FREE ESSAY ON AVIATION/AEROSPACE PSYCHOLOGY

AVIATION/AEROSPACE PSYCHOLOGY

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