Lights in the Darkness: The crash of Eastern Air Lines flight 401

Note: this accident was previously featured in episode 14 of the plane crash series on December 9th, 2017, prior to the series’ arrival on Medium. This article is written without reference to and supersedes the original.

The wreckage of Eastern Air Lines flight 401 lies in the Florida Everglades after the crash. (Ron Infantino)

On the 29th of December 1972, an Eastern Air Lines Lockheed L-1011 Tristar landing in Miami, Florida plowed into the Everglades well short of the airport, throwing dozens of survivors into a grisly fight for survival. The crash killed 101 people, destroyed a state-of-the-art airliner, and baffled the airline industry. How could the most advanced passenger jet in the skies simply fly into a swamp on a crystal clear night?

The investigation would paint a picture of a cockpit crew so focused on a burnt-out lightbulb that they forgot to fly the airplane, letting their massive jet slowly descend from 2,000 feet until it struck the ground. For the first time, the National Transportation Safety Board would highlight such modern mainstays as poor crew resource management and overreliance on automation, conclusions which are self-evident today but were unheard of in 1972. These findings would eventually place Eastern 401 among the most studied crashes of all time, becoming the seed which blossomed into a revolution in the way we fly airplanes.

An advertisement for the L-1011 from 1972, featuring an Eastern Air Lines promotion. (Lockheed)

In April of 1972, Eastern Air Lines became the first carrier to take delivery of the brand new L-1011 Tristar, Lockheed’s formidable answer to the McDonnell Douglas DC-10. The wide body tri-jet was built with a revolutionary philosophy: that only the best on-board technology was acceptable, and if that technology didn’t exist, Lockheed would invent it. The L-1011 was the first airliner capable of flying on autopilot from takeoff to touchdown; Lockheed even boasted that it could fly all the way across the United States without the pilot ever touching the control column. In some respects the L-1011 surpassed not just every airplane that came before it, but all those which have come after it as well. But to the dismay of Eastern Air Lines and Lockheed, the learning curve for this new technology would prove to be steep.

N310EA, the aircraft involved in the accident. (Jon Proctor)

One of Eastern Air Lines’ inaugural L-1011 routes was flight 401, a regular service from New York’s John F. Kennedy International Airport to Miami International Airport in Miami, Florida. In the days after Christmas, this flight was often filled with New Yorkers looking for a mid-winter getaway in warmer climes, and certainly this was the case on the 29th of December 1972. The flight had been fully booked, filling the spacious cabin nearly to capacity, but in what would turn out to be a stroke of luck, at least 65 prospective passengers never made it to the airport due to the wintry weather snarling traffic. When the flight finally departed New York, there were only 163 passengers and 13 crew on board, well short of the expected number.

The pilots of flight 401, from left to right: Bob Loft, Bert Stockstill, and Don Repo. (Rob and Sarah Elder, “Crash”)

In command of flight 401 that night were three pilots: Captain Robert Loft, First Officer Albert Stockstill, and Flight Engineer Donald Repo. They were joined in the cockpit by an Eastern Air Lines maintenance specialist, Angelo Donadeo, who would ride along in the jump seat, and an off-duty pilot who elected to sit in the cabin. The 55-year-old Captain Loft was a veteran pilot who had been flying for decades, a true old guard captain who had begun his career in the propeller era. The other pilots were not inexperienced, but none could hold a candle to Loft, who had nearly 30,000 flying hours. That experience only counted for so much, however, as none of the pilots had more than about 300 hours on the new L-1011s.

This group photo was taken by the flight attendants on the flight into New York before flight 401 on the day of the accident. All these stewardesses would be on the accident flight; two would die in the crash. (Ron and Sarah Elder, “Crash”)

Flight 401 departed JFK Airport at 9:20 p.m., climbed to its cruising altitude, and headed south toward Florida. The flight was entirely routine, except in first class, where a passenger proposed to his girlfriend (she said yes).

