might not suit his surviving family members, but their feelings are completely irrelevant. Every dead careless pilot had a family.
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Old 26th Mar 2012, 23:35
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The relevant issue is whether the captain should be "exonerated". No blame at all. So of course there were multiple causes, and of course others in the airline were also to blame, but no-one could reasonably suggest that the captain displayed faultless airmanship.

If I had to select one particular AirNZ employee who has to shoulder most of the blame, it would be Captain Collins. That might not suit his surviving family members, but their feelings are completely irrelevant. Every dead careless pilot had a family.
Thats it in a nutshell right there.
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Old 27th Mar 2012, 01:46
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ampan, I agree. Brian gives as an example a young lad sent to do a task by the RAAF, for which he was probably not sufficiently trained and experienced.

Collins was perfectly well trained and experienced to do what AirNZ tasked: stay above 16000ft to "McMurdo" (clear of Erebus whatever the track) and descend to 6000ft in VMC after liaison with ATC (radar).

He was well enough prepared to do this task, whatever the deficiencies we see now. What he was not prepared for, although he could have been, with his background and qualifications, was to descend on the coast and fly to "McMurdo".

It's not so much that AirNZ changed the goalposts as Captain Collins changed the game. It changed from an airline operation to a specialist polar operation, and AirNZ did not do this. Captain Collins did, all on his very own.

Last edited by Ornis; 27th Mar 2012 at 03:23. Reason: FL160 not 13000ft for track
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Old 27th Mar 2012, 03:54
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It's a funny thing the way this accident plays in the public mind and resurfaces from time to time, such as here at PPrune re the Paul Holmes publication. I recall the day the news of the aircraft was overdue became public knowledge and immediately knew what that meant and I don't think there was an Australian or New Zealander who was not both shocked but saddened by the accident. That it was the Antartic gave it a different mystique.

Sadly a perfectly serviceable DC-10 and 257 lives were destroyed that day on what was supposed to be a routine sightseeing charter flight. All the inquiries and investigations have shown that each and every level there were failures in systems and processes, some with human causes, some with not, but the layers of protection for Captain Collins and FO Cassin and the FE were steadily removed. The Chippendale report is as a black letter report, correct, possible cause and avoidance actions are as they were described by Mr Chippendale. CRM failed and before danger was recognised, the accident occurred. Mr Holmes would do well to understand the description of Ron Chippendale as an individual provided by Mr Justice Mahon to appreciate the man was 'old school' and by the book that is all.

Mr Justice Mahon's Commission of Inquiry pulled back the covers on the various layers of the fabric that constituted air safety and found them wanting. His findings are unimpeachable on matters of fact or law.

Critically, the relatioship between the hard chart documents and what was in the FMS of the DC-10 were different at a critical point in the aircraft's route. The reasons for this are established. The behaviour and cultures of various organisations both the Department and Air New Zealand were less than impressive for either honesty or integrity and a certain sloppiness had crept into a non scheduled route flight briefing and managment for flights involving this large aircraft and the area in which it was to be operated that was to prove fatal. The furtive activities of some were immature responses to a very real tragedy in New Zealand, like minds behave like but are not necessarily conspiring.

The original question posed was the issue of exoneration for the crew. The question is unnecessary, the crew was always to be exonerated for while they made a mistake, they were not at fault as they were deceived by the information they had and a severe lack of personal knowledge of the physical geography they were overflying. The safety systems of Air NZ failed the crew not the crew Air NZ. So there is no matter of guilt. The men and their passengers already paid for their mistake with their lives and that in my judgment is enough of a penalty.

We should let all involved rest and let time heal the wounds.
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Old 27th Mar 2012, 04:46
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Nobody is talking about guilt Grip. We are talking about responsibility.

The original question posed was the issue of exoneration for the crew. The question is unnecessary, the crew was always to be exonerated for while they made a mistake, they were not at fault as they were deceived by the information they had and a severe lack of personal knowledge of the physical geography they were overflying. The safety systems of Air NZ failed the crew not the crew Air NZ.
Are you sure they made a mistake Grip?
If so was it a lapse or a slip?

The safety system that you talk of should definately have been robust enough to withstand one or two of these without catastrophe.

Are you sure there wasn´t a violation involved?
Violations sometimes appear to be human errors, but they differ from slips, lapses and mistakes because they are deliberate ˜illegal actions, i.e. somebody did something knowing it to be against the rules (e.g. deliberately failing to follow proper procedures).
There is not a safety system in the world that can defend against violations.

