Eastern Flight 401
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...
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...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
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