The Last 4 Minutes of Flight 401
The following story is true I composed it for a business law class at Morrision University in 2011, I got an A by the way I also posted it on my linkedin site and now I’m offering it to you.
Distraction can be the beginning of the end in business, or even in everyday life. Let us just say that you are walking down the street while texting. You look up only to discover that you are now in the middle of an intersection.
Let us also say that you have a counterpart behind the wheel of a car going thru the same intersection toward you, and that person also is texting. “God rest your soul.” Distractions can kill you and even those around you. Case in point:
One of the most important training videos that a student airline pilot could ever watch is the story of what took place in the cockpit of flight 401 on December 29, 1972. Flight 401 is making it’s way from Kennedy Airport in New York City at about 9:30 pm. They reach the skies over the Miami International Airport not long before midnight.
The flight crew is made up of Robert Loft, the pilot and a 55 year old veteran of Eastern Airlines. Also along for the ride is Albert Stockstill the 39 year old first officer. Rounding out the crew is flight Engineer and second officer Donald Repo, who is 51. In just 4 minutes, flight 401 will fly or should I say glide into a swamp. 1st Officer Al Stockstill is piloting the plane. At this point they are over the Miami Airport. The flight Engineer is in the process of running down the final landing check list. All of the conversations in the cockpit are being recorded by the Cabin Audio Monitor or CAM. Up until now all is going smoothly.
Captain Robert Loft: “Miami Tower, Eastern 401 just turned final”
Miami Tower: “Eastern 401 heavy, continue approach to 9 left.”
Captain Loft: “Continue approach, roger.”
The crew’s Flight Engineer begins the check list procedures for landing the plane. This is normally a routine part of the process, but tonight things will go terribly wrong and in less than 4 minutes flight 401 will land unexpectedly, in a Florida swamp.
Flight Engineer Donald Repo: “Radar?”
Captain Loft: “V. P. off.”
Engineer Don Repo: “Dog panels check?”
First officer Albert Stockstill: “35 33”
Engineer Don Repo: “Gear down?”
At this point Captain Loft looked over at the panel of lights sitting in front of Albert Stockstill’s station. All of them showed that the landing gear was down, all but the nose gear, that light was not lit.
Captain Loft: “Bert (Albert) is the handle in?”
Albert Stockstill First Officer: “No nose gear.”
Captain Loft: “I’m gonna raise it back up.”
Captain Loft: “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.”
Miami Tower: “Eastern 401 heavy, roger, pull up, climb straight ahead to 2000, go back to approach control, one twenty eight six.
Engineer Don Repo: “Do you want me to check the lights or not?”
Captain Loft: “Yeah check it.”
What Engineer Don Repo was talking about was a procedure called the Christmas Tree. That involved flipping a switch that would turn all of the warning lights on to see if they were working. He did, and they were, that is all but one. The nose gear light.
First officer Albert Stockstill: “Ahh Bob could you just giggle the light?”
The Captain had leaned forward to giggle the light but he couldn’t reach it. That burned out bulb was on Stockstill’s side of the console, but he couldn’t check it because he was flying the plane.
Captain Loft: (still reaching for the light)“ohh I gotta try this…”
Engineer Don Repo: “it’s right above that red one.”
Captain Loft: “Ahh I can’t get to it from here.”
Engineer Don Repo: “Yeah I can’t make a pull at it either.”
There were 4 people in the cockpit that night but only one of them could have reached the light, co-pilot Albert Stockstill, however he was still flying the plane.
Captain Loft: “Put the auto pilot on here.”
Co-pilot Stockstill: “Alright.”
Since Captain Loft had ordered the auto pilot turned on, Stockstill was free to work on the light. He had managed to get it out and look at it, but he still couldn’t tell if the bulb had been burned out or not. He tried to put the light back into the socket but that to turned out to be a problem.
Captain Loft: “Now push the switch forward…no!!! oh… you got it sideways.”
Miami Tower: “Eastern 401 turn left heading 300.”
!!!! The following action was later proven to be a fatal mistake on the part of the Captain. One that would lead to the deaths of 99 people including three members of the flight crew.!!!!
Captain Robert Loft: (Loft turned around to face Engineer Repo)“Um Don get down there! and see if the damn nose wheel is down.
As he turned, he bumped the wheel thus automatically disengaging part of the auto pilot control. The Captain ordered flight Engineer Don Repo into a small compartment under the flight deck. There he would be able to look thru a slot into the nose wheel compartment. If the wheel was down and locked, Repo would see a bright red strip. He made this attempt a number of times, but to no avail. Unsuccessful at his task he went back to the flight deck.
Co-pilot Stockstill: (still working on the light)“This won’t come out Bob…if I had a pair of pliers I could push it back in.”
Engineer Don Repo: “ I could give you a pair of pliers, but if you force it you’ll break it.”
Captain Loft: “Ahh..to hell with it!! to hell with this….get back down and see if we are lined up with that red line. That’s all we care!” “Screwing around with a 20 cent piece of light equipment. And on This plane.”
The mood seemed to lighten and the Captain and crew had begun to laugh a bit. Engineer Don Repo descended back into that lower compartment, but his efforts would not be fruitful. It was to dark for him to have seen that “red line” and to discover that the wheel was indeed down, and locked. Here is where the crew of 401 though they were. It was night over the Everglades of Florida, they were cruising at an altitude of 2000 feet. The main problem was that they could not confirm that their front wheel was down and locked. They had just talked with the operator from the Approach Center and were about to head back to the airport. Their perceptions however were very wrong. Here is the transcript of what was said in the cockpit of flight 401 during it’s last 60 seconds of it’s flight.
11:42:05pm EST Stockstill: “We did something to the altitude”
11:42:07pm EST Captain Loft: “What?”
11:42:09pm EST Stockstill: “we’re still at 2000 right?”
11:42:10pm EST Captain Loft: “Hey! Whats happening here?”
11:42:12pm EST CAM: [sound of six alarm beeps]
11:42:13pm EST CAM: [Sound of impact]
In reality here is what happened. First the nose wheel light was burned out, the wheel was down and locked. Secondly soon after the Captain ordered the plane to automatic pilot he turned in his chair to have Don Repo go down to the equipment compartment, he bumped the control wheel causing it to disengage the altitude control from the auto-pilot. And thirdly, nobody bothered to check the control panel for readings until 11:42pm and at that point it was to late. They were just 8 seconds away from the Everglades. The procedures surrounding the crash of flight 401 are now required reading at airline flight training schools around the world.
The NTSB report on the crash can be found at the link below.
http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR73-14.pdf
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