It was the first crash of a wide body jet on the last Friday of 1972
Eastern Airline was the first airline to suffer the loss of the new L1011,it was the first
of the tri star wide body jet’s . Sadly this was one of the most preventable accidents in
aviation
history . Even though now the cause of this tragedy seem simple and clear cut, like
many other accidents in air travel, there is more involved then the is seen on the
surface . First let’s take a look at the aircraft in this event, EA310 was one of a dozen
L1011’s delivered in 1972. Eastern marketed the L1011 as the Wisperliner,
Manufactured by Lockheed Aircraft in Burbank California this aircraft was the first
Cat111c (Wikipedia Flt 401) autolanding system this gave the L1011 the ability to make
zero-zero landings. In the Eastern Airline configuration was able to accommodate 229
passengers and had to lower galleys , the average crew complement was 13 ten flight
attendants and three flight crew members . The L1011 did not make it to market with out
problems , there was a strike at the Rolls-Royce factory which delayed production . This
was followed by a filing for bankruptcy, that was only resolved when the United States
promised to back loans for the company , these and other delays would play a small part
in the accident .
Flight 401 went down in the Florida Everglades at 11:42 PM December 29 1972
18.7 miles from the end of runway nine left as a result of pilot error. There were 99
fatalities and 77 survivors . There were a lot of contributing factors that need to be
looked at closely to really under stand what happened on that that night . Some of the
factors I’m going to mention are upset of circadian rhythm ,deviation from Standard
operating procedure , illness dissimilar equipment and distraction .
Flight 401 had a total of four people in the cockpit at the time of the accident capt.
Robert Alban Loft, Albert John Stockskill, Donald Louis Repo, Angelo Donadeo (was
dead heading) . For this leg of the trip F/O John Stockskill was pilot flying while Capt
Robert Loft was Pilot not flying. Flight 401 was on final approach to runway nine left
when first Officer Albert Stockskill noticed that he did not have three green lights
indicating that his landing gear was down and locked . At this point the flight crew
reported to Miami tower they were going missed , and they would need to be vectored to
a hold to trouble shoot the gear problem . Donald Repo went down to the Hell hole, an
area under the flight deck where the most of the electronics were located to look threw
window of sorts to see if the landing was extended .
It was assumed at some point in the next few minuets that Capt Loft bumped his
control stick with enough pressure to disconnect the auto pilot. (the ghost of flight 401 pg
53) with the auto pilot disconnected the aircraft began an decent that was unnoticed to
the crew because of the human bodies physiology , because of the subtle and prolonged
nature of the decent the pilots were unaware of it.(Basic Flight Physiology pg128)
So we can clearly see how the burned out light caused the distraction part of the
accident chain. Now we can move on to dissimilar equipment, when the NTSB
investigators examined the forward cockpit area the found to different auto pilots
there was a model 1-7 and a model 1-8 . The difference was that one required only
fifteen pounds of pressure to disconnect the auto pilot while the other needed twenty lbs
also when one unit was disengaged the other would still read as it were working on
holding altitude when in fact it was not(http://eastern401.googlepages.com/investigation)
. So this would cover the dissimilar equipment aspect of the accident .
So the flight crew was now preoccupied and falling victim to something nobody would
have thought of by installing the two mismatched auto pilots . This is were proper
training and a set of standard operating procedures would help protect the flight crew
from mishap , not to mention better crew resource management CRM . With the flight
engineer down in the Hell hole and the indicator lights for the landing gear nearer to the
copilot it would seem that the captain should have been the one monitoring the flight
instruments , but that is just my opinion. One could also look at the layout of the
cockpit in that the C-cord chime warning was partly drowned out by the noise an air
vent. (Ghost of flight 401)
There is not a whole lot of information on the sleep patterns of the flight crew before
the accident. But we do know that there was at lest one crew member that was
complaining that he could not get a good night sleep because he was not feeling well,
we know this because Don Repo told a close friend this before the flight. (Ghost of Flight
401)
Conclusion
There seems like a lot of links in this chain were the result of bad luck and
complacency . One would hope that the lesions learned here would be remembered
for future training . In the end 103 people lost there lives Eastern lost crew a plane and
the damage to the reputation of the airline, manufacture, and the industry as a whole are
long lasting and hard to change . In the defense of the aircrew the mismatching types of
auto pilot’s seem almost criminal in its idiocy , how this was ever considered a
reasonable action one will never know . But pilots must be ready for Murphy’s Law,
every pilot has heard the mantra from there flight instructor “ no matter what happens
always fly the plane FIRST!”
Christopher Hill
September 3 2009
Everglades University
