Fatal Distraction

Fatal Distraction

Mitchell Davies

Utah Valley University

Fatal Distraction

On December 29, 1972, a state of the art Lockheed L-1011 piloted by an experienced flight crew crashed into the everglades, killing 101 people. The aircraft was operated by Eastern Air Lines and had departed New York JFK airport when it crashed en route to the Miami International Airport. Investigators later determined, that other than a burned out light bulb, there was nothing wrong with the aircraft. Individual factors, group dynamics, the aircraft, policies, environmental factors, communication, crew decisions, poor leadership/followership and standard procedures were all elements that contributed to this disaster.  

        Eastern Air Lines flight 401 prepared to land as it approached their final destination, Miami. The landing gear was lowered but the indicator light wasn’t showing green; either the landing gear was malfunctioning or the light bulb was burned out. The pilots delayed the landing to fix the problem and this would be their ultimate demise. “It was found on the Flight Data Recorder that the aircraft descended slowly at a rate of approximately 200 feet per minute. This descent rate would be totally un-noticeable to anyone not looking at flight instruments” (Kilroy, 2009).  The aircraft subsequently struck the ground during this slow descent, and investigators wanted to find out why the plane descended. The aircraft was set on autopilot but investigators found that an inadvertent bump of the flight controls could cause an override in the system. “The captain might have inadvertently bumped the throttles with his right arm when he leaned over the control pedestal to assist the first officer” (National Transportation Safety Board, 1973, p.19-20). A bump in the controls would override the autopilot for safety reasons and would have caused the slow descent. NTSB investigators determined that, “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” (National Transportation Safety Board, 1973, p.23-24).

Liveware Individual

Investigators determined the likelihood of what brought down Eastern Air Lines (EAL) Flight 401 as pilot error. Their findings influenced a need for Crew Resource Management (CRM) training for pilots. This training would allow pilots to effectively deal with complex issues while still maintaining control of the aircraft. The pilots of EAL 401 were highly experienced and their errors were certainly not the result of a lack of experience. Interestingly enough, it was their experience in such an automated cockpit that founded this accident. The interactions between the Captain, First Officer, and Air Traffic Controller influenced the outcome of this disaster.