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Lessons Learnt from the Crash of Eastern 401

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The crash of Eastern Air Lines Flight 401 41 years ago Sunday, the first crash of a widebody aircraft and, at the time, the second deadliest single-aircraft disaster in the U.S., led to wide-ranging changes in on board safety that continue to positively affect air travel today. The four-month-old L-1011 TriStar jet crashed into the Florida Everglades on December 29, 1972 at 11:42 p.m., caused 101 fatalities and there were 75 survivors.... (www.frequentbusinesstraveler.com) Mais...

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justindpilot
justindpilot 12
Don't recycle parts of crashed planes... Hauntings occur.... evidently.
devsfan
ken young 3
Not sure why you brought that up
gadget1
Rick Gull 3
"The Ghost of Flight 401" is why... It's the first thing I thought as well!
Doobs
Dee Lowry 3
Disagree, Justin. We recycled crashed planes and put them in the "Training Center"! We used them for "Mock Evacuations". As far as hauntings...yes! Just after FLT 401 went down...I was on a "stretch DC-8 in Chicago. I was in first class, as passengers were boarding and a "OMC" entered the cabin. No baggage. In an Eastern Uniform. He didn't speak but he sat in 5B. I turned away and he was gone. I asked the Flight Crew if an "OMC" had introduced himself and they said..."NO". I asked my flying partners located in the aft cabin, if they had seen him and they said "NO", as well. Eastern Second Officer Repo made many appearances after Flt 401. Mostly with Eastern but ventured out to other airlines. He was a troubled soul and had to find his way. He finally did.
As far as what we have learned from Eastern FLT 401...Nothing!
We still, after that crash... slam Airplanes into seawalls, mountains and hillsides. What or where do we go from here? Training?
mhlansdell00
Mark Lansdell 6
It's evident from the crash of an Asiana bird some 40 years later that some ate the cover instead of reading the book. It too had the auto pilot switched off and nobody was looking at the airspeed indicator and altimeter. You'll have to explain to me how this lesson was learned by anyone but the NTSB.
LarryQB
LarryQB 0
Indeed, the auto pilot was off, however the crew didn't know it. On that plane bumping the wheel will disconnect the A/P and apparently that was what happened. The "A/P disconnected" warning was a muted affair in those days.
mhlansdell00
Mark Lansdell 2
In the article there were 3 people in the office. It doesn't take all three to check a light bulb at the expense of flying the airplane. In the two instances 40 years apart the flight crew failed to fly the airplane with the same result. I'm not sure it matters how muted the warning horn was or is. It is incumbent on the front end gang to pilot the aircraft, a big part of which is a scan of the instruments. Fly first. If you have enough fuel the gear light can wait. If you don't have enough fuel you screwed the pooch differently. You the pilot are ultimately responsible for flying the aircraft not the AP not the AT, you with the arms and legs.
LarryQB
LarryQB 2
Too true. I think growing up flying small planes and learning the aviation thought pattern through having to manually fly and navigate, plus the opportunity to scare yourself in small planes, is invaluable. I've heard that because of the military situation in Korea it's very difficult to do any private flying, thus it's possible the Asiana pilots never came up via that small plane route. There is a movement in the world to put people into the airline industry ab initio and teach them large aircraft/multi-crew methods from the start. I don't like that idea.
mhlansdell00
Mark Lansdell 1
I'm not a big fan of that either. At some point a pilot has to learn how to fly rather than guide with electronics. Preacher makes the point below that the #3 was below checking the gear. That still leaves two above in the office. How many does it take to check a light bulb?. Somebody should be flying the iron or at least guiding it along and monitoring systems. If the #3 comes back up and says the LG is OK, the light bulb is of little consequence and can wait for the maintenance crew chief's inspection and opinion. Get it on the ground and worry about it then with a squawk.

