Paul Holmes and Erebus

[topend3]

I'm not in the business of picking a particular employee to blame, as there is more than enough humble pie to be served, but a question I would have raised would have been regarding the route from Hallett to McMurdo. Why directly overhead Erebus, and not following the RNC route down the sound?

I understand Air New Zealand chose this particular route (even though the previous flights operated on the other plan) in order to remain clear of military traffic going into McMurdo...

[prospector]

Really?? The brief said,

It also said,

3. Avoid Mt Erebus area by operating in an arc from 120 Grid through 360 grid to 270 grid from McMurdo Field, within 20nm TACAN CH29.

4 Descent to be coordinated with local radar control as they may have other traffic in the area.

They never got a DME lockon to TACAN 29. They were never identified by radar so how could they be advised of other traffic?? or other traffic advised of their presence??

All the rest has been debated backward and forward and sideways, but if those two mandatory requirements for VMC descent below FL160 were complied with then there would have been no crash.

[framer]

Brian, do you think the crew should be officially exonerated from any responsibility like Holmes and Dunne are calling for?
After reading your well thought out post I am genuinely interested to know.
Cheers.

[Brian Abraham]

do you think the crew should be officially exonerated from any responsibility

framer, you ask a most difficult question.

Aviation has always been bedevilled by the "you don't know what you don't know". Aviators of old were killing themselves by entering what came to be known as a "Parkes Dive". Wilfred Parke, a test pilot, accidentally entered one of these "dives" at 700 feet, and after much difficulty recovered at a height of fifty feet, the first man to ever effect recovery. You, I, and the rest of the world now know a "Parkes Dive" as a spin. This was in 1912, and it wasn't until WWI that the spin recovery procedure he discovered was taught to pilots. So pilots continued to die in the interim, because they didn't know what they didn't know.

During WWII the USAAF taught aircrew that flight through a thunderstorm was a non event for a properly trained aviator. Today we know better. They didn't know what they didn't know, at least until Robert N. Buck conducted thunderstorm research during WWII. His book "North Star Over My Shoulder" describes all.

Fast forward to more recent times and jet aircraft were crashing on take off and on approach. It took Prof. Ted Fujita to discover the microburst phenomena to explain the accidents, and so procedures (escape manoeuvre) and equipment (doppler radar) were developed to counter same. Crews were caught by not knowing what they didn't know.

Captain Collins was caught out by whiteout, as described by Chippendale. He didn't know what he didn't know, the result of inadequate training. But then, those in management writing the procedures for the polar flights probably didn't know what they didn't know. Might an attitude of "aviation invented here" be prevalent within the company at the time? It occurs in many organisations who are loath to seek advice from others with the necessary expertise outside.

There is a theory called "The Normalisation of Deviance", developed by Prof. Diane Vaughan to explain the "Challenger" space shuttle accident. NASA management became accustomed to the "O" ring degradation phenomena on the boosters when no serious consequences resulted. Normalisation of deviance was present in the loss of space shuttle "Columbia" as well. Specifications called for the external tank not to shed foam. The majority of shuttle launches recorded foam strikes and thermal tile scarring, even causing a dent four inches wide and three inches deep on one flight. Engineers came to see the foam shedding and debris strikes as inevitable and unresolvable, and a maintenance problem, not a safety of flight issue.

Normalisation of deviance is seen in the operation of the polar flights as well. The failure to comply with SOPs was known to all, and the company got away with it for a time, but as inevitable as night follows day, the inherent failures caught up with the company. That the man in the seat on that fateful day was Captain Collins is neither here, nor there, as grip pipe so eloquently put it,

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.

You can only roll the dice so often.

While the polar flights were a cowboy operation, Captain Collins played his role, and as such can not be exonerated, as is being called for in some quarters. But nor can he be blamed. Seeking to blame is for lawyers looking to savage someones bank account, and ambulance chasers. It has no place in understanding how accidents eventuate.

