WHAT Caused the Crash of Eastern Airlines Flight 401? - The Everglades Disaster

this brand new lockheed 1011 tristar is in a go-around from miami international airport due to a technical malfunction all three pilots are working together to try to solve the issue when they inadvertently activate a sub-system to the autopilot which start a chain of events that will lead to an accident that will change the way that pilots all over the world deal with things like teamwork and problem solving stay tuned a huge thank you to both aviation for sponsoring this video the story of eastern airlines flight 401 took place on the 29th of december 1972. it was a scheduled domestic passenger service from jfk international airport over towards miami international airport the aircraft that was being flown was a brand new lockheed 1011 tri-star it's a beautiful aircraft with three engines two on the wings and one in the back and it was quite sophisticated for its time it had a very good autopilot system it could do outer land and the autopilot system and one of the sub systems is actually going to become really important for this story later on onboard the flight this day was 163 passengers 10 cabin crew members and three pilots in charge of the flight was 55 year old captain robert loft he was a very experienced captain with a total time of 29 700 hours but it only flowed about 280 on the tri-star because it was very new to the fleet and the aircraft that they were about to fly on this day had only been in the fleet for about four months since august of 1972. assisting him was 39 year old first officer albert stockstill he had 5 800 hours of total time and 306 hours on the tristar and also 51 year old flight engineer donald repo he was also very experienced with fifteen thousand seven hundred hours and fifty three hours on the type the crew went through their preflight preparation just as normal then look at the no-times that look at the unroot weather and the destination weather which in miami was really nice there was only some scattered clouds around some light easterly winds and very good visibility so first off the stocktail was designated the pilot flying for the flight and at time 2120 eastern standard time they took off towards miami during the flight the pilots used the autopilot um and the autopilot on the tristar is remarkably similar to the autopilot that we're using on the boeing 737 live flight today it had two separate channels channel a and b channel a would give commands to the flight director on the captain's side and channel b will do the same on the first officer sides and those two channels are normally not used together unless you are planning to do an outer land which is exactly the way that we do it on the boeing in order to understand why this accident happened you need to understand how the autopilot works so the autopilot on the tristar could be utilized in two different ways you had a basic mode and a slightly more advanced mode in the basic mode the autopilot was used in what we call control wheel steering so that's basically a server mode where the pilots can input on the yoke for example put a pitch or a roll in and once they have put whatever pitch and roll they want in they can release it and the autopilot will continue to do what the pilots have inputted okay that's controlled with steering it's very simple and it's very rarely used at least not in normal operations and at the time at eastern airlines they weren't really supposed to use control with steering either now the slightly more advanced mode is what you guys think about when you think about autopilot it's setting a specific vertical speed telling the aircraft to climb to a specific altitude holding a specific heading and so on so that's the modes that we tend to normally use in more modern aircraft we also have things like v-nav but that wasn't available on the tristar at the time the initial part of the flight was completely uneventful the crew started briefing and setting up for an ils approach into runway 09 left in miami international and they initiated their sand during the descent the pilots used a combination of both autopilot flight and manual flight we have to remember that this was back in 1972 where the pilots relied much more on manual flight and they only used the autopilot really to relieve a little bit of workload there was back then just like now actually a discussion of whether or not pilots should be using the autopilot because they were losing manual flying skills obviously now we're flying much more using autopilot a bigger percentage of the flight than what it did back then before we go into the accident sequence in this video i just want to say a few words on behalf of one of my longest serving sponsors of the channel which is bose aviation i have been using both aviation headsets for years now starting off with the a20 going on to the pro flight series one and then pro flight series two and the reason i keep using them is because of really good audio quality and high reliability did you know for example that all bose aviation headset has to be tso approved tso stands for technical standard order and it means they have to go through a quite crazy testing regime including things like having it frozen down to minus 25 degrees celsius and then dropped from two meters onto a concrete floor and still work if you are on the hunt for a great aviation headset that you can really trust well then check out the link in the description below i've linked to all of the resellers in your specific