I don't much care whether Korean pilots can fly SEL airplanes for practice. They are evidently not taught to fly or as I've maintained in the Asiana incident their culture has taken president in the cockpit putting hundreds of PAX at risk or worse. You can learn to fly in other vehicles. The similarities of the EA401 incident and the crash some 40 years later screams that we haven't been paying attention as electronics get more and more sophisticated. AF 443 and most recently Asiana 214 warn us all that history will repeat if we don't give it proper respect and quarter.
preacher1
preacher1 2
In their defense, if there is any, the 3rd man had gone below into the electronics bay to try and get a visual on the gear
mhlansdell00
Mark Lansdell 1
I didn't read that, but even so, if the non flying pilot was assuming the engineers duties in his absence, which I expect is what occurred, that leaves the flying pilot to be in control. I don't see a defense. If the engineer observes the gear and says it's OK, we're down to a bad light bulb or faulty warning circuit worthy of a squawk with someone performing the primary duty of flying the airplane. Fly the airplane first.
Fairlassie
Sounds like you've never made a mistake. Too bad this mistake was so lethal.
kandlpasa
Ken Edelson 3
Dorothy seems to miss the the intent of these inputs. This aircraft accident was so botched that many training facilities use this crash as the the basis for their CRM training. Aircraft accidents normaly occur after a sucession of mistakes, not just one. This accident had so many mistakes you would have to wonder if this crew grasped the complexities of flying an L1011.

I'll list the mistakes we know of:

+Crew didn't accelerate after climb out and retard one throttle to very all gears down and locked, which they were.

+Didn't verify altitude hold loss after C-Chord warning.

+Nobody watched over CWS mode of autopilot.

+Crew member rotated new light module into nose gear receptacle rotating it in error 90 degrees forcing it to jam and not make contact.

+Two cockpit members went into fwd avionics bay to verify nose gear down bars, but nobody knew that the you had to release the view lens cover.

+They didn't make a low pass over the airport for the tower to verify nose gear position.

+Both pilots were involved looking down into the fwd avioics bay to communicate instead of just one.

Everyone makes mistakes, but this sucession of mistakes is beyond the pale.

KennyFlys
Ken Lane 1
It's also used among many other commercial airliner accidents by competent instructors teaching single engine private pilots and instrument pilots.
preacher1
preacher1 1
Agreed; front seats got preoccupied with the bulb; FE was downstairs. Nobody flying but otto and he was just doing as told by the bump
LuciusGravely
Lucius Gravely 4
The controller at MIA had altitude readout on his radar. His comment to the flight, when he noticed that the altitude was low was,"Is everything allright out there?" instead of "I show your altitude to be 800 feet (or whatever it was showing). That would have alerted the crew that had allowed themselves to be distracted by the light malfunction.
20U60N4
STEVE EMERY 3
or someone could have been flying the plane...
mhlansdell00
Mark Lansdell 2
Yup. Needle-ball and airspeed. Some things just don't change.
preacher1
preacher1 1
Shoulda, Coulda, Woulda. Auto pilot was supposed to have been. Blame it.
peachstate
David Cree 4
I was an IER (In-Flight Executive Representative) based in Atlanta in the early '70's for Eastern and worked Flight 401 the entire month of November as it was assigned to an Atlanta based IER staff, that month.

There was an IER on 401 that fateful night, named Jennifer Larsen, who was based out of JFK.
IER's most always rode F-Class 'must ride' passes and that evening Jennifer switched seats
with a revenue F-class passenger.

That passenger was killed....Jennifer survived. She said as the plane hit the Everglades and the fuselage began to violently tear apart, that the passenger seats began to tumble end over end. Jennifer was a lovely, petite gal and her head was well below the top of the seat, so the seat back acted as a roll bar that prevented her head from being crushed.

I saw Jennifer about 6 weeks after the crash on Key Biscayne and she barely had a scratch on her---just a little bruising from the seat belt around her lap. She continued flying...
and when Eastern discontinued the IER program when the Arab Oil Embargo began in the fall of 1973, she went to work for TWA doing the exact same job---- which I believe TWA called
In-Flight Director.

David Cree
Peachtree City, GA
preacher1
preacher1 3
I guess it's good from a comparative standpoint but this story is about the crash of an 1-1011 yet a lot of the comments are about the DC10 without any kind of comparison. Happy New Year.
mhlansdell00
Mark Lansdell 1
To many there is no difference since the engines are positioned so similarly, like the difference between a DC8 and a 707. Aren't they the same? :-).