Avoid Mt Erebus area by operating in an arc from 120 Grid through 360 grid to 270 grid from McMurdo Field

They had no means of determining their azimuth from McMurdo, so that wasn't going to work.

but if those two mandatory requirements for VMC descent below FL160 were complied with then there would have been no crash

Once again a complete failure to understand the whiteout phenomena.

[ampan]

VMC

I don't see how anyone can seriously suggest that the captain was visual. As a matter of fact, he obviously was not, given what occurred. So the issue is what he believed at the time, and we know that he believed that it was very difficult to tell the difference between the cloud and the ice. The captain did not have to have experienced a whiteout before in order to appreciate the problem (just as he did not have to have flown VMC at night in order to appreciate the problems in that regard).

So why did he purport to be visual? The probable answer is that he was actually relying on the AINS - and the AINS alone, given that he couldn't get the Tower on VHF radio. Was that allowed? Definitely not. So how was he going to get to see the scattered shacks at McMurdo Station ("I prefer here first") for the first time? Pretend to be visual.

PS - That's not defamatory, because the captain is dead. Paul Holmes knows that rule back the front.

[prospector]

They had no means of determining their azimuth from McMurdo, so that wasn't going to work.

So, what in effect you are stating is that the AINS was accurate enough to establish a position with enough accuracy to be blatting around at 1500 ft illegally, but not accurate enough to establish a position within the required arc and distance of the McMurdo TACAN above route MSA quite legally?????

While the polar flights were a cowboy operation, Captain Collins played his role, and as such can not be exonerated, as is being called for in some quarters.

And surely that is what the whole thread is about? The points that have been made are not so much to pin blame, but to disagree with the call by Paul Holmes and others for complete exoneration of the crew, especially Capt Collins.

[ampan]

"But he was visual" says NZALPA again.

So it all gets back to the VMC point.

Brian Abraham spends many words explaining the principles of visual flying, but studiously ignores the crucial sentence from the CVR transcript.

The following are undisputed facts:

Captain Collins knew that it was very difficult to tell the difference between the cloud and the ice.

He knew there was a 13000 foot mountain in the vicinity, covered in ice.

He descended from above the cloud to below the cloud, thereby putting the cloud above the aircraft and the ice below.

He descended below MSA and below the height of the known hazard.

He purported to descend VMC, which meant that took responsibility for keeping the aircraft clear of terrain, his primary tool being his eyes.

To repeat, the terrain below was covered in ice, which he knew.

To repeat, the cloud was above, which he knew.

To repeat, it was very difficult to tell the difference between the cloud above and the ice-covered terrain below, which he knew.

So did he have visual meteorological conditions below the cloud? Of course he didn't. If Brian Abraham can cite one single solitary source that says that a pilot is VMC in the above circumstances, then I'll eat my cat.

[framer]

Thanks Brian,

framer, you ask a most difficult question.

it is THE question of this thread. It is very easy for me to answer.

Captain Collins played his role, and as such can not be exonerated, as is being called for in some quarters. But nor can he be blamed. Seeking to blame is for lawyers looking to savage someones bank account, and ambulance chasers.

I agree he cannot be exonerated and that is what this Paul Holmes discussion is all about. As for laying blame, it seems every time someone says they shouldn't be exonerated others jump up and down saying "you shouldn't look for someone to blame". It's not about laying blame, it's about being realistic and accepting that the Captain of that airliner did hold some responsibility for it hitting the mountain and therefore a public exoneration is not appropriate.

[framer]

Brian,along the lines of "you don't know what you don't know", do you think that Collins a) didn't know that it was unorthidox to operate a heavy jet at 1500feet clean, 250 knots while trying to navigate visually in an area he'd never been to, with visibility issues ("very difficult to tell the difference between the cloud and the ice"), no VHF contact that he had been expecting, known ice covered terrain in the area, and crew members saying things such as "where is Erebus from here?, I'm just thinking of terrain thats all", while 14,000ft below MSA?
or b) knew that it was unorthidox but was wrapped up the ANZ culture of getting the job done and made a series of poor decisions as a result?

