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Joined: 27/06/2009
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It seems to me, after an overview of this website, that the findings of Chief Investigator Ron Chippindale have been somewhat discredited. In talking with a pilot and simulation trainer today I am backed in my belief that the findings of Chippindale are not to be overlooked. There are set parameters in which pilots are to fly, clearly above 16,000ft in this instance, these are in place for a very very good reason. The tone of this "enlightening" website is that Mahon's report takes precedence over Chippindale’s and this leads to a somewhat biased approach. The website is created by the New Zealand Air Line Pilots' association (NZALPA) which goes to show why the pilots are being protected, but knowing that Mr Chippindale was a very meticulous man in all his works leads me to ask the question, “why have his findings been tossed aside…?”.
I know my respect, and that of many others, will continue to be with the late Mr Chippindale as even after his retirement he was, time after time, approached by countless governments wanting his interpretation on international incidents.
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Joined: 27/06/2009
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I personally disgree with those who last year who along with the pilots association trying to secure flights to antartica for the 30 years anniversary in November this year. I believe well should be left alone - the place is now a resting place for those who did not come back to us. There is going to be no certainity that if they ever did fly down there you would see anything leave well alone and let those who have been tragically taken from us in such romote isolation rest in peace - they live on in our hearts
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Joined: 28/06/2009
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On the contrary, I think the information that is available enlightens me to what Mr Chippendale was up against, the technicalities of the flight, how it was operated, the environment in which it operated and I am talking about both the aircraft flight medium as well as the management and corporation medium.
The information I have seen & read re-affirms for me that Mr Chippendale was very meticulous and extremely professional in his approach, and his conclusion highlighted a major point in the envelope of flight safety.
It is very easy after 30 years of hindsight for many of us to continue analysing what we see today as the facts and come to conclusions and reasons as to the cause. In my personal opinion it was not and never will be attributable to one or the other - in my view there a was a systemic falure across the spectrum of flight safety and cupability perhaps rested with the industry as a whole. But neither this is helpful for those directly affected and there is I think some comfort that the improvements in aviation safety over the years, and industrial safety in general for that matter, has helped considerably to improve and mitigate the risks that are ever present in aviation, and this was because of the work that Mr Chippendale did.
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Joined: 28/06/2009
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Our hearts are with the people who died at Erebus and their families- also with those who worked under extreme stress to determine the cause of the tragedy. Mr Chippindale did the best he could and Gordon Vette took it to the next level by demonstrating what whiteout did to the crew of TE901.
Mahon wrote an eloquent summary of the tragedy and pointed to the single dominant cause being the change of coordinates and failure to advise the crew and Mahon went further to say that the flight crew were not responsible for the disaster.
God bless Mahon - however I feel Mahon and the crew of TE901 missed a fundamental rule in aviation (Never mix VFR and IFR)
The INS is a NAV instrument to be relied on above MSA. On the day , the crew descended under VFR with a couple of racetrack orbits and re-armed the INS NAV, providing the crew with a false and fatal level of comfort.
I propose that if the crew did not re-arm NAV mode after the second orbit - they would have aborted VFR and climbed out much earlier.
On this basis I propose that this VFR-IFR mix is the dominant cause of the tragedy.
The power of confession is redeeming.