A couple hours later, the L-1011 commenced its approach to Miami. With First Officer Stockstill at the controls, Captain Loft ran through the approach checklist, followed by the landing checklist. The weather was clear and they had the runway in sight. A safe landing seemed imminent.

But when Loft attempted to lower the landing gear, there was an immediate problem: the light indicating that the nose gear was down and locked did not illuminate. “I gotta — I gotta raise it back up,” he said, trying the age-old technique of “turn it off and back on again.” He raised the landing gear back into the wheel wells, then lowered it again with a clunk. Once again, the “nose gear locked” light failed to come on.

“Right, gear,” said First Officer Stockstill. “Well, want to tell ’em we’ll take it around and circle around and screw around?”

It would be imprudent to land without the nose gear light illuminated, because its absence could indicate a problem with the locking mechanism that might cause the gear to collapse on touchdown. They would have to circle the airport until the light came on, or until they were able to visually verify the position of the nose gear.

Flight 401 a couple hours before its departure, photo taken by a surviving passenger. (Ron Infantino)

Captain Loft got on the radio and said, “Well, ah, tower, this is Eastern 401. It looks like we’re gonna have to circle; we don’t have a light on our nose gear yet.”

“Eastern 401 heavy, roger,” said the controller, “pull up, climb straight ahead to two thousand, go back to approach control [on] 128.6.” The plan was for flight 401 to enter a holding pattern west of the airport at 2,000 feet, where it wouldn’t interfere with other planes on approach.

Strangely enough, Eastern 401 was not the only plane approaching Miami that night with a possible landing gear problem. National Airlines flight 607 had reported a similar issue but was unable to resolve it, prompting the airport to roll out a full emergency response in case the plane’s landing gear collapsed on touchdown. The air traffic controller had his hands full dealing with this emergency and was paying little attention to Eastern 401.

Meanwhile, the L-1011 commenced its short climb back up to 2,000 feet. “Put power on it first, Bert. That-a boy!” said Captain Loft.

“Alright.”

“Leave the goddamn gear down ‘till we find out what we got,” Loft added.

Flight Engineer Don Repo chimed in with a suggestion. “You want me to test the lights or not?” he asked. At the flight engineer’s station, there was a button that would allow him to perform a so-called “Christmas tree” test, illuminating every light in the cockpit to determine if the bulb had burnt out.

“Yeah,” said Loft. “Check it.”

Repo flipped the Christmas tree switch, and all the cockpit lights came on — except for the nose gear light.

“Uh, Bob, it might be the light,” said Stockstill. “Could you jiggle tha — the light?”

“It’s gotta come out a little bit and then snap in,” Repo suggested.

Loft and Stockstill set about trying to pull the light out and put it back in to see if they could get it to turn on. Even with the knowledge that the bulb had failed, they didn’t feel comfortable landing without a positive indication that the nose gear was down and locked. After all, if they landed without knowing the nose gear position and the gear collapsed, how would that look in the subsequent safety report?

Only now did Loft find time to respond to the instructions from Air Traffic Control. “Okay, going up to two thousand, one twenty-eight six,” he said, reading back the command.

Some thirty seconds later, flight 401 arrived at 2,000 feet. “We’re up to two thousand,” said Stockstill. “You want me to fly it Bob?”

“What frequency did he want us on, Bert?” Loft asked.

“One twenty-eight six,” said Stockstill.

“I’ll talk to ‘em,” said Loft. In low tones, Loft and Repo went back to arguing over how to remove the light bulb.

A short while later, Loft keyed the frequency for Miami approach control and said, “Alright, ah, approach control, Eastern 401, we’re right over the airport here and climbing to two thousand feet. In fact we’ve just — ”

“Eastern 401, roger,” said the controller. “Turn left heading three six zero and maintain two thousand, vectors to nine left final.”

“Left three six zero,” Loft replied. Turning back to his crew, he added, “Put the autopilot on here.”

“Alright,” said Stockstill, activating the plane’s advanced autopilot. It would hold them at 2,000 feet while they solved the landing gear problem, and whenever ATC gave them a new heading, they could enter it using the heading select knob and the plane would turn by itself.

