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March 29, 2008
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Eastern Flight 401
What really happened!
By
For
Aviation/Aerospace Psychology
MAS 634
Embry-Riddle Aeronautical University
Extended Campus
Fort Rucker, Alabama Resident Center
March 2000
The following National Transportation Safety Board (NTSB) abstract indicates only one of the many reasons for the actual crash.
Date: December 29, 1972
Type: Lockheed L-1011
Registration: N310EA
Operator: Eastern Airlines
Where: Miami, FL
Report No. NTSB-AAR-73-14
Report Date: June 14, 1973
Pages: 45
An Eastern Air Lines Lockheed L-1011 crashed at 2342 eastern standard time, December 29, 1972, 18.7 miles west-northwest of Miami International Airport, Miami, Florida. The aircraft was destroyed. Of the 163 passengers and 13 crewmembers aboard, 94 passengers and 5 crewmembers received fatal injuries. Two survivors died later as a result of their injuries.
Following a missed approach because of a suspected nose gear malfunction, the aircraft climbed to 2, 000 feet mean sea level and proceeded on a westerly heading. The three flight crewmembers and a jumpseat occupant became engrossed in the malfunction.
The National Transportation Safety Board determines that the probable cause of this accident was the failure of the flightcrew to monitor the flight instrument during the final 4 minutes of flight, and to detect an unexpected descent soon enough to prevent impact with the ground. Preoccupation with a malfunction of the nose landing gear position indicating system distracted the crew's attention from the instruments and allowed the descent to go unnoticed.
As a result of the investigation of this accident, the Safety Board has made recommendations to the Administrator of the Federal Aviation Administration.
This tragic accident was preventable by not only the flight crew, but maintenance and air traffic control personnel as well. On December 29, 1972, ninety-nine of the one hundred and seventy-six people onboard lost their lives needlessly. As is the case with most accidents, this one was certainly preventable. This accident is unique because of the different people that could have prevented it from happening. The NTSB determined that “the probable cause of this accident was the failure of the flightcrew.” This is true; the flight crew did fail, however, others share the responsibility for this accident. Equally responsible where maintenance personnel, an Air Traffic Controllers, the system, and a twenty cent light bulb. What continues is a discussion on, what happened, why it happened, what to do about it and what was done about it.
Maintenance personnel should have replaced a faulty indicator light bulb for the nose gear. The filament in the bulb was detached from one of the two mountings. That enabled the bulb to illuminate intermittently. When the maintenance personnel serviced the aircraft, they found the light was not working. As the mechanic was replacing the light bulb, it started working. The mechanic assumed that the light was loose in the receptacle, believing the situation corrected itself when he pressed the lamp. Because of this, the faulty bulb was not replaced. An entry in the maintenance records indicated that the light was fixed. One could say that the mechanic should have been more thorough. However, the light was functioning when the maintenance personnel released the aircraft. (Note. This device is (simply) pushed into, or pulled out of the instrument panel or receptacle to change the bulb. This design facilitates ease of bulb replacement.)
There were significant animosities between labor and management at the time of this accident. Perhaps the maintenance personnel would have been more thorough if labor relations would have been more amiable. There are many factors that could have interfered with the maintenance personnel performing the repairs properly ranging from form personal problems to job satisfaction. If the employee was subjected any undo pressures or distractions the employees performance may have been affected. This pressure could stem from many areas such as working conditions, to experiencing marital, family, or health problems.
The laboratory was able to determine that the filament in this bulb was not burning at the time of impact. Additionally the flight crew had reported to Miami Air Traffic Control Tower that they had an unsafe gear indication. The aircraft made a low approach to enable the air traffic controllers working in the tower to peruse the landing gear for the flight crew.
The sun was already below the horizon at the time of the low approach and the tower personnel were not able to ascertain if the landing gear was completely extended. Subsequently, the flight crew received the report of “ . . . gear appear to be down and locked,” with emphasis on “appear!” Moreover, the controller further reported that because of the poor lighting it was difficult to tell if the gear was in the locked position. Even with perfect lighting controllers will give the same report. Controllers are repeatedly told the pilot is ultimately responsible for the aircraft. Because of this, controllers are hesitant to make any definitive statements about anything that is not backed up in a written regulation.
