Aviationaerospace Psychology

.. aircraft. Additionally, from reading the Cockpit Voice Recorder (CVR) transcripts that the flight crew was also lacking in what is considered general operator knowledge. Specifically there was confusion between the flight crew on how to change and test the gear indicator light, and how to view the mechanical nose gear indicator in the nose compartment. The flight crew also displayed a lack of awareness of the actual aircraft’s position and had become complacent in their duties by relying on the autopilot to fly the aircraft.

This lack of awareness is displayed in the transcript when the CAM-2 microphone recorded “We did something to the altitude” CAM-1 recorded “What?” CAM-2 recorded “We’re still at two thousand right?” CAM-1 recorded “Hey, what’s happening here?” In summary, The American Heritage Dictionary defines “accident” as: 1.a. An unexpected, undesirable event. b. An unforeseen incident. 2.

Lack of intention; chance. 3. Logic. A circumstance or an attribute that is not essential to the nature of something. With this in mind, there is rarely just one cause for an accident as this NTSB abstract implies.

The flight crew could have done many things to avoid this accident. For example, fly the airplane instead of turning on the autopilot or been proficient with exchanging the landing gear indicator light bulb or the mechanical gear indicator system. If maintenance had been more thorough and replaced the twenty-five cent bulb, this flight would have landed without incident. If the controller in the tower had been sure that the gear was locked, the flight would not have crashed. If the approach controller, in the radar room had been more precise or insistent, ninety-nine people would not have died! Any one of these could have prevented this tragedy; therefore, all of these and possibly more are the true cause of it! CVR transcript of the December 29, 1972 Accident of Eastern Flight 401, a Lockheed L-1011 TriStar in the Everglades near Miami, FL, USA.

23.32:35 RDO-1 Miami Tower, Eastern 401 just turned on final 23.32:45 TWR Who else called? 23.32:48 CAM-1 Go ahead and throw ’em out 23.32:52 RDO-1 Miami Tower, do you read, Eastern 401? Just turned on final 23.32:56 TWR Eastern 401 Heavy, continue approach to 9 left 23.33:00 RDO-1 Coninue approach, roger 23.33:00 CAM-3 Continuous ignition. No smoke CAM-1 Coming on CAM-3 Brake system CAM-1 Okay CAM-3 Radar CAM-1 Up, off CAM-3 Hydraulic panels checked CAM-2 Thirty-five, thirty three CAM-1 Bert, is that handle in? CAM-? * * * CAM-3 Engine crossbleeds are open 23.33:22 CAM-? Gear down CAM-? * * * CAM-1 I gotta CAM-? … 23.33:25 CAM-1 I gotta raise it back up 23.33:47 CAM-1 Now I’m gonna try it down one more time CAM-2 All right 23.33:58 CAM [sound of altitude alert horn] CAM-2 (Right) gear. CAM-2 Well, want to tell ’em we’ll take it around and circle around and # around? 23.34:05 RDO-1 Well ah, tower, this is Eastern, ah, 401. It looks like we’re gonna have to circle, we don’t have a light on our nose gear yet 23.34:14 TWR Eastern 401 heavy, roger, pull up, climb straight ahead to two thousand, go back to approach control, one twenty eight six 23.34:19 CAM-2 Twenty-two degrees. CAM-2 Twenty-two degrees, gear up CAM-1 Put power on it first, Bert.

Thata boy. CAM-1 Leave the # # gear down tll we fid out what we got CAM-2 Allright CAM-3 You want me to test the lights or not? CAM-1 Yeah. CAM-? * * seat back CAM-1 Check it CAM-2 Uh, Bob, it might be the light. Could you jiggle tha, the light? CAM-3 It’s gotta, gotta come out a little bit and then snap in CAM-? * * CAM-? I’ll put ’em on 23.34:21 RDO-1 Okay, going up to two thousand, one twenty-eight six 23.34:58 CAM-2 We’re up to two thousand CAM-2 You want me to fly it, Bob? CAM-1 What frequency did he want us on, Bert? CAM-2 One twenty-eight six CAM-1 I’ll talk to ’em CAM-3 It”s right ……. CAM-1 Yeah, ……..

