There is an old Monty Python skit called Déjà vu; it is where comedian Michael Palin relives a moment repeatedly, e.g. the phone rings with the same message, a glass of water is repeatedly placed in front of him to drink and he runs to Terry Jones for help over and over again. It’s a very funny skit; coincidentally it was taped around the same time as the accident referenced in this article. The irony is that the aviation industry’s dealings with Déjà vu aren’t funny; they can be tragic as when we notice something that should have been remedied, but wasn’t.
The reason I do this series of Lessons Unlearned is to analyze recent accidents, find the missing pieces and make a teachable moment out of it. This week I will reevaluate an accident that was so long ago that those in the Aviation Industry at the time are either long retired or deceased; that this article shouldn’t be called Lessons Unlearned, but Lessons Forgotten, or perhaps, more appropriately: Lessons Never Experienced. In this case, I will explore an accident from decades past and try to explain why the aviation industry, both private and commercial, is doomed to repeat the same fatal mistakes made over forty years ago.
Eastern Airlines, flight 401, an L-1011, tail number N310EA, crashed in the Florida Everglades on December 29, 1972. It is listed under National Transportation Safety Board (NTSB) report AAR-73-14. Ninety-four passengers and five flight crewmembers – including all three pilots – were killed. This accident is heartrending in that it was absolutely preventable; the flight crew, the aircraft and the weather were all without issue; however, the aircraft was, to put it bluntly, flown into the ground.
And in these facts alone, my point is that: the most tragic issue of this accident was in its simplicity. No mechanic mis-rigged a flight control; an air traffic controller didn’t read back an incorrect altitude; a storm cell didn’t produce a sudden wind shear event. Instead, three highly-trained and qualified pilots allowed a mechanically-sound aircraft to fly into the scene of the accident. Eastern 401 was futility at its finest; it is also a WARNING: If things don’t change in the Aviation Industry, there will be numerous replays of this accident’s circumstances, some with similar endings.
Eastern 401 was a normal JFK to Miami flight; a well-trained flight crew, the aircraft in an airworthy condition. During a standard approach into Miami airport, the crew diverted from the landing cycle due to a nose landing gear (NLG) position light refusing to illuminate Green, aka Gear Down and Locked. The aircraft climbed to 2000 feet and, while seemingly on Autopilot, circled west of the airport to allow the crew time to ascertain if the NLG was, indeed, Down and Locked.
Two problems occurred during this basic maneuver. The first: for four long minutes, the flight crew became obsessed with whether the NLG light was bad or that the NLG had not extended; this fixation kept both pilots from monitoring the instruments, allowing the aircraft to casually fly into the terrain. The second: the flight crew was unfamiliar with the disengagement procedures of the L-1011’s Autopilot system; they unknowingly disconnected the Autopilot’s Altitude Hold function that was to keep them at two-thousand feet; they were also unaware that an aural warning announced that the aircraft exceeded a 250-foot drop in altitude.
The pilots did do some things right, e.g. the Captain sent the Second Officer to verify through the sight glass that the visual vortices – the markings on the NLG – showed the NLG as Down and Locked. However, there were two serious lapses here that cannot be understated:
- The crew diverted attention away from the flight, altogether, and,
- The flight crew did not understand how the Autopilot worked … and how it didn’t work.
The Captain and First Officer were not just preoccupied with the NLG light, they were fixated to the exclusion of everything else going on during an active flight. The L-1011’s gear position lights are on the front panel – just right of center – below the landing gear handle. Focusing attention on this position light, the pilots could not observe the flight status instruments, unless peripherally. The landing gear lights are also located below the glareshield, a ‘shelf’ that prevents instrument sun glare; this obstructed any view outside the forward windscreen. On the descent into the ground, the crew could have also hit a lighted radio tower or other aircraft.
I’ve flown in the cockpit of a B727 when the left main gear Down and Locked light did not illuminate. The Captain called for a ‘go-around’, aborting the landing to fly the pattern around the airport. The flight crew then went through their procedures to assure Down and Locked, maintaining 100% awareness of the aircraft to its surroundings. My flight crew prioritized; they were organized and they were in control.
However, just as important to me is point #2: the flight crew did not understand how the Autopilot worked … and how it didn’t work. This is where the Aviation Industry is destined to fail over and over again … and has. It is why I don’t fly anymore. Warning the Industry of this uncomfortable fact is akin to being in a really boring public service announcement that everyone fast forwards through on their DVR.
I’m not suggesting that pilots know every rivet or hydraulic line. When conducting enroute surveillance for the Federal Aviation Administration (FAA) or accident investigations for the NTSB, it has become painfully obvious that pilots and technicians are becoming complacent with the aircraft they work on.
Either Eastern 401’s Captain or First Officer accidentally turned off the Autopilot’s Altitude Hold function by bumping the control column, presumably when they were leaning over to change the NLG light bulb; they obviously didn’t know about this L-1011 quirk. Again, so simple; and yet, so fatal. If they weren’t so trusting of the technology; if they knew the aircraft a little better, the pilots may have been more attentive to Eastern 401’s flight status.
While conducting FAA enroute inspections, I discovered that many air carriers require pilots to ‘fly the computer’ more often; the reason is that the computer flies more economically, e.g. trimming the aircraft faster and more efficiently than the pilots can; this means money saved in fuel costs per flight. But by relying on the computer, the pilots become too inefficient themselves, putting too much control and dependence on computer control, pilots’ skills atrophy from non-use. Mechanics’ troubleshooting proficiencies become non-existent when they defer problem-solving to the aircraft computer’s capability to analyze itself.
Asiana flight 214 crashed on approach to San Francisco airport due to the flight crew’s mismanagement of the initial approach. A perfectly airworthy B777 aircraft crashed because the pilots couldn’t out think the technology designed to help them. Colgan 9446 crashed off Yarmouth, Massachusetts, because the pilots’ talents could not see beyond the obvious: they kept trimming nose down instead of nose up because the switches were responding in reverse. Air Midwest 5481’s pilots pushed against a mechanical stop, an immovable object; trying to force something that could not be forced; not to be glib, but they were Pushing against a door designed to Pull open. They wasted precious seconds on a futile problem they did not understand as opposed to running any other options. The Captain’s last words, “Push down,” and “Push the nose down.”
Hey, Aviation Industry, it’s coming: Déjà vu. And unlike a comedy sketch from the 1970s, this time it will not be funny.