[Brian Abraham]

It's not about laying blame

Unfortunately some of our friends are not of the same mind, even apportioning blame in percentages.

it's about being realistic and accepting that the Captain of that airliner did hold some responsibility for it hitting the mountain and therefore a public exoneration is not appropriate.

Fully concur.

ampan, absolutely nothing in your latest in anyway proves that the aircraft was in anything other than VMC. Flying the cloud break procedure and breaking out at the required 6,000 would present them with exactly the same issues.

Captain Collins knew that it was very difficult to tell the difference between the cloud and the ice. Tick

He knew there was a 13000 foot mountain in the vicinity, covered in ice. Tick

He descended from above the cloud to below the cloud, thereby putting the cloud above the aircraft and the ice below. Tick

He descended below MSA and below the height of the known hazard. By an approved means, Tick

He purported to descend VMC, which meant that took responsibility for keeping the aircraft clear of terrain, his primary tool being his eyes. Tick - once breaking out at 6,000

To repeat, the terrain below was covered in ice, which he knew. Tick

To repeat, the cloud was above, which he knew. Tick

To repeat, it was very difficult to tell the difference between the cloud above and the ice-covered terrain below Tick

The entire concept of attempting VMC below the MSA was fraught, and entirely at odds with those who do it for a living.

I'll eat my cat

You want fries with that?

Just joshing my friend.

knew that it was unorthidox but was wrapped up the ANZ culture of getting the job done and made a series of poor decisions as a result?

It is impossible to know what Collins thought of course, or why he did what he did on the particular flight. I'm inclined to come down on the side of "Normalisation of Deviance" as mentioned previously. The culture was not to comply with SOPs, and the fact that that was so was widely advertised. If I were to be asked I would say the decisions made by Collins on that fateful day were influenced by the conduct of the previous flights. But of course we will never know.

I flew for Esso in the offshore oil industry for 27 years and it was interesting to see new boys come on board. We made no attempt to comply with regulations, and despite the new boys protestations about what was asked of them, they soon happily fell into line. Such is the influence of organisational demands and perceived peer pressure. I say perceived because no actual pressure came from the other pilots, other than the old boys going out and getting the job done.

[prospector]

The entire concept of attempting VMC below the MSA was fraught, and entirely at odds with those who do it for a living.

That surely was why the only descent available was as quoted many times on this thread.



Quote:

They had no means of determining their azimuth from McMurdo, so that wasn't going to work.

So, what in effect you are stating is that the AINS was accurate enough to establish a position with enough accuracy to be blatting around at 1500 ft illegally, but not accurate enough to establish a position within the required arc and distance of the McMurdo TACAN above route MSA quite legally?????

Could you advise if you think this statement is incorrect, and if so why???

He descended below MSA and below the height of the known hazard. By an approved means, Tick

I cannot agree with that tick.

[ampan]

As you well know Prospector, there's no answer.

It appears that everyone accepts that Captain Collins was not blameless and should not be exonerated. My question is whether his error/s was/were more culpable than the error made by Captain Van Zanten in 1977.

In my view, Captain Collins was more culpable. He should not have gone below MSA, but having made that mistake, he had 20 minutes to retrieve the situation. Van Zanten never got that chance.

[Brian Abraham]

That surely was why the only descent available was as quoted many times on this thread.

And they would still be subject to the vagaries of whiteout.

As I said.

Flying the cloud break procedure and breaking out at the required 6,000 would present them with exactly the same issues.

I cannot agree with that tick.

Sorry, I did not make it clear. The ticks refer to if the cloud break procedure was flown.

[prospector]

Yes, starting to split hairs a bit here, but basically the accident was caused by non compliance with SOP's and CAA regs,

Not as Mahon and NZALPA claim the shifting of a waypoint.