With the plane now on autopilot, all three pilots turned their attention back to the broken light bulb. Stockstill had managed to remove the bulb and was now trying to put it back in, but it became jammed half way into the socket and wouldn’t move.

“See if you can get that light out,” said Loft.

“Alright.”

“Now push the switches just a… forward. Okay. You got it sideways, then.”

“Naw, I don’t think it’ll fit,” said Stockstill.

“You gotta turn it one quarter turn to the left,” said Loft.

The controller contacted the flight and said, “Eastern 401, turn left heading three zero zero.” This vector would take the plane out to the west of the airport, over the vast wilderness of the Florida Everglades. As the plane began to turn, the lights of the city disappeared, replaced by the featureless void of the swamp.

“Okay,” said Loft. “Three zero zero, Eastern 401.”

Captain Loft decided that they had wasted enough time messing with the bulb. He turned around and said to Repo, “Hey, hey, get down there and see if that damn nose wheel is down. You better do that.”

Although it was inconvenient, there was one way to confirm the position of the gear without relying on the light bulb. Beneath the cockpit floor was the avionics bay, a cramped room colloquially known as the hellhole, which could be accessed via a hatch in the cockpit floor. Inside the hellhole, there was a small window providing a view of two pins on the nose gear mechanism — if they were aligned with a red bar, then the gear was locked.

“You got a handkerchief or something so I can get a little better grip on this?” Stockstill asked. “Anything I can do it with?”

“Get down there and see if that damn thing…” Loft said to Repo as he fumbled with the trap door.

“This won’t come out Bob,” Stockstill complained. “If I had a pair of pliers, I could cushion it with that Kleenex!”

A man climbs into the “hellhole” on an L-1011. (Miami Herald)

As the pilots focused on the problem with the bulb, no one noticed that an entirely new problem had already begun to develop. When Captain Loft turned around to tell Repo to go check the gear position, he accidentally pushed on his control column with just enough force to cause the autopilot to cede manual control over the elevators. Unlike earlier models, the L-1011’s autopilot had more possible configurations than just “on” or “off;” instead, pilots could set it to control any combination of the various vectors of motion that they so desired. In order to allow the pilots to quickly take control from the autopilot in an emergency, each of these components could be selectively disabled by making a sufficiently forceful input in its respective plane of motion using the control column. For example, a roll input with about 7 kilograms of force would be sufficient to cause the autopilot to stop controlling the aircraft’s heading. If such an input is made while the autopilot is fully engaged, the autopilot mode select lever will move from the “command” position to the “control wheel steering” position, a fairly obvious change, and the heading light on the autopilot panel will extinguish. In control wheel steering (or CWS) mode, the autopilot merely stabilizes the aircraft’s trajectory, holding whatever attitude and direction the pilot applies, instead of actively controlling the aircraft, as it does in command mode.

The path of flight 401 during its final minutes. (NTSB)

But the “altitude hold” function of the autopilot worked differently. When a force of 7 kilograms or more was applied on the pitch axis, the autopilot would stop holding the plane at the selected altitude, and the “ALT” light on the autopilot display would extinguish, but the autopilot mode select lever would remain in the “command” position without reverting to CWS. Indeed, it would continue to operate in command mode for all other vectors of motion, but for the pitch axis, it would operate as though it was in CWS mode. Therefore, when Captain Loft bumped the control column and accidentally disengaged the altitude hold function, the autopilot stopped holding the plane at 2,000 feet and ceded full command of altitude and descent rate to the pilots. The only indication that this had happened was the absence of one small light on the glare shield, and a glance at the position of the autopilot mode select lever would have given no indication that the autopilot was not fully engaged.

Initially, nothing about the aircraft’s trajectory changed, since no one made any further inputs. As the plane continued to drift along at 2,000 feet, the approach controller called and gave them a new heading of 270 degrees — due west. Captain Loft acknowledged, and Stockstill used the heading select knob to command the autopilot to fly to this heading. It dutifully complied.