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As an airline Captain for the world’s largest airline with over 14,000 hours of flight time, I for one certainly appreciate the attempt of exonerating the pilots from blame in this tragic accident. Please understand that my comments here are not intended to disrespect anyone. Unfortunately, I believe the CVR arguments are a moot point and seem to serve only as a distraction from the obvious reason for the crash. CONTROLLED FLIGHT INTO TERRAIN (CFIT). The investigators can argue about, manipulate, change, alter, or even fabricate CVR conversation, but they cannot change the fact that the flight crew flew the aircraft into the ground. Whether or not they were in IMC conditions is somewhat irrelevant. It’s quite obvious that for whatever reason, they did not visually see the terrain which was directly ahead in their path. If they were IMC, or if they were heads down looking at charts or radio squelch knobs, is immaterial (i.e. Eastern Airlines L-1011 Flight 401 VMC CFIT crash into the Florida Everglades in 1972). cockpit discussions did not indicate any type of aircraft problem other than a minor communication glitch. The aircraft was not in distress and it was flying normally when the flight crew received the GPWS warning. They were obviously unaware they were about to receive this GPWS warning. While they did respond appropriately to the GPWS warning, it is a warning which they should have never received. Although my interpretation may be harsh and unwanted, I believe the flight crew believed they were 26 miles from a necessary climb point, when in reality they were in need of an immediate climb. This locates them about 30 miles from where they thought their position was. This certainly does not mean they were lost as some have put it, it just means that their acceptable navigational error tolerance was much too high. As a low level tactical attack pilot for the US Navy, our navigational error tolerance was reduced to nearly zero when we were flying low level missions below terrain level. My sincere condolences certainly extend to everyone involved in this tragic story, but trying to pretend it was the result of something other than pilot error CFIT is truly counterproductive to safety. The recent AirFrance crash seems to be following in this same path. My harsh but probable opinion is very much the same. Pilot error due to continuing into a Level 5 massive thunderstorm. Not many aircraft are built to withstand 100 mph instantaneous vertical wind velocity changes. My point here is that even as professional pilots, we are all capable of making mistakes, which in my opinion this flight crew did. In conclusion, in the name of safety, we should not cover up the obvious in an attempt to protect or honor our fallen comrades. SW
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Joined: 29/06/2009
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Admittedly, I am a layman, but to me the cause is very obvious.
The Flight Plan called for lowering to 16,000 feet for sightseeing, or to 6,000 feet in good weather with at least 20 miles visibilty.
Due to poor visibility, Flight 901 went right down and was below 1,500 feet when it hit Erebus. It should not have gone below 16,000 feet.
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Having worked for Ron Chippindale and later in the Royal Commission would I support the comments that Ron Chippindale was a meticulous and thorough investigator, but I did not agree with his findings. His investigation was made all the more difficult with the reluctance of Air NZ to release documents that later became available to the Royal Commission along with the records of shredded documents. However, we could go on disecting the accident. It remains, clearly, a human factors accident. How we allocate the proportions of human failure or weakness can be debated. The crew were not trained for such visual phenomena, and having a 16,000 ft limit set by management is unrealistic when the only signs of human habitation or scenic attraction are visible from about 2,000 ft. The loss of our friends and colleagues only becomes bearable if we have learnt from this tragedy. Can we make the same or similar mistake again???
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To Maninblack: I am very limited to the space allocated for such forums, so I may be forced to break up my lengthy thoughts into several posts. Under the guise of safety, I have been reviewing this case nearly all day long. Maninblack, I believe your numbers are correct, and your analysis seems to be dead on accurate.
To the Investigators: My analysis of this accident is 30 years after the fact; however, now I have well over thirty years of aviation experience to base my opinions. I also suspect that my thoughts will not fall upon deaf ears, as this accident has undoubtedly and unfortunately affected many families and changed many lives.
FYI: I spend my valuable time doing this because I still think there are several benefits from doing so. First of all, surviving family members of flight TE 901 still desperately need logical, but not masked answers with hidden agendas, and they also need closure from such a disaster. Secondly, as fellow aviators, we also need answers and closure, albeit the answers and closure we need stem from different sources and emotions.
I believe most of the arguments about the CVR are irrelevant, unless the investigators just wanted to discover who on the flight deck voiced concern over their fateful descent into terrain. I have some difficulty believing that no one in the caukpit (gets edited if spelled correctly) had serious concerns about their altitude. This of course was a part of the CVR dispute. Even in crystal clear VMC, it should have been a concern for everyone. The 6000 foot “hard deck” was set for a reason, and like Maverick, in the movie “Top Gun” they saw no danger and they (or perhaps just the Captain) chose to go below the hard deck. This decision is most likely what killed 257 people including the Captain. Had they not had a flight plan error, they may have gotten away with it, but it doesn’t change the fact that it was in bad judgment to descend to this extremely low altitude.
