Lockheed L-1011-1 Tristar

11:42pm December 29, 1972

Flight 401

Sajid Nadeem - 12002001004

Summary

101 fatalities (99 initial crash fatalities, two died shortly afterward)

75 survivors

Crash reason: entire flight crew becoming preoccupied with a burnt-

out landing gear indicator light and failing to notice the autopilot had

been disconnected. As a result, the aircraft gradually lost altitude and

eventually crashed while the flight crew was distracted with the

indicator problem. It was the first crash of a wide-body aircraft and at

the time

Four-month-old aircraft - the pride of Eastern's fleet

163 passengers and 13 crew members (10 female flight attendants)

This re-enactment was filmed in a simulator, and was not produced by Eastern Airlines.

In this video, following the unintended departure from 2000 feet, a warning tone is heard, and footage of the altimeter shows a continuously flashing amber light. Eastern Airlines had repressed the flashing alert light below 2500 feet above the ground, so on the accident airplane, only the tone was produced, at 1750 feet. There would have been no flashing light.

This discrepancy in the video could lead the viewer to assume that the flight crew must have ignored, or missed, two warnings, while in reality, the only warning that would have existed would have been a single, short duration, aural tone

According to the FAA

What in your opinion is the category of this crash?

Question From Audience

• Over reliance on Automation

• CFIT

Answer:

Captain Robert Albin 'Bob' Loft, 55, a veteran EAL pilot ranked 50th in seniority at Eastern (from 4000 pilots). Captain Loft had been with the airline for 32 years and had accumulated a total 29,700 flight hours throughout his flying career.

280 hours in the L-1011

Pilot In Command

Albert John Stockstill, 39, had 5,800 hours of flying experience

Second Officer (flight engineer) Donald Louis 'Don' Repo, 51, had 15,700 hours of flying experience.

First Officer and Flight Engnr.

Warren Terry, a co-pilot, and Angelo Donadeo, a maintenance specialist. Both of whom were off duty airline employees who were "dead-heading" - airline slang for employees hitching a free ride to return from a duty assignment.

Extras On-board In Jump Seats

The crew of Flight 401, taken aboard Flight 26 while on the ground in

Miami earlier the day of the crash.

Because it was the end of the month the crew

would be breaking up soon. "This is going to be

our last trip together,"

The Whole Story

The flight was routine until 11:32 p.m. when the flight began its approach

into Miami International Airport.

After lowering the gear, first officer noticed that the landing gear

indicator, a green light identifying that the nose gear is properly locked in

the "down" position, did not illuminate. The landing gear could have

been manually lowered either way. The pilots cycled the landing gear

but still failed to get the confirmation light.

By "down there," CAPT was referring to the forward avionics bay, a space

beneath the flight deck more commonly called the "hell hole." The bay was

accessible through a small square trap door on the floor of the cockpit.

Inside the hell hole was an optical sighting device which could be used to

view the landing gear itself.

The Investigation

The investigation focused primarily on determining why the unexpected

descent had occurred.

The NTSB considered four possible causes:

• Subtle incapacitation of the pilot

• Auto flight system operation

• Flight crew training

• Flight crew distractions

Medicals

The Crew And The Aircraft

CVR and CDR found intact

So Why Did This Happen?

Pilot`s Medical Ruled Out

Is Training Adequate?

Automation ?

Air Traffic Controller ?At the NTSB public hearings in March 1973, Mr. Johnson (ATC) was asked

why he didn't warn EAL 401 of its low altitude when he first noticed the 900

foot reading on his radar screen. Mr. Johnson testified that he wanted to

see another sweep of the radar before making any judgements, that the

readouts often differed from the actual altitude.

He went on to say that in his opinion, the pilots appeared to be in

command of the flight, as evidenced by their calm demeanour and rapid

response to his instructions and questions.

Johnson's supervisor, Carl E. Joritz, Chief of the Miami ATC Center, later

pointed out that it is not the controller's duty to monitor the distance

between the airplane and the ground, but rather the distance between

airplanes. This was technically true at the time.

The Crash Summary

Investigators discovered that apart from one burned out bulb, there was nothing wrong with the L-1011.

The main causal factor in this accident was not the aircraft, but the crew, the human factor.

Cognitive Tunnelling

Even though the crew was dealing with the landing gear indicator, they still could have

noticed their surroundings and the aircraft's altitude.

As long as stress levels are not too high, the average human has enough additional

information processing capacity to notice things unrelated to the current task, such as the aural altitude warning, and instruments indicating a descent (Robson, 20082). When stress

levels increase, however, it is possible for cognitive tunnelling to develop (Chou, Madhavan,

& Funk, 19963); this is where one particular task is given a very high priority at the expense of

other tasks. It can be especially dangerous when the task being focused on is actually less

important than those tasks being neglected. Initially, it may seem that the crew was

presented with the simple task of changing a light bulb. However, as the cover had

jammed, both the captain and first officer likely experienced cognitive tunnelling as they tried to establish a way of replacing the bulb without breaking the cover. In this case, all of

their attention was given to this one small problem, at the expense of flying the aircraft.

Lack of CRM

The fact that all three crew members were dealing with the problem in the first

place was an extreme command/control failure. (Poor Delegation of tasks)

The most basic level of command/control is crew coordination, ensuring that

individual tasks, such as replacing the bulb, and flying the plane, are effectively

divided between crew members so that the main overall objective, in this case

landing the aircraft safely, can be successfully accomplished (Kanki & Palmer,

19934). This was a deficiency on behalf of the captain to either delegate or

take control of the landing gear, and have at least one pilot in charge of flying

the plane.

At the time, CRM was not a developed system and so the crew did not have

the opportunity of developing the same effective team-work skills as modern

pilots.

Steps Eastern Took:

Eastern captain Daniel Gellert testified to the NTSB on February 6th that he

had noticed that the altitude hold function could be disengaged by

bumping the control column.

Many pilots doubted Gellert's testimony, but the incident was strikingly similar

to a situation encountered by Thomas Oakes, another Eastern pilot. Oakes

had been one of the first captains qualified to fly the L-1011. He had the

altitude hold function disengage on a flight on January 8th, ten days after

the crash of flight 401. Oakes testified that he and the co-pilot noticed the

malfunction and proceeded to reset the autopilot and then trip it off by

bumping the control column several times. They noted this behaviour in their

log book. Although these seemed to be freak occurrences, Eastern took it

seriously to send a printed notice to all it's L-1011 pilots on January 15th.

The information that “bumping” into the control column on a Tri-Star could disengage autopilot was put-up on the notice board and mailed to all

L-1011 pilots.

What did NTSB do?

Introduce new regulations to prevent such future accidents

ATCs now had the duty to contact the A/Cs when they are too near the ground

Still, CRM was not introduced. & years later, Tenerife 1977 accident occurred. NASA started to work on it after that.

Any Questions?