An annotated flight path diagram by Matthew Tesch in MacArthur Job’s “Air Disaster: Volume 1.”

A few seconds later, Loft’s frustration boiled over. “To hell with it, to hell with this,” he said. “Go down and see if it’s lined up with the red line. That’s all we care about. Screwing around with that damn 20-cent piece of…”

The entire crew let loose a little nervous laughter. As Repo opened up the hatch and disappeared into the hellhole, Loft went on the radio and said, “Eastern 401, I’ll go ah, out west just a little further if we can here and, ah, see if we can get this light to come on here.”

“Alright, we got you headed westbound there now, Eastern 401.”

“Alright.”

“How much fuel we got on this son of a bitch?” Loft asked.

“Fifty two five,” someone said.

“It won’t come out, no way,” said Stockstill.

At around this time, Stockstill observed that they were a little bit too fast and made a slight reduction in power. What he didn’t know was that the autopilot would not compensate for this drop in power by using the controls to keep the plane at 2,000 feet. With less power and nothing to counteract it, flight 401 entered a shallow descent.

“Did you take it out of there?” Loft asked.

“Huh?”

“Have you ever taken it out of there?”

“Hadn’t till now,” said Stockstill.

“Put it in the wrong way, huh?”

“In there, looks square to me.”

“Can’t you get the hole lined up?”

“I don’t know what the hell is holding that son of a bitch in,” said Stockstill. “Always something; we could have made schedule.”

A chime sounded at the flight engineer’s station to indicate that the plane had descended more than 250 feet below the selected altitude of 2,000 feet. No one noticed.

Inside the “hellhole,” this was the sight which greeted Don Repo. (Michael D. Davis)

“We can tell if that son of a bitch is down by looking at our indices,” said Loft. “I’m sure it’s down, there’s no way it couldn’t help but be…”

“I’m sure it is,” said Stockstill.

“It freefalls down.”

“The tests didn’t show that the lights worked anyway.”

“That’s right.”

“It’s a faulty light,” said Stockstill. But he kept trying to fix it anyway. “Bob, this piece of crap just won’t come out!”

“Alright, leave it there,” said Loft, giving up on the matter altogether.

At that moment, Repo returned from the hellhole. “I don’t see it,” he said.

“You can see that indicator for the nose wheel, there’s a place in there you can look and see if they’re lined up,” said Loft.

“I know, a little like a telescope,” said Repo.

“Yeah.”

“Well…”

“It’s not lined up?” Loft asked.

“I can’t see it, it’s pitch dark and I throw the little light and I get nothing.”

Technical officer Angelo Donadeo, who had until now been silently watching, finally chimed in. “Wheel well lights on?” he asked.

“Yeah, wheel well light’s always on if the gear’s down,” said Repo.

But it turned out that he was wrong, and the lights weren’t on after all. Loft switched on the wheel well lights and said, “Now try it.” Repo shuffled his way back down the ladder into the hellhole, and Donadeo followed him down to render assistance.

Artist’s impression of the moment flight 401 first touched the water. (Anonymous author)

At Miami International Airport, the National Airlines plane had by now landed safely; the fire trucks were deployed but ultimately proved unnecessary. With the distraction over, the approach controller turned back to his display, where he suddenly noticed that the altitude indication on Eastern 401’s radar return read only 900 feet. Miami had recently become one of the first airports in the world to install an advanced secondary radar system capable of displaying every aircraft’s altitude, speed and heading, but its accuracy was questionable. Large altitude deviations were sometimes displayed for up to three sweeps of the radar before returning to normal. But just to be sure, the controller called flight 401 and asked, “Eastern 401, how are things coming along out there?”

Anticipating a confirmation of the gear position at any moment, Loft replied, “Okay, we’d like to turn around and come, come back in.”

This self-confident reply was enough to convince the controller that the altitude deviation was nothing more than a radar glitch. “Eastern 401, turn heading one eight zero,” he said.

