Mt Erebus Disaster 40th Anniversary
Every time the Erebus accident comes up on PPRuNe, we get the same old re-hashing of the arguments. I know a lot about this accident, having read the reports and most of the books, but I'm not going to express my opinion here.
Instead I thought I would recount an experience I had a few years ago at AKL. I arrived at the airport very early for my flight, so instead of immediately returning my car, I drove to the Erebus Crew Memorial Garden on the eastern end of Tom Pearce Drive, parked and sat there for half an hour. A very peaceful and (relatively) quiet place to sit and reflect.
" This garden is your special place "
Instead I thought I would recount an experience I had a few years ago at AKL. I arrived at the airport very early for my flight, so instead of immediately returning my car, I drove to the Erebus Crew Memorial Garden on the eastern end of Tom Pearce Drive, parked and sat there for half an hour. A very peaceful and (relatively) quiet place to sit and reflect.
" This garden is your special place "
Whispering "T" Jet
- if the crew had taken heed of the McMurdo controller who advised the conditions were not suitable, due to cloud and whiteout, for sightseeing in the area then the crash would have been avoided.
- if any of the crew had questioned the relative position of Bird Island then the position error could have been picked up.
- given the inability to see any of the expected landmarks in VMC if any of the crew (some of who were trained navigators) had plotted a position on the chart or atlas the crash would have been avoided.
- if the crew had decided that given their unfamiliarity with Antarctic operations they were just going to follow published procedures for let down below MSA instead of opting for a figure eight descending pattern in VMC when the CVR shows they weren't 100% certain of their position then the crash would have been avoided.
- if the crew had initiated a climb to above MSA at the first instance of doubt being expressed as to their situation the crash MAY have been avoided.
.
- if any of the crew had questioned the relative position of Bird Island then the position error could have been picked up.
- given the inability to see any of the expected landmarks in VMC if any of the crew (some of who were trained navigators) had plotted a position on the chart or atlas the crash would have been avoided.
- if the crew had decided that given their unfamiliarity with Antarctic operations they were just going to follow published procedures for let down below MSA instead of opting for a figure eight descending pattern in VMC when the CVR shows they weren't 100% certain of their position then the crash would have been avoided.
- if the crew had initiated a climb to above MSA at the first instance of doubt being expressed as to their situation the crash MAY have been avoided.
.
- if the Navigation Section hadn't changed the final waypoint to a position directly behind high terrain.
- if after making this change, had advised the operating crew about it.
I notice the tone of the posts now are softening a little in respect to blame versus contributing factors. It's a pity Ron Chippendale didn't apply that sentiment when he drew up his final report. The findings of his report (Pilot Error) was what ignited the search for truth.
There has always been three camps in this debate. The Chippendale, Mahon and Moderates.
The Mahon report contained overwhelming evidence it was not pilot error that caused this accident. That finding upset the Chippendale/Air New Zealand and NZ Government so began years of trying to overturn that conclusion. To no avail. In fact, the compensation paid out to victims by the Air NZ insurers and NZ government, the failure of the appeal to the Privy Council to overturn the findings in the Mahon inquiry and finally an apology by both these parties to the families of the flight crew, further crystallized the Mahon findings. They have never been overturned on appeal.
I have no doubt this debate will continue but The Honourable Justice Mahon got it right and the findings in his inquiry still stand today.
India Four Two, a very nice touch and prudent post to end (until the next chapter) this debate.
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3 Holer,
On perusing your published details of licences held in public profile, I see you have displayed HR/MC, is this a joke? The only licences I can find with these letters are HR=Heavy Rigid, and MC= Multi Combination.
Is this indeed the case?, if so hardly qualifications for laying down the law in an aviation forum. I believe this question was raised many years ago, but as all the previous posts, years ago, on this subject of Erebus, have disappeared I am afraid I cannot recall your answer.
On perusing your published details of licences held in public profile, I see you have displayed HR/MC, is this a joke? The only licences I can find with these letters are HR=Heavy Rigid, and MC= Multi Combination.