I’m not sure about the GPWS (in the industry we call it Gipwhizz) system they had in their aircraft in 1979, but all of our current GPWS systems also have configuration sensors too. The warning criteria are too complex and numerous to discuss in this forum, but at 1500 feet AGL and not configured for landing, this will give us several types of loud and obnoxious warnings and normally for good reason. Additionally, height above the ground is very difficult to determine visually, especially if visibility is marginal. The flight crew may have been going strictly on visual cues and not paying close attention to their actual altitude. Jet aircraft can change altitude very succinctly, quietly, and rapidly, if not carefully and diligently monitored. Undesired or excessive altitude changes have surprised many of the most experienced flight crews in the world. Flying commercial jet aircraft is a supremely unforgiving and dynamic environment.
Apparently their flight plan was changed giving them some lateral navigational errors, but it still does not mitigate the fact that the aircraft impacted the ground at 1400 feet. This is well below the tops of surrounding terrain and is quite apparent in the photos. Why a flight crew would descend to a questionable altitude is perhaps a debatable topic as well. Some might say this crew was most likely trying to go above and beyond the call of duty to give the paying customers a show for their money. This is totally understandable, nevertheless, the outcome from unrehe****d and spontaneous aviation acts like these are often times catastrophic. In the Navy we called this “Flat Hatting.” Hmmmm, Think about it. I have lost many talented pilots and close friends to daring acts like these.
Re-evaluation: AFTER reviewing the crash site pictures, I must reassess my earlier evaluation in only a few ways. In a former post I said the flight crew may have not been IMC, but just possibly heads down in the caukpit. This was based on reports that pax took pictures showing clear skies all the way until impact. From a vast experience base, I can assure everyone involved that slant range visibility which is what the pilot views is totally different from what the pax were taking pictures of. After looking at the surrounding terrain, direction of flight, impact trajectory and altitude, I must draw a slightly different conclusion. I now believe the slant range and forward visibility for the flight crew was extremely limited. I also still believe that they had a positional error which they were totally unaware of. My original opinion was that their acceptance of navigational error tolerance was too high, but actually that may not have been a contributing factor at all. After further analysis, it is more likely that their position error was a dispatcher induced and ignored or un-highlighted flight plan change which may have placed them in a different position than they thought they were. This may have lulled the flight crew into a nonchalant and false sense of complacency of altitude concern and awareness. This scenario makes much more sense.
Must Run.
SW
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Joined: 28/06/2009
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Waves - I would like to understand further your comment that whether they were IMC is immaterial
Could this tragedy have occurred if they stayed IMC ??
thanks..JC (+64 21 041 9379 )
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The official report and all those so called experts who wrote books, papers and told thier opionons will always believe what they have to say is right. We will always agree to disagree with what we do not like about this case and very public tragedy. Thirty years in November will see the anniversary again of this disaster - those who are the so called experts will still be debating this in 30 more years
At the end of the day 257 tragically lost thier lives we all do something each day - speed, dont put seat belt on, talk on the cell phone, various other thing against the rules ie the law and while we dont have an accident or get caught out the going is good when something goes wrong that we question why it has been done like that for so long
No amount of blaming will bring these people back they pilot should have not done this, air new zealand should have done that - we could debate forever wether we really know what we are talking about, why not leave these people to rest in peace
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To JC Universe: Part of my quote was this: “Whether or not they were in IMC conditions is somewhat irrelevant. It’s quite obvious that for whatever reason, they did not visually see the terrain which was directly ahead in their path. If they were IMC, or if they were heads down looking at charts or radio squelch knobs, is immaterial.” At the time of the impact, I believe they were indeed IMC, however, what I mean by this statement is just this. For whatever reason, the flight crew did not see the terrain directly in front of the aircraft. I don’t think anyone will dispute this fact. The only reason they began evasive action to avoid hitting the ground was due to a Ground Proximity Warning System alert, and not because they visually picked up terra firma. There are only four possible reasons why this aircraft impacted the ground. First, is they had a mechanical problem which made it impossible to climb or control the aircraft. This one I believe is easily ruled out. There is no evidence of any aircraft problem that I am aware of. Second, they were distracted in some way or just not paying attention to the terrain in front of them. Possible, but not likely. Third, they were IMC and could not see the terrain in front of them. Most likely. Forth, in a completely snow covered area, depth perception and altitude is very difficult to discern so they may have unintentionally descended below a safe altitude. I haven’t seen all of the transcripts so I can’t say for certain if the flight crew intentionally descended to this altitude, or if they lost track of their descent profile and descended well below their intended level off. Why this all becomes immaterial is because the fact is that the flight crew intentionally or unintentionally descended to an unsafe altitude and then they hit the rocks. Game Over. Pilot Error! The CVR arguments should be focused more on WHY they went down to this unsafe altitude. Without being privy to the CVR, I can’t rule out one last possibility. One last thought and possibility: It is certainly possible that they never reset their altimeters after descending through 18000 feet. Extreme cold temperature and low pressure can induce significant altimetry errors. Additionally, they could have also misread their altimeters. Not likely, but these errors have caused numerous major crashes and it is possible; however, the investigators most likely would have been able to determine if these types of errors were a causal factor. JC, I hope I have answered your question.