As Stockstill entered the new heading into the autopilot, he happened to glance at his altimeter, and for the first time he noticed that something was wrong. “We did something to the altitude?” he said, sounding confused.

“What?” Loft asked.

“We’re still at two thousand, right?” said Stockstill.

Loft caught sight of their altitude rapidly ticking down toward zero and exclaimed, “Hey, what’s happening here?”

The full breakup sequence of the aircraft, as illustrated by Matthew Tesch in Macarthur Job’s “Air Disaster: Volume 1.”

The radio altimeter emitted a series of chimes as flight 401 closed in on the ground. Loft pitched up and reached for the throttles, but it was too late. At 11:42 p.m. and 12 seconds, Eastern Air Lines flight 401 slammed into the watery surface of the Florida Everglades, plowing into the swamp at 365 kilometers per hour. The lights flickered and went out, and the pitch-black cabin filled with a cacophony of rending metal as the violent impact tore the plane apart. The fuselage disintegrated, and huge chunks of the L-1011 tumbled through the shallow water, spewing debris and passengers out into the darkness. Waves of fuel washed through the cabin, followed by the searing heat of flames. Finally, the mangled wreckage ground to a halt amid the mud and sawgrass, leaving a trail of destruction stretching for several hundred meters, a ghastly, silent hellscape littered with the dead and dying.

In the tower, the controller suddenly noticed that his radar wasn’t picking up flight 401’s transponder properly. “And, ah, eastern 401, are you requesting the equipment?” he asked. There was no reply. “Eastern 401, I’ve lost you on the radar there, your transponder,” he continued. “What’s your altitude now?” This message too was met with silence. “Eastern 401, Miami?”

Another pilot soon delivered the chilling news. “Ah, Miami tower this is National 611,” he said. “We just saw a big explosion, looks like it was out west. I don’t know what it means, but I thought you should know.”

An aerial view of the crash site and the extensive wreckage trail. (NTSB)

Out in the Everglades, the survivors of flight 401 awoke amid a surreal scene of random devastation. As the plane came apart, some passengers were thrown out into the swamp as far as 100 meters away from the plane, mostly with fatal results. Others found themselves still strapped into their seats, upright and attached to the cabin floor, but with the walls and roof ripped away around them. Injuries ranged from superficial to immediately fatal without any apparent rhyme or reason. Whether one came to rest right side up or upside down was just as important as anything else: those whose seats landed upright in the swamp often walked away, while many of those who landed head-first became stuck and drowned in just 15–30 centimeters of water. While some horribly injured passengers flailed in the biting sawgrass, others walked off mangled chunks of the plane without any injuries at all — one survivor even recalled standing around with other passengers, all totally unharmed, discussing their respective careers as though nothing untoward had happened. In another area, a flight attendant stood atop the wreckage of the tail section and tried to calm people in the swamp by gathering to sing Christmas carols, which worked well until suddenly no one could remember the words to “Frosty the Snowman.” Others reacted with anger: one man allegedly yelled, “I always knew Eastern was no good! I do business with them, they take sixty days to pay their bills!”

Another aerial view of the wreckage. From left to right, one can make out the cockpit, the center section, and a life raft which was released during the breakup. (Bureau of Aircraft Accidents Archives)

The first people to realize what had happened to flight 401 were not the air traffic controllers, but airboat pilot Robert “Bud” Marquis and his hunting partner Ray Dickinson, who were out on the swamp catching frogs when they caught sight of the L-1011 coming in low overhead. Seconds later, a huge explosion rose up from the swamp, throwing up a 30-meter-high wall of fire that seemed to continue for the better part of a mile. Although the flames quickly died down, they managed to pinpoint the location of the crash and rushed to the scene in their airboat, realizing that they had arrived only when their bow bumped up against a dark mass of wreckage. The scene they discovered was hellish beyond all imagination. All around them, people were screaming and crying; bodies, stripped of their clothes, lay strewn amid the scattered pieces of the plane, and the smell of aviation fuel hung heavily on the air. Braving jet fuel burns on their legs, the two frog hunters jumped into the water and set about saving anyone they could. Their first priority: to find anyone stuck upside down in their seats, and if their legs were still kicking, to turn them the right way around.