When a senior check pilot accepts a invitation from a radar operator for a low level run at 1500ft, and makes that fact known to all and sundry and no action is taken by either the Company or CAA then it can be called a cowboy operation.

As was stated earlier in the thread Hubris on the part of some ANZ Captains of the time had a part to play also.

[ampan]

F*ck "Hubris", Prospector (whatever that is).

Captain Collins was the worst pilot ever employed by AirNZ, or TEAL. According to Holmes' book, he couldn't even manage to pass School C. The only surprising aspect about his death in 1979 is that it took that long to happen.

Any arguments?

[prospector]

Hubris: Arrogance or overconfidence, especially when likely to result in disaster or ruin.

Any arguments?

You are having a bad day. .

[topend3]

Holmes does a good job of using selected arguments to mount his case whilst conveniently ignoring others (such as the FL160 requirement).

He also hones in on Chippindales actions involving the CVR tapes, taking them to Farnborough for further analysis on his own, as pointed out by Mahon at the Royal Commission.

All valid points, however that doesn't change the facts. Holmes is not a pilot with any considerable experience, just like Chippindale wasn't. But the crews decision to leave FL160 and then descend below 6000' without being fully aware of their exact position was still the point at which the accident became inevitable, as Chippindale pointed out.

[ampan]

Prospector: Did you get School C?

What does the altitude of 6000 feet have to do with this accident? Let's assume that the captain levelled out at 6000 feet instead of 2000. So what: He would still have hit Erebus.

[prospector]

just like Chippindale wasn't

From a previous post of mine. Holmes and Mahon would have the public believe the nonsense they portray as to Ron Chippendales experience in the Aviation Feild.

From John Kings "New Zealand Tragedies,Aviation.

[quote] Ron Chippendale was the first witness to take the stand when the hearing began in an Auckland office building on 7 July 1980.

But while Mahon praised his witness for being a model witness, composed, impertuble and sure of his position, he belittled the capabilities of both the Chief Inspector and his staff. None of them, he said had ever been jet pilots, etc etc

The commissioners assessment of his first witness ignored Chippendales considerable experience as a flight instructor and transport pilot in the RNZAF.He had been formally involved in military flight safety and accident investigation for several years before being seconded to similar duties in civil aviation, and his standing in the world community is such that as someone scrupulously fair and independant, he has been asked to help investigate some accidents of a particularly delicate political nature. (Recently, for instance, he was appointed to the five strong United Nations team to investigate the loss of the Korean Airlines Boeing 747 airliner, Flight KAL007, shot down by a Soviet fighter near the Island of Sakhalin in 1983.)

What does the altitude of 6000 feet have to do with this accident? Let's assume that the captain levelled out at 6000 feet instead of 2000. So what: He would still have hit Erebus.

Not if they descended in the approved let down arc and distance from the TACAN station, and if at the bottom of that descent they could not still see Erebus, or any of the buildings at McMurdo they would know they did not have the required VMC conditions and no doubt would have climbed back to MSA within that same arc and DME distance. If you read the descent instructions you will note they were specifically designed to avoid Erebus.

You will no doubt have noticed that those descent instructions state that the only descent is VMC in that arc. It was not a cloud break procedure. No where is it approved to invent your own VMC descent.

The fact that civil equipment was not designed to receive azimuth information from the TACAN is irrelevant, The AINS was quite capable of providing that information. Remember it was a VMC descent they were supposed to carry out so using the AINS below MSA was quite legal

.

[ampan]

I'm slightly disappointed, Prospector. Imperial was the British empire's version of Pan Am - and they took you on without School C?

Your rule-based argument can't work. If the "SOP" for SYD-AKL said to go under the harbour bridge on landing approach, would you do it? Of course not.

Your airmanship argument, however, cannot be argued with. I've followed it for years and it turned me right around.