I am not defending Air New Zealand or the CAD, there were plenty of room for improvement on all sides, but to say that the crew were in no way responsible for the crash not realistic.
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Old 27th Mar 2012, 05:16
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deceived by the information they had and a severe lack of personal knowledge of the physical geography they were overflying
And with that severe lack of knowledge they decided to descend to 1500ft, trusting on the AINS for track guidance. They certainly knew Ross Is and Mt Erebus were close, but they never sighted them once, certainly not enough for a positive identification of their position.

It has been established without doubt that the AINS was not to be used for Nav below route MSA.

The route MSA was the same no matter what the final waypoint position was, the TACAN or the head of McMurdo Sound, it was FL160.

The safety systems of Air NZ failed the crew not the crew Air NZ
That statement has been proven wrong so many times by so many eminent people, including Judges, Airline Pilots, Aircraft Accident Inspectors that the only people who believe it to be correct are obviously lay people with no knowledge of the workings of Civil Aviation, Paul Holmes being a good example.

passengers already paid for their mistake with their lives
And what exactly was their mistake????

Last edited by prospector; 27th Mar 2012 at 08:20.
 
Old 27th Mar 2012, 07:18
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I don't know what to say. Did you read any of these comments, grip pipe? Follow any of the arguments?

Let me try another analogy. You are an instructor and finally you decide to send a student on the first solo. So you depart the aircraft and tell the student to do one circuit and land. To you horror, the student vacates the aerodrome and subsequently crashes into Mt Pirongia.

So, tell me, grip pipe, are you to blame for this crash? You sent the student on a simple task you judged him ready for and he buggers off to do his own thing.

No grip pipe. The fact of the matter is, and it's harsh, Captain Collins took the aircraft down below MSA without adequate preparation and safeguards and killed his passengers.

Happens all the time in General Aviation. The difference with this crash is the refusal to face the truth and the classic "Appeal to Authority" argument. Mahon might well have been right about about AirNZ, but he didn't have a clue about aviation. And that's a fact. I don't know much either but I know bull**** when I see it.
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Old 27th Mar 2012, 14:25
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Quote....grip pipe......The original question posed was the issue of exoneration for the crew. The question is unnecessary, the crew was always to be exonerated for while they made a mistake, they were not at fault as they were deceived by the information they had and a severe lack of personal knowledge of the physical geography they were overflying. The safety systems of Air NZ failed the crew not the crew Air NZ. So there is no matter of guilt. The men and their passengers already paid for their mistake with their lives and that in my judgment is enough of a penalty.

nothing personal grip.....but that, I find disturbing....we have come along way in the many years since this very sad situation,(Training CRM Accident investigation)..that could have been easily averted.........I have learned from it myself.....but once Collins accepted and signed that Dispatch release(as it is today also), HE...becomes ultimately responsible ..........as I am when I accept the release...and yes there are many factors in this situation........but Collins becomes the end game
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Old 27th Mar 2012, 20:49
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Gentleman, your strong condemnation of the crew is of concern to me as the issues that resonate most about this tragedy, concern what was known and what was not known and thus inform us about the probable state of mind of the PIC of this flight. That was what Justice Mahon was on about, the reasons not just the acts. Chippendale's version is about the acts not the reasons. Neither Commission of Inquiry or Accident Investigation is comfortable or pleasant reading.

In defence of the crew on the day there are a lot of presumptions made but none really known except what we found out later from the hard physical facts of the evidence that remained. There are a lot of assumptions about safety systems and CRM and there are a lot of assumptions about SOPS.

The issue of deception is critical to understanding what went on that day.

The deception caused by the change in the route coordinates. The deception of time and place and geographical illusions combined with visual illusions. The deception that comes from a reliance on SOPS which were inadequate and poorly thought out.

What was not known was the change in the nav coordinates by AIR NZ flight planning, what was not known was that the changes placed the aircraft in a perilous position at a critical phase in flight where it was expected that the aircraft would be visual, positive of the position and positive about what they were seeing. They were deceived about where they were going to fly.

They were decieved by what they saw. So you think you are one place,your somewhere else, you look out the window and it looks the same, it appears to look like it should ice and sea about the right shape and orientation, but you have never seen it before, you look out the window and it is a sodden grey-white sky with a sodden grey-white surface below. What you may have expected to see and what you were actually seeing may have even been quite incomprehensible except to a trained and experienced eye.

They were deceived by the complacency that was created by past flights operating below MSA without problems in the most inhospitable place on the planet.

The overall deception of safety that was created by the view that it was just another charter flight.

The deception of what to expect and see created by not having current and relevant visual photographic materials and charts properly put together as a briefing aid.

The deception created by the reliance on visual identification to a person who was not part of the flight crew nor an experienced aviator.