CAM-3 I can’t make it pull out, either CAM-1 We got pressure CAM-3 Yes sir, all systems CAM-1 # # 23.35:09 RDO-1 All right ahh, Approach Control, Eastern 401, we’re right over the airport here and climbing to two thousand feet. in fact, we’ve just 23.35:20 APP Eastern 401, roger. Turn left heading three six zero and maintain two thousand, vectors to 9 Left final 23.35:28 RDO-1 Left three six zero 23.36:04 CAM-1 Put the .. on autopilot here CAM-2 Allright CAM-1 See if you can get that light out CAM-2 Allright CAM-1 Now push the switches just a .. forward.

CAM-1 Okay. CAM-1 You got it sideways, then. CAM-? Naw, I don’t think it’ll fit. CAM-1 You gotta turn it one quarter turn to the left. 23.36:27 APP Eastern 401, turn left heading three zero zero RDO-1 Okay.

23.36:37 RDO-1 Three zero zero, Eastern 401 23.37:08 CAM-1 Hey, hey, get down there and see if that damn nose wheel’s down. You better do that. CAM-2 You got a handkerchief or something so I can get a little better grip on this? Anything I can do with it? CAM-1 Get down there and see if that, see if that # thing .. CAM-2 This won’t come out, Bob. If I had a pair of pliers, I could cushion it with that Kleenex CAM-3 I can give you pliers but if you force it, you’ll break it, just believe me CAM-2 Yeah, I’ll cushion it with Kleenex CAM-3 Oh, we can give you pliers 23.37:48 APP Eastern, uh, 401 turn left heading two seven zero 23.37:53 RDO-1 Left two seven zero, roger 23.38:34 CAM-1 To # with it, to # with this.

Go down ans see if it’s lined up with the red line. That’s all we care. # around with that # twenty-cent piec CAM * * * 23.38:46 RDO-1 Eastern 401 ‘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 23.38:54 APP Allright, ah, we got you headed westbound there now, Eastern 401 23.38:56 RDO-1 Allright CAM-1 How much fuel we got left on this # # # # CAM-? Fifty two five CAM-2 (It won’t come out) no way 23.39:37 CAM-1 Did you ever take it out of there? CAM-2 Huh? CAM-1 Have you evre taken it out of there? CAM-2 Hadn’t till now CAM-1 Put it in the wrong way, huh? CAM-2 In there looks * square to me CAM-? Can’t you get the hole lined up? CAM-? * * * CAM-? Whatever’s wrong? CAM-1 (What’s that?) 23.40:05 CAM-2 I think that’s over the training field CAM-? West heading you wanna go left or * CAM-2 Naw that’s right, we’re about to cross Krome Avenue right now 23.40:17 CAM [Sound of click] CAM-2 I don’t know what the # holding that # # # # in CAM-2 Always something, we coulda make schedule 23.40:38 CAM [Sound of altitude alert] CAM-1 We can tell if that # # # # is down by looking down at our indices CAM-1 I’m sure it’s down, there’s no way it couldnt help but be CAM-2 I’m sure it is CAM-1 It freefalls down CAM-2 The tests didn’t show that the lights worked anyway CAM-1 That ‘s right CAM-2 It’s a faulty light 23.41:05 CAM-2 Bob, this # # # # just won’t come out CAM-1 Allright leave it there CAM-3 I don’t see it down there CAM-1 Huh? CAM-3 I don’t see it CAM-1 You can’t see that indis .. for the nosewheel ah, there’s a place in there you can look and see if they’re lined up CAM-3 I know, a little like a telescope CAM-1 Yeah CAM-3 Well.. CAM-1 It’s not lined up? CAM-3 I can’t see it, it’s pitch dark and I throw the little light I get ah nothing 23.41:31 CAM-4 Wheel-well lights on? CAM-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/N TSB 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 Bibliography 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/N TSB 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 Aviation Essays.

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