Serious question, was the L-1011 one of if not the last commercial airframe Lockheed built before going all mil spec?
preacher1
preacher1 2
Not sure but I believe you are correct. There is not another one that comes to mind.
preacher1
preacher1 2
I can agree on the engine similarity but I really can't pin it down in the thread to where it started on the 10. As far as the 1011 and the 10 or the 707/8/ or CV880 for that matter, they had 3 and 4 engines respectively and looked similar from the outside to the traveling public.LOL
mhlansdell00
Mark Lansdell 1
Happy new year, Capt.
R123154
R123154 2
As a uncle to one of the survivors that accident was an accident from Hell.It was years before he could sleep all night without medication assistance.
KennyFlys
Ken Lane 2
So, how many more decades could we go back for proof that bad things can and will happen when a pilot fails to apply the first rule?
preacher1
preacher1 4
A cockpit full of electronics and advanced and advanced over the years, but still has the very basic things and it still falls back on visual skill of the 2 that are sitting in the pointy end.
canuck44
canuck44 2
Of note, autopsy showed the Captain had a large meningioma in his brain, one that in this era would immediately be diagnosed on either CT or MRI. The rules changed at that point and pilots were no longer able to have their medicals performed by their family physicians unless they were flight surgeons.
franklinokolo
Frank Okolo 2
Interesting. I have been teaching CRM to scores of airline pilots for years and have occasionally used Eastern 401 as a case study. The captain having a meningioma, whether benign or malignant, is new information to me. I'll try and verify it. Thanks for the information.
preacher1
preacher1 2
I can remember that change. You used to could give your family doc a $10 bill and walk out with a current card. Used to be about the same for a DOT physical for a commercial driver. That too changed when the CDL came along.
mhlansdell00
Mark Lansdell 1
I remember going in for my re-up one year when I was working in DC around '67 or 8. When he walked into the room, The doc asked me, in a cheery tone, "How ya feel?" Mu response was, as usual, pretty fair. Then he asked me "what color is that trash can over there? When I answered "green" he said "see ya next time you're due". At the time I thought a hospital was some place you visited other people and so never gave it a thought until years later.
captainjman
Jason Feldman 1
those were the good ol days eh?
airclaxon1
Paul Claxon 2
Someone should have been in control of the aircraft.
yr2012
matt jensen 2
Two of my friends were onboard. One died and the other survived. He never flew in a jet since.
allench1
allench1 1
Sorry to hear that Matt. I flew for eastern out of Miami when this occurred.
N21078
Dan Douglas 3
Learnt?
mumblinsumpthin
Mark Dixon 3
Yes, 'learnt'. It's English, as in British-English. Same as 'spelt', not 'spelled'. And 'dived', not 'dove'.

Oscar Wilde was quite accurate when he said, "We have really everything in common with America nowadays, except, of course, language." - from 'The Canterville Ghost', ( 1887 ).
Ref : http://en.wikiquote.org/wiki/English_language
mhlansdell00
Mark Lansdell 1
Yea. Where's spill check when you need it. :-)
htthree
Harry Thomas 1
Yea, like 'burnt'.
mikewalshaviation
Michael Walsh 2
Hi folks. It has become apparent, more so in the new millennium than previously, that automation is not the perfect solution. It is imperative for modern pilots to become cockpit systems managers. I fly single-pilot business jets, where full autopilot systems are mandatory, but it is the pilot's responsibility to manage the systems effectively, and when in doubt, to override and take control of the aircraft. I personally hand-fly the aircraft on departures and approaches to keep my hand in, and try to remain vigilant when Otto is flying. Automation is designed to simplify our lives, not replace us. I don't blame any pilot involved in an accident, as one cannot merely pontificate on the severity of the stresses encountered. I've had my fair share of highly stressful situations, where automation becomes ones best friend. But it means being aware that it is a manageable system designed to aid the pilot, and reduce the workload. I'm pretty sure that in the 70's the mentality might have been completely different. Sure, the systems weren't perfect then, and still are not, despite the myriad lessons learned. My point is that pilots are not replaceable by computers just yet, so be vigilant.
clabo
gene kwiecinski 1
Wellp, there are recent articles out there about all the whiz-bang gadgets coming out in cars, too, like lane-drift indicators, blind-spot indicators, etc., and even with basic amenities such as auto-on headlights and wipers, all those gadgets do is create a class of idiots who don't have enough common sense to drive a car.

I see black cars at night with *NO* lights on, just pull out of parking-lots into the street. Blind-spot indicators came into vogue because idiots can't be bothered to actually turn their heads to check when changing lanes. And worse.

My favorite was an idiot in a black suv, at night, with *NO* lights on, who actually flicked on his brights (flash-to-pass) a few times to wake up the guy in front who wasn't moving fast enough when the light turned green. No, the irony's not lost on me, either.

How is this any different for planes?

