In December 29, 1972, on a cold winter evening, a new Lockheed L-1011 Tristar, the Eastern Airlines number 310, Flight 401 left John F. Kennedy International Airport’s Terminal One bound for Miami. It crashed on final approach, killing 103 of the 153 onboard. I would like to provide an insight of the accident, focusing on the human errors that contributed to the disastrous incident.
Al though the Captain, Co-pilot, and Flight engineer were very much experienced and distinguished in their fields, and knowledgeable with the technicalities of aviation, every bit of their expertise was doomed with their collective reaction to a very minor malfunctioning of a very minor part of the aircraft – a faulty light bulb.
The chain of errors started with the unlit nose gear indicator light. This has led to manifest the crew’s under utilization and mismanagement of the resources available on the plane, and the Miami ATC’s seeming lack of effective protocol in giving warning signals. First, the crew focused their attention to the faulty light bulb. While they attempted to repair it, they had neglected to monitor other flight instruments at the control surface – altimeters, vertical speed indicator, and most importantly, the low altitude warning alarm while the plane descended 200 feet per minute.
Thus, their preoccupation with the indicator light blinded them of the other instruments just within their reach. Second is that the Captain wasn’t able to facilitate and organize the crew’s effective communication in the cockpit as he also missed to effectively delegate authority over the other crew members. His command to the flight engineer to go to the hell hole to visually check if the nose gear was down, was delayed. This happened because the Captain was also preoccupied with supporting functions such as radio communication. If
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EF 401 Crash 3
only he was able to be firmly in command, it could not have happened that three crew members were focused on doing a single task. Lastly, the ATC, which was responsible for external monitoring should have given a sterner warning to the aircraft. In addition to this, its personnel could have politely given suggestions and/or reminders to the crew, as they (ATC) are also aware of the resources available in the plane. The professional authority of the Captain and his crew may have deterred the ATC in doing so, but ethically speaking, the welfare of the passengers should be their utmost concern.
This accident was fully preventable. If only the backup system of checking the wheel was successful, if the crew knew their fundamentals in resource utilization by heart, and if only a pilot was clearly in command and was focused in monitoring and flying the aircraft, 103 lives could have been spared.
This accident is a lesson for other crews as well. The crew of the Eastern Flight 401 were experienced, skillful, and knowledgeable. However, they experienced a chain of errors, which was aggravated by apparent lack of monitoring and authority, effective communication, and resource management skills in time of adversity. Moreover, the disengagement of the autopilot system reminds us that we, humans become complacent with the efficiency of automation. We cease to monitor its function. We depend and trust too much on it. But when it fails, we face the consequences, even if lives are at stake. Thus, this accident reminds us that we should handle and utilize automation responsibly. We should not cease to figure out its limitations and behavior in varying situations.
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References
The Crash of Eastern Air Lines Flight 401, from http://eastern401.googlepages.com
Elder, R., et al. (1997).
Crash. Atheneum, New York Kilroy, Chris. Special Report: Eastern Air Lines Flight 401 from http://www.airdisaster.com Crash of Eastern Airlines Flight 401 from http://www.freshgasflow.com/flight401.htm
