Eastern Flight 401

Synopsis of Accident

Eastern Airlines Flight 401 departed New York’s JFK airport on December 29, 1972 for the short flight to Miami International airport. The Locheed L-1011 crashed into a wooded area of the Florida Everglades 18.7 miles west-northwest of the airport. (Monduct 2003 On approach to runway 9L the crew noticed a nose gear light abnormality after lowering the the landing gear. The crew was instructed to execute a “pull up” and climb to 2,000 feet. After the crew executed the pull up they were vectored around the airport for another approach while they sorted out the problem. Distracted by the abnormality the autopilot was inadvertently disconnected and the aircraft entered a shallow descent that went unnoticed by the crew until it was to late. The aircraft impacted the ground at a relatively shallow angle in a 28 degree left bank. Of the 13 crewmembers and 163 passengers, 94 passengers and 5 crewmembers die in the accident.

Questions:

How did the crew ignore the aircraft because of a minor warning indication?

Prior to the full acceptance of CRM into airline operations there was a more individualistic approach to the operation and conduct in the cockpit. The Captain was the only and final authority to how things were done on the flight deck. This concept has both a regulatory and organizational input that fostered and strengthened this tradition. The FAA in the early years focused on individual pilot proficiency for training and checks with little or no emphasis on a team approach to problem solving. Because of this regulatory and organizational groupthink this crew did not take initiative to assure that someone was doing the primary job on the flight-deck…flying the aircraft. Everyone in the cockpit was involved in solving the minor problem and allowed the autopilot to become disconnected from the altitude hold feature and descend unnoticed into the ground, usually referred to as controlled flight into terrain or CFIT.

Did...