In the rear economy lounge, the roof and walls were torn away, leaving the floor with seats intact. (Ron Infantino)

The local Coast Guard rescue station was notified of the missing L-1011 just moments after it vanished from radar, and within five minutes of the crash a helicopter was in the air. The pilot initially did not believe he was headed to a real emergency: after all, how could an advanced L-1011 crash on flat terrain on a perfectly clear night? Surely it was all just a misunderstanding.

At the crash site, Bud Marquis saw the helicopter approaching, but it seemed lost, looking in the wrong part of the swamp. He grabbed his high-power frogging flashlight and moved it back and forth like a beacon, catching the pilots’ attention and undoubtedly hastening the rescue. Within a short time the helicopter managed to land on a nearby flood control levee, and the rescue began in earnest. As Marquis and Dickinson used their airboat to ferry survivors to the levee, rescuers from the helicopter hurried into the apocalyptic debris field. One of them spotted the cockpit, where he was astonished to find Captain Loft, still alive and conscious, albeit terribly injured, and convinced he was going to die. But despite his rescuer’s assurances to the contrary, Loft did indeed die of his injuries within minutes, joining First Officer Stockstill, who lay lifeless beside him.

Looking at the wreckage, it’s hard to believe so many people survived. (The Miami Herald)

As rescue teams continued to arrive at the scene, more and more survivors were pulled from the battered wreckage and from the surrounding swamp. Among those found alive were Flight Engineer Don Repo and technical officer Angelo Donadeo, who had been inside the avionics bay at the moment of impact. The rescue proved chaotic, as the plane had crashed nearly 13 kilometers from the nearest road, but emergency vehicles were eventually able to get within 100 meters of the site by driving in single file down the flood control levee, which doubled as a helicopter landing pad. Amid the mayhem, it took 64 minutes for the first survivors to be airlifted from the crash site, and the last weren’t evacuated until well after 3:00 in the morning. Initially, 79 people survived, as well as a dog, which was the first victim to arrive at Mercy Hospital in Hialeah. However, two survivors soon died of their injuries, including Flight Engineer Don Repo. Over the following month, two more passengers also succumbed as many of the survivors fought deadly gas gangrene infections caused by bacteria in the swamp water. Those who could not be treated in hyperbaric chambers were forced to have the affected body parts amputated.

This piece of the center section was one of the more recognizable parts of the plane. (Ron Infantino)

All told, of the 176 people on board, 101 died and 75 survived. The death toll was at the time the largest in the United States in an accident involving only one airplane, underscoring the fears of rising body counts that accompanied the introduction of wide body jets two years earlier. Eastern Air Lines flight 401 was in fact the first fatal crash of a wide body airliner, and many speculated at the time that so many people survived because the size of the plane shielded them from the impact. In reality, the soft surface into which they crashed likely played a larger role in ensuring a high survival rate despite the almost total destruction of the airframe. Later, investigators would also cite the design of the L-1011’s passenger seats, which were much stronger than called for by regulations.

The remains of the cockpit, from which only Angelo Donadeo escaped alive. (The Miami Herald)

While the survivors recovered from their injuries in hospital, the National Transportation Safety Board launched a major investigation to determine the cause. Although testimony from Angelo Donadeo put them on the right track, it was only after examining the contents of the black boxes — including the L-1011’s advanced flight data recorder, which kept track of far more parameters than contemporaneous models — that the frustrating sequence of events began to emerge.

When the crew first attempted to lower the landing gear, they received no indication that the nose gear was locked. An inspection of the wreckage revealed that the two bulbs in the nose gear light had burnt out and the gear was down and locked the whole time, but the pilots could not have known this without additional verification. Their decision to enter a holding pattern until they figured out the status of the nose gear was entirely prudent. It was when they leveled off at 2,000 feet that events began to go downhill.