The flight crew then requested authorization to maneuver or fly in a holding pattern to enable them to work out their problem. The approach (radar) controller vectored the aircraft out over the Everglades, about twenty miles northwest of Miami Airport and instructed the aircraft to stay in a specific block of airspace. The controller was more concerned about the upper vertical limits of this airspace as opposed to the lower or horizontal limits. In this location, the aircraft would be free to maneuver under other arriving and departing air traffic.
The Federal Aviation Administration (FAA) handbook 7110.65 contains guidance, rules, and standard phraseology used in the control of air traffic. As time progressed the controller, checked with the flight crew as he continued to work other traffic. Unfortunately, for the passengers and crew onboard this flight specific phraseology did not exist for the controller to use when he noticed the aircraft’s altitude readout indicate a gradual descent. The aircraft had been flying around at two thousand feet for about twenty minutes, casually reporting their status periodically. After noticing the descent, the controller asked the flight crew: “Eastern 401, ah how are things coming along out there?” The crew responded “Okay, we’d like to turn around and come back in.” The controller did not know that the altitude hold feature of the aircraft’s autopilot had been inadvertently turned off. Thirty seconds later the aircraft flew into the Everglades and disappeared from the Approach Control radar screen.
The controller new something was amiss. However, an informal atmosphere had developed because the flight crew never declared an emergency and the controller was distracted with other duties he did not persist in inquiring about the aircraft’s gradual descent. Additionally the controller believed that he was providing excellent service to the flight crew by providing the extra service the flight crew requested.
Today controllers know to say: “(aircraft Identity) low altitude alert! Check your altitude immediately!” Some would say that the controller should have said something else to alert the flight crew of their descent. That is the reason for the new phraseology and an example of “Blood Priority”. Blood Priority can be defined as: Nothing regulatory speaking happens until after a dramatic accident occurs that receives media attention resulting in raised public outcry which prompts legislative action to correct the problem.
The system failed in this case and many others because it is resistant to change. The resistance comes from human nature and avoidance of the costs involved with change. Low Altitude Alert and the prescribed phraseology are directly attributable to this accident. Low Altitude Alert is a capability of the radar and computer system monitoring aircraft altitudes in relation to a safe or minimum vectoring altitude (MVA). Once an aircraft goes below the MVA an alarm sounds, the particular aircraft’s identity data block is tagged with the letters “LA” all of which flashes on the radar displays in the controlling facility.
The flight crew failed in many ways in allowing this flight to end in tragedy. This aircraft, the Lockheed L-1011 unitizes three flight-crewmembers pilot, co-pilot and flight engineer. All three flight-crewmembers became completely engrossed with what ultimately was determined to be a malfunctioning gear position indicating system. The pilot in command should have taken charge and appointed someone to monitor and fly the aircraft. All flight crewmembers were negligent in not monitoring the status of the aircraft. Additionally, from reading the Cockpit Voice Recorder (CVR) transcripts that the flight crew was also lacking in what is considered general operator knowledge. Specifically there was confusion between the flight crew on how to change and test the gear indicator light, and how to view the mechanical nose gear indicator in the nose compartment. The flight crew also displayed a lack of awareness of the actual aircraft’s position and had become complacent in their duties by relying on the autopilot to fly the aircraft. This lack of awareness is displayed in the transcript when the CAM-2 microphone recorded “We did something to the altitude” CAM-1 recorded “What?” CAM-2 recorded “We're still at two thousand right?” CAM-1 recorded “Hey, what's happening here?”
In summary, The American Heritage Dictionary defines “accident” as:
1.a. An unexpected, undesirable event. b. An unforeseen incident. 2. Lack of intention; chance. 3. Logic. A circumstance or an attribute that is not essential to the nature of something.
With this in mind, there is rarely just one cause for an accident as this NTSB abstract implies. The flight crew could have done many things to avoid this accident. For example, fly the airplane instead of turning on the autopilot or been proficient with exchanging the landing gear indicator light bulb or the mechanical gear indicator system. If maintenance had been more thorough and replaced the twenty-five cent bulb, this flight would have landed without incident. If the controller in the tower had been sure that the gear was locked, the flight would not have crashed. If the approach controller, in the radar room had been more precise or insistent, ninety-nine people would not have died! Any one of these could have prevented this tragedy; therefore, all of these and possibly more are the true cause of it!