Is this indeed the case?, if so hardly qualifications for laying down the law in an aviation forum. I believe this question was raised many years ago, but as all the previous posts, years ago, on this subject of Erebus, have disappeared I am afraid I cannot recall your answer.
Last edited by prospector; 5th Dec 2019 at 21:15. Reason: Correct finger error
I notice you have left out two important IF(s).
- if the Navigation Section hadn't changed the final waypoint to a position directly behind high terrain.
- if after making this change, had advised the operating crew about it.
I notice the tone of the posts now are softening a little in respect to blame versus contributing factors. It's a pity Ron Chippendale didn't apply that sentiment when he drew up his final report. The findings of his report (Pilot Error) was what ignited the search for truth.
There has always been three camps in this debate. The Chippendale, Mahon and Moderates.
The Mahon report contained overwhelming evidence it was not pilot error that caused this accident. That finding upset the Chippendale/Air New Zealand and NZ Government so began years of trying to overturn that conclusion. To no avail. In fact, the compensation paid out to victims by the Air NZ insurers and NZ government, the failure of the appeal to the Privy Council to overturn the findings in the Mahon inquiry and finally an apology by both these parties to the families of the flight crew, further crystallized the Mahon findings. They have never been overturned on appeal.
I have no doubt this debate will continue but The Honourable Justice Mahon got it right and the findings in his inquiry still stand today.
India Four Two, a very nice touch and prudent post to end (until the next chapter) this debate.
- if the Navigation Section hadn't changed the final waypoint to a position directly behind high terrain.
- if after making this change, had advised the operating crew about it.
I notice the tone of the posts now are softening a little in respect to blame versus contributing factors. It's a pity Ron Chippendale didn't apply that sentiment when he drew up his final report. The findings of his report (Pilot Error) was what ignited the search for truth.
There has always been three camps in this debate. The Chippendale, Mahon and Moderates.
The Mahon report contained overwhelming evidence it was not pilot error that caused this accident. That finding upset the Chippendale/Air New Zealand and NZ Government so began years of trying to overturn that conclusion. To no avail. In fact, the compensation paid out to victims by the Air NZ insurers and NZ government, the failure of the appeal to the Privy Council to overturn the findings in the Mahon inquiry and finally an apology by both these parties to the families of the flight crew, further crystallized the Mahon findings. They have never been overturned on appeal.
I have no doubt this debate will continue but The Honourable Justice Mahon got it right and the findings in his inquiry still stand today.
India Four Two, a very nice touch and prudent post to end (until the next chapter) this debate.
But they went against policy and the basics for descent below MSA/LSALT. How can that not be the fault of the crew?
The McMurdo controllers mentioned the difficulties they would have had in monitoring the aircraft on its descent due to the radar limitations (1.5° pencil beam and only calibrated to a 20° elevation - max available being 30°) and the fact that the eastern end of the approach sector was located over head the radar site, and therefore invisible, the controllers also had no information about the approach procedure, or the area in which it was to take place, so the controllers couldn't monitor events, as one controller said, the procedure was "absurd".
The VMC descent procedure was introduced on the penultimate flight where radar monitoring was not required. The controllers had not received the flight plan of the fatal flight and said that they would have disagreed with overflight of Erebus, probably because they had knowledge of ten metre diameter boulders being thrown up to the height of the 16,000 LSALT, and other smaller debris higher. The entire reason the RNC route runs where it does.
It was an operation run by folk who were completely out of their depth, an accident was inevitable, unfortunately as is often the case, good people paid with their lives, "Tombstone Mentality" requires an accident before lessons are learnt.
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"The reason they did is because that was the SOP adopted. McMurdo controllers stated that no flight ever made its descent from the LSALT in accordance with the laid down SOP, they always came up McMurdo Sound at low altitude, at times below 1,500 ft."