Inside the wreckage of the center section. (The Miami Herald)

After Stockstill engaged the autopilot, a remarkable thing happened: the human pilots simply stopped flying the plane. Loft, Stockstill, and Repo gave the landing gear light their wholly undivided attention, leaving no one to ensure that the plane remained on course. It was apparent that they subconsciously trusted the autopilot to perform the seemingly simple task of keeping the plane straight and level. Having engaged the autopilot, tasks such as monitoring airspeed and altitude were compartmentalized away in some inconspicuous realm of thought where they were subordinated to the apparently more urgent task of confirming the status of the landing gear. When Captain Loft accidentally disengaged the autopilot’s altitude hold function and the plane began to descend, there was little to inform him of the deviation or to warn him of his proximity of the ground, except for the expectation that he would exercise due vigilance in scanning his instruments. The only overt warning — the C-chord chime emitted from the flight engineer’s station when the plane left 2,000 feet — was easy to miss when their attention was focused elsewhere, especially since the flight engineer wasn’t in the cockpit.

Another aerial view of the wreckage reveals the sheer scale of the debris field — and this is only part of it. (The Miami Herald)

To better understand what took place on board the flight, investigators examined how the pilots had been trained to use the autopilot. As it turned out, Eastern Air Lines actively discouraged dependence on automation by banning the use of the autopilot in Control Wheel Steering mode: the system was to remain either in total control or turned off at all times. The intermediate modes, in which the autopilot would hold an attitude inputted via the yoke, were therefore off limits, and the details of how they worked were not covered in training. In fact, the airline seemed completely unaware that this particular mode even existed, and pilots who had experienced it thought the autopilot had malfunctioned.

Ironically, this effort to avoid a too-swift transition to the era of autonomous flight left the pilots unaware of some basic aspects of the system’s functionality. This lack of knowledge made it unlikely that they could have predicted the autopilot’s behavior, and consequently they were less likely to notice when it quietly reverted to an intermediate mode.

A view of the crash site from farther afield reveals more of the wreckage. (Ron Infantino)

Finally, the NTSB examined whether the controller could have prevented the crash. In the last minute of the flight, he observed that the L-1011’s radar return displayed an altitude of only 900 feet, but a number of factors prevented him from realizing that a dangerous situation had developed. First, the unreliability of the new radar system meant that large erroneous changes in altitude could persist for up to three sweeps before self-correcting, so a reading of 900 feet was not by itself indicative of a dangerous situation. Even so, in 1972 keeping planes away from terrain was not part of an air traffic controller’s job description, and he was under no obligation to ensure that flight 401 was still at 2,000 feet, unless it came into conflict with another aircraft. Therefore, his vague question asking if everything was alright already went above and beyond the call of duty, and Captain Loft’s response so completely put him at ease that he never looked at flight 401’s altitude again. Considering the circumstances, the NTSB felt that few controllers in that situation would have caught on to the problem.

The center section and the cockpit of flight 401. (The Miami Herald)

The investigation into the crash of Eastern Air Lines flight 401 broke new ground in several areas. In its final report on the crash, the NTSB for the first time ever cited an overreliance on automation as a major contributor to an accident, noting that in just a few short months, L-1011 pilots had found its sophisticated autopilot to be so reliable that they habitually allowed it to control the plane with little to no oversight. Only after the accident did reports emerge of other flight crews who had observed the autopilot reverting to CWS mode or disengaging altitude hold after they accidentally bumped the yoke. Given the lack of training on CWS, combined with pilots’ trust of the automated systems, it was probably just a matter of time before an L-1011 was involved in accident or near miss due to this quirk.

Investigators work near the remains of the cockpit. (Ron and Sarah Elder, “Crash.”)