CVR transcript of the December 29, 1972
Accident of Eastern Flight 401,
a Lockheed L-1011 TriStar in the
Everglades near Miami, FL, USA.
23.32:35 RDO-1 Miami Tower, Eastern 401 just turned on final
23.32:45 TWR Who else called?
23.32:48 CAM-1 Go ahead and throw 'em out
23.32:52 RDO-1 Miami Tower, do you read, Eastern 401? Just turned on final
23.32:56 TWR Eastern 401 Heavy, continue approach to 9 left
23.33:00 RDO-1 Coninue approach, roger
23.33:00 CAM-3 Continuous ignition. No smoke CAM-1 Coming on CAM-3 Brake system CAM-1 Okay CAM-3 Radar CAM-1 Up, off CAM-3 Hydraulic panels checked CAM-2 Thirty-five, thirty three CAM-1 Bert, is that handle in? CAM-? * * * CAM-3 Engine crossbleeds are open
23.33:22 CAM-? Gear down CAM-? * * * CAM-1 I gotta CAM-? .....
23.33:25 CAM-1 I gotta raise it back up
23.33:47 CAM-1 Now I'm gonna try it down one more time CAM-2 All right
23.33:58 CAM [sound of altitude alert horn] CAM-2 (Right) gear. CAM-2 Well, want to tell 'em we'll take it around and circle around and # around?
23.34:05 RDO-1 Well ah, tower, this is Eastern, ah, 401. It looks like we're gonna have to circle, we don't have a light on our nose gear yet
23.34:14 TWR Eastern 401 heavy, roger, pull up, climb straight ahead to two thousand, go back to approach control, one twenty eight six
23.34:19 CAM-2 Twenty-two degrees. CAM-2 Twenty-two degrees, gear up CAM-1 Put power on it first, Bert. Thata boy. CAM-1 Leave the # # gear down tll we fid out what we got CAM-2 Allright CAM-3 You want me to test the lights or not? CAM-1 Yeah. CAM-? * * seat back CAM-1 Check it CAM-2 Uh, Bob, it might be the light. Could you jiggle tha, the light? CAM-3 It's gotta, gotta come out a little bit and then snap in CAM-? * * CAM-? I'll put 'em on
23.34:21 RDO-1 Okay, going up to two thousand, one twenty-eight six
23.34:58 CAM-2 We're up to two thousand CAM-2 You want me to fly it, Bob? CAM-1 What frequency did he want us on, Bert? CAM-2 One twenty-eight six CAM-1 I'll talk to 'em CAM-3 It''s right ........... CAM-1 Yeah, ............ CAM-3 I can't make it pull out, either CAM-1 We got pressure CAM-3 Yes sir, all systems CAM-1 # #
23.35:09 RDO-1 All right ahh, Approach Control, Eastern 401, we're right over the airport here and climbing to two thousand feet. in fact, we've just
23.35:20 APP Eastern 401, roger. Turn left heading three six zero and maintain two thousand, vectors to 9 Left final
23.35:28 RDO-1 Left three six zero
23.36:04 CAM-1 Put the ... on autopilot here CAM-2 Allright CAM-1 See if you can get that light out CAM-2 Allright CAM-1 Now push the switches just a ... forward. CAM-1 Okay. CAM-1 You got it sideways, then. CAM-? Naw, I don't think it'll fit. CAM-1 You gotta turn it one quarter turn to the left.
23.36:27 APP Eastern 401, turn left heading three zero zero RDO-1 Okay.
