* Forwarded by Keith Jillings (2:257/71.10)
 My friend Robin wrote this in the UK PILOTS area, which is virtually
 defunct.  He can't access this one, but I'll forward any replies.
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Hello Everybody !
I wonder if anyone can help me, please ?
I am in Turkey, and reference sources just are not available to me.
The text below is an extract from a Technical Paper I am writing, and I
would be most grateful for confirmation that what I say is right (or
correction, if I'm wrong), and also for a little more "fact" - the
Flight Number and Airline, for instance, and the date. I have just said
"the airliner", but "Utopian AirLines Flight 178" is obviously how I
should phrase it. I would also be grateful for a "citation" that I can
quote as a Reference :
 Where major incidents occur, it is frequently the case that the
 situation develops slowly, with each progression seeming not to be
 particularly significant as it happens, until it is too late to try
 to prevent it. Frequently, each stage in the escalation process is
 `something we have dealt with before', and the overall picture is
 lost because attention is concentrated on the matter in hand.
 The classic case of this collective state of mind in a totally
 different field was the crash of the airliner in the Florida
 Everglades - the crew was concentrating upon the failure of the
 under-carriage locking light to come on, and ignored the
 malfunction of the automatic pilot which allowed the aircraft to
 descend slowly into the ground. In aviation circles it is an
 acknowledged phenomenon.
 > Robin Clay       Osmaniye, Southern Turkey (2:250/410.32)
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When you said Florida Everglades crash, I thought initially of the
ValueJet crash, but this is clearly not what he is talking about.
There are several books about airline crashes, which sometimes can
be borrowed at a library. 363.1241 is the Dewey Decimal number
to use, and also 387.706 (about the airline indistry and airlines)
and some biographies. 363.124 will also get you books about the
Challenger disaster, and 387.70973 is the history of the airline
insdustry in the United States.
I found a mention of what I think is this crash in one of the airline
crash books I borrowed: Terror in the Skies - The Inside Story of
the World's Worst Air Crashes by David Grayson (Citadel Press, 1988)
This contains a number of chapters, some relativeley long, and some
very short; some crashes and some near misses, like that plane on
the way to Miinesota (TWA Flight 841, April 4, 1979 - a Boeing 727)
which was saved only because the pilot was familiar with acrobatic
maneuver.  The number 7 slat had apparently gotten stuck. The pilot
may have engaged in a littkle cover-up as to how all that happened
by erasing the cockpit voice recorder right when he landed.. I can
write about that crash - or others - if you want.
The crash you are probably talking about is Chapter 6, entitked
"Crew Distracted - Jumbo Jet Flies into Ground" between pages 87
and 98
Unfortunately, this book contains no index - you have to be a bit
familiar with this to use it best. It is written in very simple
language, by the way. Citadel Press was a division of Lyle Stuart,
which I think is out of business. By the way, if someone gives me
an address, I'll even maybe airmail a few pages if someone will
promise a letter (about something about air crash investigation)
in return.
Frank Borman also wrote about this crash in his autobiography.
Countdown by Frank Borman with Robert Serling. (William Morrow,
1988) Robert Serling has written very many books about the airline
industry, which are filled with knowledge. This books covers alot
pof ground from the space program to the takeover of Eastern Airlines
by Frank Lorenzo (Lorenzo eventually lost control - it went
bankrupt - a lawyer for the creditors manged to damage it further.
Martin L. (Marty) Shugrue, a former execuitive at Pan Am was the
bankruptcy trustee. The books were finally closed two years ago
maybe several years after it stopped flying. Shugrue toyed with
reviving Eastern, but eventually decided to use the Pan Am name
instead which someone he joined with had acquired the legal rights
to. The crash is discussed on pages 284-290.
The plane was a Lockheed 1011 Tristar - a model which has not been made
since 1983. It was a commercial failure, although maybe it might
not have been. It was known as Eastern Airlines Flight 401 (EAL 401)
and this happened on December 29, 1972. It took off from John F.
Kennedy Airport in New York at 9:20 P.M. and was headed for Miami
Florida (Miami Airport - MIA)
When the plane approached Miami, the landing gear handle was placed
in the down position, but the green light that would tell you it
was really down failed to light up. The captain tried again, but
the green light still did not go on.