The report on the crash of flight 401 was also one of the first times that the NTSB pointed to a lack of proper crew resource management as a contributing factor. Although the term “crew resource management” did not yet exist, the NTSB specifically mentioned one of the key symptoms of poor CRM: a failure to delegate. The captain, in his role as commander, is expected to delegate tasks to the other crewmembers to ensure that everyone has a clearly defined role and that all necessary duties are accounted for. On flight 401, Captain Loft allowed events to develop organically without ensuring that someone maintained a holistic view of their situation. If at the moment of the nose gear light failure Loft had said, “Bert, you fly the plane; Don, you go check the indicator; and I’ll work the radio and try to fix the light,” then the crash almost certainly would not have happened. This type of analysis would be expected today, but was so new in 1972 that it made waves throughout the industry despite occupying little more than a page in the final report.

The jet’s tail section was one of the other recognizable chunks. (Bureau of Aircraft Accidents Archives)

Upon the conclusion of its inquiry, the NTSB issued three recommendations, including that procedures be developed to allow air traffic controllers to help flight crews when an altitude deviation is noticed; that all crewmembers have seat belts and be required to wear them; and that the flashlights issued to flight-attendants be stored in a consistent and secure location where they can be found after a crash. The Safety Board also noted that the FAA was considering requiring ground proximity warning systems, and encouraged the agency to continue with those efforts. In addition, Lockheed voluntarily modified the L-1011’s landing gear system so that the wheel well lights would turn on automatically when the gear was lowered, and introduced an amber warning light to accompany the chime when leaving a selected altitude.

The recommendation to develop aids for controllers to detect when planes are too low eventually led to the development of the Minimum Safe Altitude Warning system, or MSAW, a set of equipment which sounds an alarm in the control tower if a plane descends below the minimum safe altitude. The systems first entered service in 1977 and were installed at major airports across the United States by the end of the 1980s.

Official poster for the TV movie version of “Ghosts of Flight 401. (Amazon)

Among the general public, Eastern Air Lines flight 401 is best known not for its safety lessons, but for an alleged haunting which became one of the most widely shared urban legends to emerge from the aviation industry. According to the story, popularized by the 1976 pseudo-nonfiction novel Ghosts of Flight 401, Eastern Air Lines salvaged intact galley equipment from the wrecked airliner and installed it on another L-1011, after which passengers and crew began seeing lifelike apparitions of Bob Loft and Don Repo in the galley area. The story became so popular that Eastern Air Lines had to tell its employees to stop writing up ghost sightings in the flight logs. However, the actual origin of the sightings is much more prosaic. In fact, the story seems to have originated in a 1973 Flight Safety Foundation article about an engine failure on another Eastern Air Lines plane, which jokingly described the pilot “[thinking] he saw the ghost of Don Repo.” Someone took this attempt at humor too seriously, and the story spread from there, often being taken as canon, even though no one saw a ghost until after the story was published, nor was there any evidence that equipment from flight 401 was actually salvaged.

From the center section, looking toward the cockpit. (Ron and Sarah Elder, “Crash”)

The true legacy of Eastern Air Lines flight 401 was far more real than any ghost story. The crash in the Everglades came to be seen as a seminal moment in aviation history only after years of analysis and debate revealed it to be the perfect case study of the underlying factors that cause human errors. Although various accidents are credited with causing the industry to adopt the principles of Crew Resource Management, Eastern Air Lines flight 401 was the event which prompted scientists and safety experts to start taking cockpit cultural problems seriously in the first place. The expected relationship of the crewmembers to one another was at that time essentially unchanged since the dawn of aviation, and the existing modes of thought were plainly inadequate for an environment in which pilots were expected to work as a team. Even though the NTSB made no recommendations in this area, and no sweeping FAA initiatives explicitly cited Eastern 401, the crash undoubtedly led to the recognition that change was needed, a critical progenitor of progress which is often overshadowed by the catalysts of its eventual implementation. After all, if a state-of-the-art airplane could crash because of a burnt-out lightbulb, there was no way to deny that we, the humans who build and maintain social systems, were the root cause of the problem.

_________________________________________________________________

Join the discussion of this article on Reddit!

Visit r/admiralcloudberg to read and discuss over 200 similar articles.

You can also support me on Patreon.