To bettibop: Pilots and Investigators analyze crashes not to be disrespectful. We do it to understand what went wrong so that we don’t make the same mistakes over and over. We want to know if it is a mechanical problem, a design problem, a communication problem, a CRM problem, or pilot error, etc. I have flown bigger aircraft than this DC-10 with more passengers aboard. This is my job. I don’t want to injure or kill any of them. One of them may be you someday.
Thanks, SW
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Waves - thanks for your full response
I have only flown VFR in light aircraft so my question is
I thought IMC requires a pilot to be MSA or higher ? or if flying below MSA - a ground reference like VOR, DME, Radar vectoring etc ?
have I misunderstood ?
thanks..jc (+64 21 041 9379 )
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To JC: I didn’t fully understand your question, but I believe I do now. You have a slight misunderstanding of the aviation acronyms which is very common in aviation. You seem to be confusing the terms VFR/IFR with the terms VMC/IMC. These terms are not interchangeable and have completely different meanings. VFR and IFR are acronyms for Visual or Instrument Flight Rules. Without getting too deep, these rules are in place and generated by the FAA or ICAO. These rules govern how we fly our aircraft in CONTROLLED airspace. VMC and IMC describe the Visual or Instrument Meteorological Conditions only. IFR does not imply one is flying in IMC, and conversely, IMC does not imply one is flying IFR. Also worth mentioning, IMC does not necessarily imply only inclement weather conditions. IMC basically refers to conditions in which the pilot must use instruments to properly fly the aircraft. In other words, without true references to terra firma, we must use instruments to keep the aircraft with the shiny side up. Flying VFR on an absolutely clear night over the ocean with no ambient light many times forces a pilot to rely solely on instruments. This condition is actually IMC even though there isn’t a cloud in the sky. In some cases, flying over a snow covered area with a white out below and overcast above can be very similar. I believe your question was actually referring to IFR and not IMC. Had flight TE 901 remained on an IFR flight plan, you are correct they would have been fine; however, IFR flight plans do not normally include site seeing tours in uncontrolled airspace. I haven’t looked at charts for that area, but my guess is that below 18,000 feet it is all uncontrolled airspace. Either VMC or IMC in uncontrolled airspace allowed them to do just about anything they desired. If they were in uncontrolled airspace, they were neither VFR nor IFR. I hope this has cleared up any misconception between these aviation terms and their respective meanings. My belief is that flight TE 901 was IMC in uncontrolled airspace. I’m not certain they were in uncontrolled airspace, but I am convinced they were IMC. Terrain doesn’t normally sneak up on a flight crew while in VMC. Additionally, one of the flight crew said they must begin a climb in 26 miles, indicating they knew they were well below surrounding terrain elevation. I believe their positional error coupled with their complacency with their altitude while in IMC is what caused this accident. It is also my opinion that flying a low level mission in a DC-10 at extreme latitudes in IMC is in bad judgment and bordering irresponsibility. The very second that they entered IMC, they should have initiated an immediate high performance climb. This would have undoubtedly saved them from their ultimate demise. Waiting until a GPWS warning was obviously much too late. As a young naval fighter pilot flying a low level into the Fiords of Norway, my wingman and I flew into IMC. With terrain on both sides of us and nowhere to go but straight up, I initiated a high performance climb straight up. We climbed to 31,000 feet without ever breaking out of the weather. Had we continued straight ahead using inertial nav and ground mapping radar and then hit the rocks, the investigators would have been scratching their heads wondering what happened and why. Whose fault would that crash have been do you suppose? Again, I hope this post answered your question a little better. SW
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waves.. thanks very much .. I'm getting to understand better
so am I correct in interpreting that a) the crew were VFR at 1500 ft and b) that the INS-Nav is an IFR instrument ?