So at 11:34 P.M. on December 29, 1972, Eastern Standard Time, the pilot
radioed the MIA tower told them that they were going to have to circle
because they didn't have a light on thier nose gear yet. The tower
told them to climb to 2,000 feet. After receievingh instruction,
the captain told the First Officer, who was flying the plane, to
put the plane on autopilot. This had the effect of keeping the
plane at an altitude of 2,000 feet. Now the Fisrt Officer went
to work attempting to repair the nose gear light. He removed the
light lens assembly to examine it. Then when he attempted to
replace it, it jammed. The captain told him to go down into
the electronic bay, just below the cockpi, and check to see if
maybe the landing gear, in spite of the light, was really extended.
Meanwhile the controller checked in with the tower, and arranged
to turn to a new heading so they could continue circling. There
were altogether four people in the cockpit: The captain (or pilot)
the First Officer (or Co-pilot) the flight engineer (or Second
Officer or controller) and a maintenance specialist, riding deadhead
in the cockpit.
Several minutes later, the co-pilot came back and reported that
it had been too dark to see if the nose gear was really extended.
So they went back to work on the trying to separate the nose gear
light lens from its retainer, to no avail. So the captain told the
co-pilot to go back into the electronics bay and look again. And
they contacted the control tower.
All this time the plane was an autopilot.
For two minutes now the captain and the co-pilot discussed how they
might maybe have re-inserted the nose gear position light assembly
incorrectlky.
Suddenly a half-second musical C-chord sounded. This was an automatic
warning that they had deviated more than 250 feet from the selected
altitude.
The crew ignored it. (The problem here, I think, is ground proximity
warnings at this time gave too many false alarms. The habit sometimes
was to ignore it)
Maybe they figured that 250 feet wasn't serious enough to worry about.
Or they just ignored it on principle. They maybe weren't used to it.
Maybe it just didn't make sense to them.
The aircraft had started to gradually descend. What had happened, you
see, was that the co-pilot, had tried to look and see into the
electronics bay to see how the flight engineer (and another man) was
doing in looking to see if the landing gear was extended. Of course
he couldn't tell anything, but people get impatient and curious. He
had, without noticing it, leaned so far forward that he had pressed
against the control yoke with enough force so as to disconnect the
autopilot.
Some time later the Second Officer said:
® I can't see it. It's pitch dark and I throw a little light  - I get
nothing. ¯
A flashlight wasn't helping him.
Now the maintence specialist volunteered to go look. They were
evidentally taking turns, each one looking to see if they could see
the landing gear and taking several minutes minutes doing this.
Now what a good pilot would usually do is fly over the airport and ask
someone on the ground to look, but these people, evidentally, wanted to
handle this all on their own or maybe nobody in the cockpit, or at least
the captain,  was familiar enough with the oral history or folklore
of flight to know that that is what he should do. Instead, they
persisted for a few minutes in trying to see themselves if the landing
gear was extended, and kept on failing, meanwhile forgetting everything
else for a little over five minutes. Maybe they just didn't want to
trouble them if they could solve it themselves.
In the meantime the plane was slowing sinking lower and lower, while
the crew thought the autopilot was taking care of things. Not only
had the autopilot been disconnected, but the power had been cut. They
were over the Florida Everglades. There was no moon, nor anything on the
ground to tell them they were getting close.
At this point, the air traffic controller noticed that the jet was
reported as being at 900 feet. (He later testifiued that the display
was wrong often enough so you couldn't be sure that was really true.)
He radioed Flight 401:
® Eastern, ah, four oh one, how are things coming along out there? ¯
EAL replied:
® O.K., we'd like to turn around and come back in ¯
The pilots evidentally, by this time, had decided that the landing
gear really was extended, and they were ready to land. Or maybe they
just wanted to get closer and were prepared now to ask someone at
the airport.
So now the air traffic controller told the plane to come in for
a landing and gave them a heading.
In the entire conversation. . .
The air traffic controller did NOT MENTION the altitude, although that
was the reason he had contacted the plane. I guess he was afraid of
being embarassed in case he was wrong. He may have assumed that if
the plane was too low, it would be the result of some mechanical
difficulty, and they would know it.He asked the question obliquely.
Suddenly, at 11:42:05, while turning with the wing lowered, the co-pilot
said:
® We did something to the altitude.
Captain: What?
Co-pilot: We're still at 2,000, right?
Captain: Hey, what's happening here? ¯
This was all conversation inside the cockpit, recorded on the cockpit
voice recorder.
At 11:42:10 altimeter beep sounds began to get noisy. The pilot and the
co-pilot tried to pull up.