Not so
But the only other flight that had the weather conditions similar to this flight , Capt Roger Dalziel's went to the alternative sightseeing route over the South Magnetic Pole. Surely the weather conditions that were passed to the crew, and the recommendation that sightseeing was not advisable in the Mc Murdo area are the relevant details.
As to all the flights going up McMurdo Sound, at 1,500ft or lower the following would refute that statement.
" The police investigation focused on Mayne Hawkins, the pilot of the first company flight to the Antarctic-- the previous excursions had been flown for a travel agency-- who flatly denied under oath, flouting the rule about the 6,000ft minimum. If he could be proved guilty of perjury the way was open to demolish the airline's case completely and prove the conspiracy theory..
"I thought of all the people to give evidence, mine was the least controversial" says Hawkins, "but the police scoured the world to find evidence that I'd gone low. I sat in limbo, completely frustrated"
My lawyer approached the police to ask why nothing had happened, why there was no talking to me, and they asked him what I had to hide. They didn't believe the evidence of the other members of my crew, saying it was a bit like a wife giving evidence for her husband."
The one piece of 'EVIDENCE' was a remark that the DC10 was "going down to a lower altitude" which proved absolutely nothing when no mention of its previous height was made, and the case was quietly dropped.
The case was quietly dropped, the person that gave the flight crew the weather report of conditions at McMurdo was not called to give evidence, could one not be forgiven for seeing a pattern developing.
Once again nobody is stating that a lot of folks did not do their jobs properly, but he statement that the crew were completely blameless is patently ridiculous.
Not so
But the only other flight that had the weather conditions similar to this flight , Capt Roger Dalziel's went to the alternative sightseeing route over the South Magnetic Pole. Surely the weather conditions that were passed to the crew, and the recommendation that sightseeing was not advisable in the Mc Murdo area are the relevant details.
As to all the flights going up McMurdo Sound, at 1,500ft or lower the following would refute that statement.
" The police investigation focused on Mayne Hawkins, the pilot of the first company flight to the Antarctic-- the previous excursions had been flown for a travel agency-- who flatly denied under oath, flouting the rule about the 6,000ft minimum. If he could be proved guilty of perjury the way was open to demolish the airline's case completely and prove the conspiracy theory..
"I thought of all the people to give evidence, mine was the least controversial" says Hawkins, "but the police scoured the world to find evidence that I'd gone low. I sat in limbo, completely frustrated"
My lawyer approached the police to ask why nothing had happened, why there was no talking to me, and they asked him what I had to hide. They didn't believe the evidence of the other members of my crew, saying it was a bit like a wife giving evidence for her husband."
The one piece of 'EVIDENCE' was a remark that the DC10 was "going down to a lower altitude" which proved absolutely nothing when no mention of its previous height was made, and the case was quietly dropped.
The case was quietly dropped, the person that gave the flight crew the weather report of conditions at McMurdo was not called to give evidence, could one not be forgiven for seeing a pattern developing.
Once again nobody is stating that a lot of folks did not do their jobs properly, but he statement that the crew were completely blameless is patently ridiculous.
Last edited by prospector; 6th Dec 2019 at 01:29. Reason: addition
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anyone who has been involved in safety investigation knows that we are not trying to allocate blame, we are trying to identify the causal factors that contribute to the incident and then see if procedures or knowledge can result from the investigation that may help prevent a similar incident in the future. The lack of a thorough and balanced report in this case goes against all best practice.
Conduct a new investigation, with contemporary investigation practice.
This thread being re-activated on significant anniversaries may cease in theses tones if that occurred.
But do not allow the ATSB to have anything to do with it.
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And this;
Nailed it again.
(Sorry Ollie, re-formatted in the way I read and thought about it, and a little bit of OCD)
I think you will find that I repeatedly state in all of my posts that I consider the contributing factors and systemic failures associated with AIR NZ are incontrovertible fact and as you state without the navigation bungle the crash would not have happened. I am just pointing out that you can not alleviate the crew of ALL responsibility either as to do so means that many learnings from this accident will be lost.
I agree there are major flaws with Chippendale's report as even though he identified some relevant issues he totally ignored the part that the company played.