The deception of how to to do it when you got there created by not doing sim sessions, where white-out could be experienced and phases of the flight practiced, particularly if a crisis or emergency arose. So a descendng high speed visual fly up into a funnel of rising terrain in an area guaranteed to be probelematic due to visual illusions became an acceptable current airline operational practice and was not practised.

So when a critical decision was finally made to climb out to safety in the right direction was made, the crew were completely and thoroughly deceived and hence not clear about what they were doing and where they were doing it and they forgot how to do it. The leisurely way in which the crew reacted tells you everything about the state of complacency brought about by the deceptions which lulled them into that place in the first place and which promptly killed them and everyone else.

So you would hold Capt Collins responsible for his and this deception?

I cannot.

I can hold him accountable for his mistakes but not the debauched way in which he was led to make them.

The flights should never have been conducted as they were in the first place. The flights should never have been authorised or approved by either the Airline or the Regulator. They were not properly planned, briefed or practised. The aircraft carried no appropriate survival or safety equipment. There was no appropriate alternate place of safe landing once past 60 degrees south.

Those failures of responsibility belong to the Chief Pilot and the Chief Check Pilot and the Operations Department and the Airlines management. They were all responsible.

So no one really asks the critical question:

Is it really a safe thing to do to fly a commercial airliner carrying 257 passengers over the Antarctic and past or near to a mountain range and a volcano that is 12,500 ft high into possible white-out conditions that virtually coincides with the PNR without safety equipment and alternatives ?

And the answer to that is a simple - No it is not and as the events show it was not. The outcome was always predictable, if it had not been Captain Collins and his passengers that day, then it would have been another Captain and another crew another day at some time.

So it is my view that no one is absolved of blame in this one, no one.

Last edited by grip pipe; 27th Mar 2012 at 21:36.
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Old 27th Mar 2012, 22:14
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Gentleman, your strong condemnation of the crew is of concern to me
Grip I don't think many here actually want to knock the crew. I think most were happy to let time pass and stay quiet. It is the cal for "exoneration" that has promted some of us to point out that the crew hold some responsibility for the jet flying into Erebus and therefore an exoneration is not appropriate.

Your last sentence
So it is my view that no one is absolved of blame in this one, no one.
seems to be in agreance with that because if no one is absolved of blame then there can be no exoneration.

At the end of the day Collins took his heavy jet down to 1500 feet at 250kts, clean, in an unfamiliar location not long after he had made comment on the difficulty to distinguish between the ice and the sky.He didn't do this once south of Erebus. It would have been a very uncomfortable flight deck.
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Old 27th Mar 2012, 23:04
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Very uncomfortable: Just before getting down to 2000 feet, and three minutes before the decision to climb out, F/E Brooks said "Where's Erebus in relation to us at the moment?" followed by "I'm just thinking of any high ground in the area, that's all".

Everyone, including Vette, Holmes, and Collins, accepts that the DC10's inertial nav system wasn't to be used to go below MSA.

"But he was visual", says NZALPA.

No, he wasn't - and he knew he wasn't. The captain's repeated "VMC" utterances on the way down did not make it any easier to distinguish the cloud from the ice.

Yes, other captains went below MSA. So what? They were visual. No-one else did what Collins did. Dalziel took the alternate route, while Ruffell went to the Dry Valleys. The rest had blue skies, and went where they pleased, perfectly safely.
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Old 27th Mar 2012, 23:20
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Is it really a safe thing to do to fly a commercial airliner carrying 257 passengers over the Antarctic and past or near to a mountain range and a volcano that is 12,500 ft high into possible white-out conditions that virtually coincides with the PNR without safety equipment and alternatives ?

Yes it is, if proper respect for the mandatory requirements re descent and low level flight are complied with. And a modicum of common sense re suitable weather conditions for these low level sight seeing flights is exercised.

There was a number of flights carried out without any drama, even though CAA requirements of minimum altitudes were allegedly abused, by some very senior pilots, including at least one check pilot.

If these flights are inherently dangerous why are they still being carried out by another airline??

Antarctica Flights
Have a look at the flight route for 15th Jan 2012. Observe the amount of bare rock at the summit of Mt Erebus, completely shoots down the Mahon argument that there would be no return from the radar due to dry snow on the mountain, Was the Radar even turned on?? or was that another mistake.

If as you say flying in the Antarctic is so very dangerous why do many service aircraft operate there regularly, even transporting VIP's, without any problem???

And the answer to that is a simple - No it is not and as the events show it was not. The outcome was always predictable, if it had not been Captain Collins and his passengers that day, then it would have been another Captain and another crew another day at some time
Not unless the same blatant disregard for all the requirements that had to be complied with before descent below route MSA were not complied with.

Last edited by prospector; 27th Mar 2012 at 23:54.
 


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