23.36:37 RDO-1 Three zero zero, Eastern 401
23.37:08 CAM-1 Hey, hey, get down there and see if that damn nose wheel's down. You better do that. CAM-2 You got a handkerchief or something so I can get a little better grip on this? Anything I can do with it? CAM-1 Get down there and see if that, see if that # thing ... CAM-2 This won't come out, Bob. If I had a pair of pliers, I could cushion it with that Kleenex CAM-3 I can give you pliers but if you force it, you'll break it, just believe me CAM-2 Yeah, I'll cushion it with Kleenex CAM-3 Oh, we can give you pliers
23.37:48 APP Eastern, uh, 401 turn left heading two seven zero
23.37:53 RDO-1 Left two seven zero, roger
23.38:34 CAM-1 To # with it, to # with this. Go down ans see if it's lined up with the red line. That's all we care. # around with that # twenty-cent piec CAM * * *
23.38:46 RDO-1 Eastern 401 'll go ah, out west just a little further if we can here and, ah, see if we can get this light to come on here
23.38:54 APP Allright, ah, we got you headed westbound there now, Eastern 401
23.38:56 RDO-1 Allright CAM-1 How much fuel we got left on this # # # # CAM-? Fifty two five CAM-2 (It won't come out) no way
23.39:37 CAM-1 Did you ever take it out of there? CAM-2 Huh? CAM-1 Have you evre taken it out of there? CAM-2 Hadn't till now CAM-1 Put it in the wrong way, huh? CAM-2 In there looks * square to me CAM-? Can't you get the hole lined up? CAM-? * * * CAM-? Whatever's wrong? CAM-1 (What's that?)
23.40:05 CAM-2 I think that's over the training field CAM-? West heading you wanna go left or * CAM-2 Naw that's right, we're about to cross Krome Avenue right now
23.40:17 CAM [Sound of click] CAM-2 I don't know what the # holding that # # # # in CAM-2 Always something, we coulda make schedule
23.40:38 CAM [Sound of altitude alert] CAM-1 We can tell if that # # # # is down by looking down at our indices CAM-1 I'm sure it's down, there's no way it couldnt help but be CAM-2 I'm sure it is CAM-1 It freefalls down CAM-2 The tests didn't show that the lights worked anyway CAM-1 That 's right CAM-2 It's a faulty light
23.41:05 CAM-2 Bob, this # # # # just won't come out CAM-1 Allright leave it there CAM-3 I don't see it down there CAM-1 Huh? CAM-3 I don't see it CAM-1 You can't see that indis ... for the nosewheel ah, there's a place in there you can look and see if they're lined up CAM-3 I know, a little like a telescope CAM-1 Yeah CAM-3 Well... CAM-1 It's not lined up? CAM-3 I can't see it, it's pitch dark and I throw the little light I get ah nothing
23.41:31 CAM-4 Wheel-well lights on? CAM-3 Pardon? CAM-4 Wheel-well lights on? CAM-3 Yeah wheel well lights always on if the gear's down CAM-1 Now try it
23.41:40 APP Eastern, ah 401 how are things comin' along out there?
23.41:44 RDO-1 Okay, we'd like to turn around and come, come back in CAM-1 Clear on left? CAM-2 Okay 23.41:47 APP Eastern 401 turn left heading one eight zero
23.41:50 CAM-1 Huh?
23.41:51 RDO-1 One eighty 23.42:05 CAM-2 We did something to the altitude CAM-1 What?
23.42:07 CAM-2 We're still at two thousand right?
23.42:09 CAM-1 Hey, what's happening here? CAM [Sound of click]
23.42:10 CAM [Sound of six beeps similar to radio altimeter increasing in rate]
23.42:12 .... [Sound of impact]
References
1. Mr. Johnson was an air traffic control instructor at Miami International Airport.
2. National Transportation Safety Board Abstract Available [Online]http://www.rpi.edu/dept/union/raf/public/NTSB_Accident_abstracts
3. Air Disaster.com Available[Online] http://www.airdisaster.com/cvr/cvr_ea401.html
Title: Eastern Air Lines, Inc., L-1011, N310EA, Miami, Florida, December 29, 1972.
NTSB Report Number: AAR-73-14, adopted on 06/14/1973
NTIS Report Number: PB-222359/2
Bibliography
1. Mr. Johnson was an air traffic control instructor at Miami International Airport.
2. National Transportation Safety Board Abstract Available [Online]http://www.rpi.edu/dept/union/raf/public/NTSB_Accident_abstracts
3. Air Disaster.com Available[Online] http://www.airdisaster.com/cvr/cvr_ea401.html
Title: Eastern Air Lines, Inc., L-1011, N310EA, Miami, Florida, December 29, 1972.
NTSB Report Number: AAR-73-14, adopted on 06/14/1973
NTIS Report
Word Count: 2869
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