The Mahon review did the total opposite, he identified the company errors and totally disregarded some errors made by the crew.
I personally like to learn from these incidents and have been involved with Safety and Accident investigation for many years for mainly selfish reasons. Because of accidents like this one if I am flying into an airfield or environment with high terrain that I am unfamiliar with I will carry out full procedural arrivals over a visual approach every time even in CAVOK conditions until I have gained some local knowledge as I have read way to many reports of CFIT where a loss of situational awareness of position and terrain lead to loss of life.
I can't hand on heart say that I would have done anything different on the day to the crew onboard TE901, we should be in an industry though that accepts the errors that get made and do our best to learn from them. Having a 'blameless' culture is detrimental to a good safety system as ignored errors are errors that will happen again.
I agree there are major flaws with Chippendale's report as even though he identified some relevant issues he totally ignored the part that the company played.
The Mahon review did the total opposite, he identified the company errors and totally disregarded some errors made by the crew.
I personally like to learn from these incidents and have been involved with Safety and Accident investigation for many years for mainly selfish reasons. Because of accidents like this one if I am flying into an airfield or environment with high terrain that I am unfamiliar with I will carry out full procedural arrivals over a visual approach every time even in CAVOK conditions until I have gained some local knowledge as I have read way to many reports of CFIT where a loss of situational awareness of position and terrain lead to loss of life.
I can't hand on heart say that I would have done anything different on the day to the crew onboard TE901, we should be in an industry though that accepts the errors that get made and do our best to learn from them. Having a 'blameless' culture is detrimental to a good safety system as ignored errors are errors that will happen again.
(Sorry Ollie, re-formatted in the way I read and thought about it, and a little bit of OCD)
The nzherald published an article yesterday that hides behind a paywall, titled "Maynard Hawkins: Executive pilots 'sacrificed' in the effort to apportion blame for Erebus". Anyone able to post article?
I can't hand on heart say that I would have done anything different on the day to the crew onboard TE901
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Ego, not a dirty word.......
You have to admit it though, us pilots are somewhat egotistical! It’s a highly rewarding yet skilful job. It’s very competitive and most pilots are very good at what they do. Combine that with reasonably good pay and a high level of accountability and responsibility and you get some ego’s coming out to play. Besides, if it weren’t for pilots and the never ending pissing contests, PPrune really would be a drab place to hang out. C’mon boys and girls, be honest now, we know it’s true.
I know I have the benefit of hindsight, but why did he not confirm exactly where he was? I know I don’t go descending below MSA’s until I know exactly where I am. Just because you think you know where you are, it doesn’t mean you are. When you KNOW where you are, then descend
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A diligent crew would have found time to plot their computer flight plan Lat/Long coordinates unto their Ross island RNC (Radio Nav) chart, connected the dots and then clearly seen that their track was 27 nautical miles east of their intended course, east of McMurdo Sound. I still do that when crossing the ponds.
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I know I have the benefit of hindsight, but why did he not confirm exactly where he was? I know I don’t go descending below MSA’s until I know exactly where I am. Just because you think you know where you are, it doesn’t mean you are. When you KNOW where you are, then descend
THEN he didn't take the moment to plot his position off the INS readout - a quick, basic, 30 second job which would've saved everyone's lives.
And then a sequence of poor decisions followed - most of which can be summarised as a complete failure of situational awareness.
Whispering "T" Jet
A diligent crew would have found time to plot their computer flight plan Lat/Long coordinates unto their Ross island RNC (Radio Nav) chart, connected the dots and then clearly seen that their track was 27 nautical miles east of their intended course, east of McMurdo Sound. I still do that when crossing the ponds.
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Suppose TE901s changed track was not as a result of the Navigation section, but of the crew wrongly entering the single digital manually into the INS (as they did for these flights). It easily could've happened. Would you then still blame the accident on that one single factor?
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Jaayyus, how much longer before this thread becomes bigger than the Glen Buckley vs. CASA one?