Eastern Flight 401 Human Factors

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