Meanwhile, back at the Air Traffic Control tower, the Air Traffic
Controller noticed that the letters CST (for Coast = Sea level) had
appeared in thw box of information next to the radar blip. So he
radioed them asking them if they needed emergency equipment. His
thought was that maybe they had crash landed. (he was not that much
aware of the geography to know they were over the Everglades or
maybe there could have been a place)
Then. . .
The blip disappeared.
® Eastern four oh one. I've lost you on the radar. What's your altitude
now, Eatern four oh one? ¯
. . .said the air traffic controller.
The only reply was. . .silence.
Back on the plane, as I mentioned, the pilot and co-pilot tried to
pour on the power. But a jet engine takes about 4 to 6 seconds to
"spoolup" and develop thrust.
Two seconds after they reacted, the plane went into the swamp. The time
recorded on their cockpit voice recorder was 11:42:12.
The left wing struck the muddy ground first, then the left engine, then
the left landing gear and the aircraft disintegrated. Wreckage was
scattered over a path 1,600 feet llong and 300 feet wide. The passenger
compartment broke into four main sections, and, almost onvariably
happens a fire began. This one started outside the plane, but some
of the burning fuel penetrated the cabin area. But basically there
was no fire, which surprised Frank Borman when he went aboard the
plane. (There was a woman inside screaming she had lost her baby and
he put his arms around her and looked around for the baby, without
any result, and then went out)
Frank Borman arrived at the crash scene not too much later. Some rescue
helicopters had preceded him. A man trapped in wreckage died right in
front of him. (There was a *little* solid ground nearby for helicopters.)
The result was as follows:
INJURIES       CREW      PASSENGER     TOTAL
  FATAL          5         96 *         101
  NON-FATAL      8         67            75
* Frank Borman wrote 93 passengers were fatally injured.
The very low angle of descent, and the fact that the cargo compartment
was below softened the impact. There was some speculation that maybe
there was some extra layer iof protection in the frame of this large
an aircraft, but the true reason was that the fuselage itself did not
hit the survivors. Either their seats remained attached to the floor,
or they were thrown clear of the wreckage. The passenger seats also
had energy absorbers in the support column. This was the first crash
of any jumbo jet, and also of a an L-1011. Eastern had been the first
to take it into service, ontriducing them only a few months before.
The plane was very good, but the Rolls Royce engine was not. The
blades were forged and not cast, unlike the way General Electric and
Pratt and Whitney made their engines. It took several years for
Eastern to get them to change.
The National Transportation Safety Board spent some time investigating
this crash. The thing is this - there were two altimeters on the plane -
why didn't anybody see them?
An autopsy of the captain revealed a moderate size tumor on the
right side of his brain (or what the pathologist thought was a tumor)
so they spent some time on that. Maybe the captain's peripheral vision
had been affected. Their family told them, however he didn't have
difficulties. Eventually, they dropped that angle.
The autopilot had been disconnected about five minutes before the
crash, just when the Captain had told the the flight engineer:
® Get down there and see if the. . .nose wheel's down. ¯
They speculated that maybe the captain had applied force to the
content wheel while talking. (Frank Borman's book has the co-pilot
doing this, so I guess it's not all that clear what happened)
But the thing is there was more. Besides the disengagement of the
altitude hold function, there were a series of reductions in power,
so they began losing altitude starting about three minutes before
impact. In fact maybe you needed both things to happen in order to
descend - I'm not sure. In other words, first disengage the auto-pilot,
and then cut the power. Only if both happen, do you go down.
The speculation was that the captain maybe bumped the throttles
with his right arm when he leaned over the control pedestal, or
maybe the co-pilot's left arm accidentally bumped the throttles
while he was fiddling with the nose gear indicating system. Another
possibility is that one of the pilots deliberately cut the power
because he saw they were going faster than they should for circling.
The NTSB concluded that the "probable cause" was the failure of
the flight crew to monitor the flight instruments during the final
four minutes of flight, and thus to detect their unexpected descent
until they were too close to the ground.
There are some better crashes to illustrate your principle. This
onme mostly really is, having too much confidence in machines and not
being aware of the possibility of the unexpected. Since they could
not even imagine how things could go wrong, they didn't even check.
They also were doing something not habitual.
Meanwhile they worried about a less important safety problem.
I'm sorry if this is a bit too long, or clumsily written.
--- PCBoard (R) v15.3/M 10
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