area and there's also a link about how the tso testing is done which is quite fascinating so check it out when the aircraft got stabilized on final approaching drum with zero nine left first of the stock still asked for gear down captain loft reached over selected the gear down but realized quite quickly that he only got two out of the three green indicator lights illuminated the one on the north wheel was not illuminated these three green indicator lights are really important because they indicate not only that the gear has been extended but also that it has locked into a safe position so it will not collapse when you land on the runway in the 737 that i fly we have two separate indicators so we have one just next to the gear and then one in the aft overhead panel and if you get a green light on any of these indicators it means that the gear is down and locked so you can have a burned out light bulb for example on one of them but if you get it on the second one you can continue to land it's not a problem on the loki 1011 though it was a little bit different so on that aircraft if one of the lights did not illuminate then you would have to go out and do a visual check of the landing gear from lenses that were available in certain parts of the aircraft and obviously that will take a little bit more time so captain loft he cycled the gear and meant he took it back up again and then extended it hopefully that would solve the problem unfortunately it didn't so the nose landing gear light still stayed extinguished at time 2334 captain loft calls up air traffic control and it calls uh tower this is eastern 401 it looks like we're uh we're gonna have to circle here we we don't have the lights for the nose wheel yet miami tower comes back and responds eastern 401 that's roger climb straight ahead to 2000 feet and contact approach control on 128 decimal 6 and this is then read back by the crew so the crew has now decided to go around which is the correct thing to do they need to make sure that the aircraft is fully safe before they attempt the landing and from a fuel standpoint this is not a problem at all in fact they took off from jfk with 85 000 pounds aboard and the planned trip fuel was only 42 000 pounds so they had almost twice as much fuel on board as they would need to that would never happen today because we are so conscious about the weights that we're carrying but back in the day fuel burn not so much of a deal and in this case it means that they have plenty of time to troubleshoot this problem once they've gone around during the go around the gear was left in its down position and the flaps were left in 18 degrees when they reached 2000 feet captain loft contacted the approach controller and told them that they were having a problem with the nose gear indicator landing light and that they wanted to be kept in the area approach control came back and told them that that was acknowledged and that they could turn left onto a noddly heading initially during the turn and at time 23 3604 captain love to tell first of stock still to engage the autopilot and he does so that's going to become very important for what's about to happen next air traffic control comes back in and tells eastern 401 to turn left onto heading of 300 the crew reads this back and in the subsequent 30 seconds there is a discussion between the pilots where first of the stock still is removing the light fitting for the nose gear indicator light once it's done so he's done trying to put it back in again but it jams in position and they have a discussion of why this is happening now anyone who's been following this channel for a while will probably pick up that this is where the first real problem with crew resource management is appearing because who is actually flying the aircraft remember first off the stock still is the pilot flying and he is now also dealing with the problem as the captain is talking to him about that same problem what we have to remember here though is that back in 1972 there is no such thing as crew resource management training in fact the accident that is about to happen here is going to be one of the driving reasons for crm training to be taken up by the entire industry and things like for example dividing the cockpit making sure that one pilot is concentrating on flying and the other pilot is the one dealing with the problem is going to become standard but at this time that's not the case at time 2337 captain loft turned back in the cockpit toward flight engineer repo and tells him that he needs to go down into the electronic bay and look through a lens to see if he can verify that the north gear actually is in down and locked position now what has potentially happened here is that as captain lovett turns back he accidentally pushes the yoke remember what we talked about the difference between control weird steering of the autopilot and command which is when you have the normal vertical speed heading and altitude hold nodes well another peculiarity with this is that you can go from the command mode into the control wheel steering mode by actually manually inputting on the yoke and if you're doing so the autopilot is actually not disconnected it's just going into a lower mode of automation which means that there's no warning in the cockpit when this is happening so if captain loft accidentally pushed the yoke here the only indication that they would see of the aircraft going from altitude hall that 2000 feet into controlled wheel steering when it's now doing whatever input that the pilots had