thanks..this is all leading to the conclusion that the responsibility for the accident lies with the flight crew
jc ( +64 21 041 9379 )
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I’m sorry JC, but I believe neither is correct. If they were in controlled airspace, then you would be correct, but if they were in uncontrolled airspace, which I am presuming they were, then they were not being controlled by anyone. In other words, NO RULES. So Visual Flight Rules (VFR) would not apply. This is an over simplification, but for the most part, that is how it works. Example: In uncontrolled airspace, there are no rules as there are in VFR to maintain specific distances from clouds. Compared to VFR, uncontrolled airspace is a dangerous free for all. As a point of interest, if Flight TE901 was in uncontrolled airspace, they would have been legal to fly in and out of clouds as much as they desired. Legal, but not wise! In the US, we have very little uncontrolled airspace above 1200 feet AGL, but we certainly have lots of it below 1200 feet AGL and 800 feet AGL. Check out any VFR sectional.
Inertial Navigation Systems (INS) are for position information and they usually work in conjunction with VOR, DME, and GPS systems. Inertial Reference Systems (IRS) and Attitude, Heading, Reference Systems (AHRS, pronounced Ahars) generally provide the instrumentation to fly solely with reference to instruments. I hope this information is helpful.
SW
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The conclusion of Ron Chippendales report at the time was the same as yours - pilot error. I am certainly no expert in this feild and your analysis provides alot of information for laymans such as myself. But I am interested in flight deck safety and situational awarness and it seems that this played a part?
I can't help but wonder if this is what situational awareness is all about, especially the need to be able to somehow recognise when something might become a problem? It is interesting to me that the crew could see, but didn't seem to know what they were seeing, likewise the knew where they were (in their minds), but actually didn't know where they were, it is somewhat like an oxymoronic situation.
How do pilots manage this sort of thing today? How is situation awareness managed? what has flight deck safety learned from these sorts of issues?
I appreciate that this might not be appropriate, but are there similarities in the accident at Perpignon? (I hope I don't get flamed for saying that, I mean no disrespect). I appreciate the report is not out, and only an interim report has been published, which as far as I can read seems to more about facts. But facts are facts, and it is not disproven there was no problem with the aircraft , but again I contrast an oxymoronic situation - too slow, too low in any event.
Please forgive me for my post, I hope it does not offend anyone and is amateurish but I am interested in these topics as whenever I'm flying, I am one of those pax who enjoys looking out the window and is not particularly interested in the IFE, knowing that several inches away from me is death.
George
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To Investigator: For starters, our navigational equipment has improved dramatically since this 1979 accident. Most of our aircraft nav systems continuously cross check our position with ground reference stations and Satellite Global Positioning Systems. These systems are unbelievably accurate even in high latitude areas. For certain types of navigation and approaches, we must check the system for drift which we call RNP (Required Navigation Performance). Additionally, procedures for my airline for international flight require plotting all ocean crossing points. Better nav equipment would probably not have helped TE 901, but plotting their course may have illuminated their apparent route change. SA (Situational Awareness) and CRM (Cockpit Resource Management) are vast subjects that involve many different areas much too involved for discussion here.