Basics such as keeping the pointy end forward and shiny side up are lost on those who rely on auto-everything to do the flying for them.
preacher1
preacher1 1
Well said
kandlpasa
Ken Edelson 1
I believe R. Schneberger has the correct analysis of the autopilot disconnect scenario. Some others added comments about the breakout forces on the yoke. In the CMD mode the breakout force in most L1011's was 25 lbs (Eastern L1011 was less as I remember). In the CWS mode the pitch force was 4 lbs. and the roll force was 3 lbs. As others have stated there was missing Cockpit Resource Management.

M. Walsh says he never blames any pilot involved in an accident. He may never have read an NTSB report!
ktnxpi
Rich Pelkowski 1
I often utilized this accident as an example, when a Air Traffic Controller chose to not issue a Low Altitude Alert (LA) to a pilot. My point was, you don't know what is going on in the cockpit. The pilot might be tying his shoe (a little hyperbole of course) and not notice the aircraft altitude. What would you say at an NTSB Hearing when the Examiner asked you, Mr. Controller clearly the Low Altitude Alert is flashing on your display and blaring in the background on the audio tape, why is it you did not issue the Low Altitude Alert to the pilot and 101 passengers died?
allench1
allench1 1
It was my belief that the auto pilot disconnect should have been 20 lbs of pressure on the yoke and that in this L1011 it was set at 10 lbs. of pressure so when the captain pushed on the yoke in order to stand up so that the he could observe the flight engineer in the hell hole he had unknowingly disengaged the auto pilot.1st officer also seemed to be distracted as well.
preacher1
preacher1 1
I'm thinkin' that they were not set the same anyway. I believe they were at 15 and 25. I don't remember which was which but for whatever reason there was a difference in the one for the Captain and the FO, plus it seems like they each made a separate to the AP rather than be joined and make a single input. I think in that report there is a recommendation to do some changing there, but I don't know for sure what it was.
allench1
allench1 1
Could not agree more James. Just the other day I almost ran the tanks dry in a j3 I was having so much fun.
kandlpasa
Ken Edelson 1
The L1011 auto pilot did have a wailer sound with auto pilot disconnect and it was loud. However, if a pilot moved the yoke above 15 to 25 lbs breakout force (airline option)in the CMD mode, the autopilot shifted to the CWS mode (still autopilot on) and the wailer doesn't make any sound. The only time there would be a wailer would be if the bat handle was placed in the off position or it was disengaged by actuation of autopilot disconnect switch on either control wheel. If there was a altitude hold setting and the altitude changed during the yoke movement the C-Chord sound goes off. This was heard on the tape. Certainly investigators wondered why the crew didn't react to the C-Chord sound.
The L1011 autopilot was a marvelous system and was the first US aircraft to be certified for Cat 111a approaches. However, one thing that was very unusual was there were over 15 cockpit audio warning sounds and that is pretty much of an overload and may be one of the reasons pilots were insensitive to some audio warning sounds. None of this is stated to minimize the pilots lack of situational awareness. Just wanted to add some real facts about a very complex autopilot system.
chalet
chalet 1
Obviously this crew as well as that of the United DC-8 that crashed in Seattle in Dec. 1978 and several other ones simply forgot one of the very first lessons drilled by every CFI at the beginning of a PPL course: AVIATE, NAVIGATE AND COMMUNICATE.
chalet
chalet 1
Obviously this crew as well as the
GSC2012
Peter Tomlinson 1
I was on business in San Francisco just after the DC-10 crash, booked back to Chicago on a DC-10 at 0700 3 days later. Shared limo driver ran late, I jumped out of it and ran in to the terminal at 0658, had to pick up tickets and run. They got my bag on the plane and a stewardess waiting at the gate said "We waited for you, Sir". Very few passengers. I soon realised that those on the plane that crashed had very probably watched it happening on the TV screens.
kandlpasa
Ken Edelson 1
There were many errors contributing to this crash as shown in the comments. I'd like to include a few more. When the nose wheel down light did not light, the left or right gear light module could have been put in the nose wheel light receptacle to verify gear down. However, the poor design of that light receptacle allowed an incorrect 90 degree rotation by a crew member to jam the light receptacle and the light module wouldn't go all the way in. In spite of this error a crew member went down to the forward avionics compartment to view the nose gear down bars with a little scope on the aft bulkhead. However, you have to be knowledgeable about the view lens cover release knob to see the nose gear down bars. Apparently the crew never read the manual about this fact. They were not able to verify the gear due to this error.