put would only be a slight change in the flight mode enunciation and obviously if you monitor the flight instruments you would also see that the aircraft is starting to deviate from what it's supposed to do because from the flight data recorder there was an indication when the captain turned back and started talking to the flight engineer of the aircraft starting a slight descent and it descends within the next few seconds about 100 feet before it stops because of a slight pitch up momentum air traffic control now comes in and tells eastern 4-1 to turn left onto heading of 270 degrees this is most likely an extended downwind to prepare the aircraft so that they're ready for a left turn in and start another approach in front of zero nine left the crew reads this back and following this both the captain and the first officers continue to discuss the fact that first officer stockstill cannot get the light fitting back in for the nose wheel indicator light and they're clearly very involved in this discussion both of them the captain also turns back to remind the flight engineer to once again go back down into the electronics bay under the cockpit to verify the position of the nose wheel at time 23 38 41 captain loft calls our traffic control and tells them that they're still working on the problem with the nose gear indicator light and that they're going to need a little bit more time now traffic control also reads this back once that call is finished flight engineer repo pops his head up into the cockpit and says i can't see nothing down there it's all black now at this point there is actually a fourth person in the cockpit rhythm it's a deadheading pilot who's been sitting on the jump seat and he volunteers to come down and help the flight engineer down inside of the electronic space to see if they can figure it out why they can't see anything in the subsequent investigation after the accident it was found that in order for the flight engineer to be able to look through that lens in the electronics bay two things needed to happen first the captain would have had to switch on the nose wheel light which was situated in his eyebrow panel up to the left and also flight engineer repo when he got down into electronics bay he needed to pull a little knob next to the lens that removes a lens cover and that enabled him to look out so if one of these things were not done remember this was during night time that might be an explanation to why the flight engineer could not see anything no matter how hard he was looking through the lens while the flight engineer is down in the electronics bay trying to look through the lens you can hear on the cockpit voice recorder a half a second c chord chime this chime is a warning that's indicating that the aircraft has deviated more than 250 feet from the selected altitude on its mcp but when you listen to the voice recorder there's no indication that any of the other pilots heard this or at least reacted to it but how is it possible that pilots didn't hear this and is there no other indications available in the cockpit that the aircraft is deviating from the altitude what it turns out that that chime is actually played from a speaker that's situated above the flight engineer station and remember the flight engineer is down in the electronics bay at this point also there is a light that's supposed to be flashing in the cockpit whenever this happens but eastern airlines at the time have chosen to deactivate that whenever the aircraft is below 2500 feet so in this situation that half a second c chord chime is the only indication that the aircraft is leaving the cleared altitude except for of course the actual altimeter in itself as the pilots are concentrating on getting this light fixture back into place the speed of the aircraft has been gradually increasing now the outer throttle was not engaged at the time so at some point one of the pilots must have reached over and reduced the trust slightly possibly because they saw that the speed was creeping up the fact that they did that caused a slight pitch down of the aircraft which increased the vertical speed at time 23 4140 the miami approach controller calls up eastern airlines and they said eastern 401 how are things coming along out there the reason the approach controller is calling this is because he looks at his radar screen and he realizes that the aircraft is about to leave his controller area but he also realizes that the altitude that is shown coming from the aircraft mode c transponder is only indicating 900 feet now at the time the approach controller was not worried about the safety of the aircraft and the reason being that the mode c transponder altimeter readout quite frequently showed erroneous values it needed at least one two or three radar swipes before he would take any type of action captain loft responded to this message saying um okay yeah i would like to to turn around and come back in again miami approach controller said okay in that case turn left on a heading of 180 degrees now you might be asking yourself if this aircraft is descending down towards the ground and none of the pilot seemingly is monitoring their instruments isn't there a system like the ground proximity warning system that will be triggered well this is the thing back in 1972 it was not mandatory to have ground proximity warning system installed on commercial jetliners there had been accidents before this accident so the work was actually ongoing on putting this mandate in place but it was not yet in place seconds after