As an airline pilot, I often analyze questionable accidents like this one so as to not follow the same path and make similar mistakes. It is certainly not my intent to sound condescending, arrogant, intolerant, or disrespectful in any way. I have not read every detail of this accident and I am certainly not privy to all of the information, so my synopsis of this accident is brief and succinct, and I could certainly be incorrect. Part of my theory could be considered to somewhat contradict some of the alleged data to some degree. Here is why. Accident investigators state that film from passenger’s cameras revealed clear skies until impact. If this is indeed correct, then my theory still holds true, but it places even more blame on the pilots. The fact is, the flight crew flew a perfectly good airplane into the ground (CFIT), and they didn’t know it was coming until they received a GPWS ground proximity warning. So either they were not paying attention to what was visually ahead, or they were IMC. I cannot imagine ANY flight crew not at least taking an occasional glimpse out the front windscreen, especially when they knew they were below surrounding terrain elevation. This makes no sense to me whatsoever. Additionally, their conversation about needing to climb in 26 miles confirms (to me) that they could not visually see the terrain directly in front of them. Had they been looking at the terrain, they would have surely said instead, “Let’s start a climb to get over this terrain, or “We need to come left or right to avoid this terrain.” They didn’t! I believe they were completely unaware of their position error caused by incorrect or changed coordinates, and they believed they were at a safe altitude for their position. Why else would they be there? Unfortunately, their actual position was not confirmed before descending into IMC with mountainous terrain all around. I believe this was their downfall and sealed their fate. SW
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Waves... to quote you here, and this is the basis of your position. " So either they were not paying attention to what was visually ahead, or they were IMC."
I believe that this single line is the dividing point for most peoples' position........ the point of ALL of Gordon Vette's work is they did not or could not make this choice... there was nothing alarming about what they could see visually ahead for them to not pay attention to... they simply could not see the mountain right in front of them in clear conditions as it had been renderred invisible, worse still it had been renderred a 'flat expanse of ice shelf' to the horizon due to sector whiteout, i.e the scattering of the diffuse light below an overcast in clear air that surruptitiously removes all textural cues while leaving the flat horizon appearing in the distance.
They did not ignore or act inattentively to anything, who could when flying around there.
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To Kavette:
They did not ignore or act inattentively to anything, who could when flying around there. I completely agree with you. Your entire post is very well stated. As I have said before, not paying attention to the terrain in front of them is not plausible. At least it isn’t to me. Positional error with a white out in front of them is the only logical explanation to me. Reiterating my previous comments, their positional error was undoubtedly a contributing factor, but not the direct cause. Purposely descending to an altitude which is well below surrounding terrain without assurance of terrain clearance is where the pilot error comes into play.
Another example of this type of CFIT accident is the American Airlines Cali crash. For a safety review during recurrent training, I was allowed to listen to the CVR in this accident. As the aircraft was rapidly descending between two mountain ranges, the pilots allowed the aircraft to make a turn directly into the mountains. While they were trying to figure out why the aircraft turned, they received a GPWS warning just like TE901, and just like TE901, they immediately responded, but about 150 feet too late. This crash also resulted from a positional error and a lack of visual references at night. SW
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Hi again waves..
The Cali accident is very different in that they were descending proceedurally at night in IMC in mountainous terrain, they inadvertantly selected the wrong direct to waypoint after a late runway change while distracted and setting up for the new approach, and continued to descend below mininum safe altitude without the charts ready.... the Speedbrakes remained deployed which did not help and the were very aware they had become lost... they did fail to climb immediatley to a safe altitude when lost in IMC, this is not a comparable event, this crew had every cue that they were in a comprimised position.
To quote you again...Purposely descending to an altitude which is well below surrounding terrain without assurance of terrain clearance is where the pilot error comes into play."
Having conducted an approved cloud break procedure, Collins and his crew were flying at the time under VFR (visual flight rules), below an overcast, with the assurance of 'visual' terrain clearance.... they indeed had the required visual assurance, this allows them to descend all the way to 1500 ft or lower, provided they have adequate visibility, which the photos at impact reveal they did have. However the crew and the company were unaware that VFR under an overcast in Polar conditions is not possible due to the "malevolent tricks played by the polar light" (to quote a smart man).
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