One last fact worth mentioning is the landing gear warning horn. When any throttle is retarded to the lower thrust range with any landing gear not down and locked when airspeed is below 190 knots the horn actuates. They didn't even try this!
racinron
racinron 1
I'm sure he meant to write learned. He was just testing us to see how many responses he'd get.....or maybe not.
ksp10
K P 1
He probably also "burnt" the cabin to the ground.......and "orientates" his maps....and "me and him" are going to the store....etc.
Scullydog01
The autopilot was not disconnected, the control wheel (Yoke ) was moved causing the autopilot paddle switch to drop to the "control wheel steering" autopilot mode. This autopilot change was not caught by the crew. While in this mode, the control wheel "yoke" was nudged forward by a crew member, while attempting to get to the gear down indicator bulb.
In the control wheel steering autopilot mode, the autopilot will hold whatever change is made by moving the "yoke". The aircraft began a very shallow descent ( holding whatever the rate of descent was that the slight forward nudge obtained ) until impact.
mhlansdell00
Mark Lansdell 2
Nevertheless, no body checked the airspeed nor the altimeter. While 3 guys were looking at an indicator light, nobody was flying the airplane except Jeeves.
devsfan
ken young 2
That is what I would refer to as "a total breakdown protocol."
nutsnbolts09
Roger Herman 1
"Learnt" ??? Learned is more correct, please.

[This poster has been suspended.]

nicholasweber
nicholas weber 4
The DC10 was not a 'fantastic' aircraft! It was launched by Douglas knowingly unsafe!
That is one of the reasons they are not now in business. Remember the cargo door incidents. When Douglas tested it during the aircraft development it flew open and they did nothing about it!
Also DC10 maintenance was a nightmare.

As for the L1011. Yes Lockheed put all their civilian eggs into it. It was a good aircraft and therefore much more expensive to buy etc. (airlines always want averything on the cheap!). Look at BOAC they did everything they could to trash the VC10 knowing it to be a much superior aircraft to the 707. Yes it cost a little more to run per mile but its maintenance was much less and the airframe had a longer life.
The fact that it was almost always full of passengers preffering it to the 707 was deliberately overlooked by BOAC.

As for lessons learnt by accidents suchas Eastern 401? The crew of AF447 didn't pay attention obviously.
chalet
chalet 2
The L-1011 was not a stellar product that cost Lockheed too much money to develop and had to exit the civilian aircraft business for good. The DC-10 was a better long-range tri-jet aircraft but it also cost too much money to Douglas and according to experts they should have instead stuck turning out the larger capacity DC-8-63s for which Boeing did not have a competitive aircraft making tons of money in the process enabling them to come up with a nextgen airframe much better than the MD-11. Oh, well.
preacher1
preacher1 2
We can all be rich and safe if we could just figure out how to get this 20-20 hindsight and NTSB crash reports to work before something happens
nj2e4
The prime reason the Tristar was a commercial failure was the engines! Once read an article by the head of Pan Am's powerplant department, "I can work with a dog of airframe and good engines. I can't make a good airframe with bad engines work". The RB211s, were late and under performers. So the government had to refinance Rolls Royce and by the time the 211s arrived, Douglas had capture the widebody trijet part of the market. The floor collapse, caused by cargo compartment depressurization that took down the 10s, was a problem lurking in all wide bodies. Venting floor panels were mandated in all wide bodies after the ORD accident.
chalet
chalet 2
I don't quite agree with your statement for the RB211 has been performing extremely well on 757s for American, British and others although I believe I read then that the mating of the RB211 with the Lockheed airframe was not an efficient one resulting in a non economical cost per seat-mail of the L1011.
preacher1
preacher1 2
I'm kinda like CHALET; I'm not in agreement with your statement on the RB-211's. We traded our 707 for a 757 in 1986 after the 211's were ETOPS certified and they performed just fine. As a matter of fact, they were ETOPS certified several years ahead of the P&W's. I flew it until I retired the first time in 2009 and never had a major problem with them. Best I remember, Eastern was the launch customer for that plane. The economics may have played the part on the 1011 but there was no performance problem on the 757 nor other models that I am aware of.
jrbeejay
John Beech 1
As above, you seem to love to blame the operators, there were design errors in both aircraft, more in the DC10 than the L1011. Check your facts.
chalet
chalet 1
I got talking to an Eastern L-1011 crew and they told me that the plane was manufactured using aerospace (rocketry) specs thence it became too expensive for one and that efficency-wise (cost per set-mile) she was really bad. I also asked them why EA 401´s radio altimeter did not send the appropriate warnings but their answer was evasive.

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