the turn is initiated first officer stock still says we did something to the altitude and captain hall responds what that's down followed by stock still saying uh we're still at 2 000 feet right and captain loft saying hey what what's going on here that's the last message on the voice recorder only two seconds after that at time 23 42 12 the first sounds of impact can be heard on the cockpit voice recorder the aircraft crashes into the everglades swamps at a speed of 197 knots and with a bank of 28 degrees as the aircraft is trying to reach the heading of 180 as instructed by the pilots because it's in a turn it impacts with the left wing first followed by the left engine and the left main landing gear and the impact is so strong that the aircraft immediately shatters into several smaller pieces 101 passengers and crew perish in this accident but miraculously 75 people actually survives when the pieces comes to a complete stop well then the survivors managed to get outside but here they are faced with the next problem and that is that the cabin crew at this time is not mandated to have any flashlights with them at their stations so as the surviving crew gets outside and tries to help and to get the passengers together and away from the wreckage they find that it's pitch black they don't have any flashlights it's very hard for them to organize the work so as a consequence of this you'll find now in every commercial aircraft if you have a look at where the cabin crew is seated that there's always a flashlight ready so that if something like this would happen in the hours of darkness they'll be able to organize the work and help the survivors as good as possible when air traffic control realizes that they've lost greater contact with eastern airlines flight 401 that immediately push the button indicating that a crash has happened this sends out a message to the coast guard who starts looking for the aircraft and they find it fairly quickly at the time when they find it there's actually been some locals who have been out frog fishing in the swamps during the night who had seen this aircraft coming in at very low altitude they have managed to reach the crash site before the coast guard gets there and they have been helping survivors to get away from the wreckage when it comes to the flight crew both captain loft and first of the stock still are killed in the impact and the flight engineer donald repo he actually survives the impact initially is brought to hospital but dies because of his injuries later on the air accident investigation found that the probable cause of this accident was the failure of the pilot to monitor their flight instruments during the last four minutes of the flight this was caused by all of the pilots being preoccupied with the nose gear indicator light and no one was actually really flying the aircraft what this led to together with some other accidents that happened around this time as well was that the aviation world started focusing in on the area of crew resource management crm and this actually kick-started the crew resource management training that all pilots are doing up to this day it is extremely important that pilots when faced with some kind of malfunction divide the roles in the cockpit so that one pilot pilot flying is focusing on aviate navigate communicate keeping the aircraft safe and flying and the other pilot focusing on dealing with non-normal checklists and sorting out the malfunction and that they communicate well between each other another thing that was sped up by this accident was as we mentioned previously the adaptation of ground proximity warning systems and the fact that all commercial airliners right now will have a system like that in force there was also recommendations that that cabin crew needed to have access to a flashlight in case of an evacuation and also some smaller technical instruction for lockheed to make sure that the viewing length down in the electronics bay had a little placard next to it that explained how to use it properly and that potentially they could put the uh switch for the nose wheel light next to it during the autopsy of the flight crew they also found that the captain actually had a rather large brain tumor that was growing that could potentially have affected his peripheral vision without him even noticing it but that was fairly quickly ruled out as a cause because both colleagues that had been flying with him during the weeks before the accident as well as his family indicated that he had had no problems whatsoever with vision up until that point now you might have heard that this accident led to some quite persistent ghost stories and a few years back i did a halloween special that you can check out up here if you want to hear them also if you want to see a great example of where crm really works well well then check out this video i have here remember the acronym class and have an absolutely fantastic day bye

Channel: Mentour Pilot

Views: 445,055

Keywords: eastern airlines 401, crash animation plane, eastern airlines, air crash investigation, mentour pilot, mentour pilot crash, mentour pilot crash investigation, mentour pilot plane crash, fear of flying, fear of flying help, nervous flyer tips, explained, lockheed martin, lockheed tristar, air accident investigation, air accident documentary, air accident simulation, pilot error, boeing 737, flight engineer, everglades, miami, everglades crash flight 401, plane crash

Id: PhO-87wwLJs

Length: 22min 40sec (1360 seconds)

Published: Sat Oct 30 2021