Air Emergency (2003–…): Season 5, Episode 9 - Who's at the Controls? - full transcript
The crash of Eastern Air Lines flight 401 proved yet again that humans are the cause of majority of air crashes. Relying on technology to save their lives, they prove over and over that the smarter their technology, the dumber they get.
A single light bulb is preventing
a modern jet liner from landing.
Struggling to fix a minor problem,
a much more serious one develops.
The plane crashes in a remote swamp
Those who survive the crash face a new danger.
The swamp has filled with jet-fuel.
Eastern 401 was a pivotal accident
in aviation history
The crash would point investigators
to an astonishing danger
lurking in all commercial cockpits.
Fatal distraction (Who's in Control)
December 29th, 1972.
the dawn of the Jumbo-Jet era.
On its way to Florida,
this L-1011 Tristar is the most
advanced passenger-jet in the world
The Lucky Tristar was a fascinating bird
It was a beautifully airplane that
had a tremendous amount of power
and a lot of innovation to it.
The cabin of this Eastern
Airline's jet is large and quiet.
The service is first rate.
Bob Loft is the Captain for
Eastern Airline's Flight 401
He has been with the airline
for more than 30 years.
His First Officer is Albert Stockstill
His Second Officer is Donald Repo
The jet has left
the bitter cold of New York behind
and is now descending towards Miami.
'Welcome to Miami
The temperature is in the low seventies
and it's a beautiful night until today'
Angelo Donadeo is an off-duty maintenance expert
He is catching a ride back to Miami.
There are 176 people on board tonight's flight.
Most are heading South for New Year's.
Ron and Lily Infantino have
been married for only 20 days.
They just spend Christmas with his family.
'The seatbelt-sign came on, that is normal,
We are in a final approach.
I looked out the window there
and I could see lights at the airport'.
Close to midnight, the plane begins its approach
to Miami International Airport
Stockstill flies the plane,
while Repo performs a checklist.
The Captain notices a problem
'No nosegear'
The light showing that the nosegear is locked,
hasn't lit up.
The gear might not be all the way down.
Loft tries again.
The sound of the landing gear
echoes through the plane
'It makes a pretty
loud grinding noise
If you fly much
you are familiar with that sound
The pilots did that several times
We weren't alarmed,
these are just one of those things
that happen sometimes.
We looked to each other and said:
"Great, we will be late getting home
Still no light!
Loft isn't sure
if his front landing gear is locked.
If it isn't, landing could be disastrous
You wanted to test the lights or not?
Yeah, check it
Flight engineer Repo performs a test,
nicknamed: the Christmas tree.
It lights up every warning light in the cockpit
to see if the bulbs are working.
The nosegear indicator light fails the test.
The bulb is probably burned out.
But there is slim chance of a double failure:
Both the light bulb AND the landing gear
could be broken.
But the troublesome bulb
is out of the Captain's reach.
On the ground, Air Traffic Control
directs Flight 401 to climb to 2000 ft.
and circle away from the airport
until the problem is solved.
It is a moonless night.
As the plane veers away from Miami,
there is total darkness outside.
All of a sudden it turned out it is dark again.
And that means we are going West
towards the Everglades.
Copilot Stockstill is flying the plane,
but Captain Loft needs his help
to solve the problem.
Put the autopilot out here
The Tristar is equipped
with the most sophisticated autopilot in history
It has the ability to land the plane on its own
Stockstill programs in to fly at 2000 ft.
Now, see if you can get that light out
The light is finally removed.
Richard Pragluski is an aviation engineer.
He takes this flight regularly
and can tell that the plane is
experiencing technical problems.
It was heading towards the Everglades,
I knew there was something wrong
If you have a delay, they will circle the plane.
The irritating problem isn't getting better.
Now, Stockstill cannot get the light back in.
Get down and see if that nose wheel is down
The electronics bay is underneath the cockpit
The room, nicknamed the Hell-hole,
is a unique feature on wide-body jets.
The front landing-gear mechanism
can be seen from there.
Give a handkerchief or something
so I can get a little better grip on this.
As the crew struggles to fix the problem,
in the cabin Richard P.
sees something peculiar out of his window.
I could see the tower to my right,
in the distance,
and it looked like we are going to a glide-path
which I found very strange,
Pragluski has noticed something
the pilots haven't
The plane is getting closer and closer
to the swamp below.
Eastern Airlines Flight 401 is
flying over the Florida Everglades.
Below it, nothing but a dark deserted swamp.
To passenger Richard Pregluski,
something doesn't seem right.
I felt strange that
they haven't made any announcements
But again, it was still high of the ground
and I figured that they would come out and tell us
that when they make the landing
so I wasn't overly concerned
'You put it in the wrong way, huh?'
Without a green light,
they still don't know if
their landing gear is locked
Flight engineer Don Repo is now
in the belly of the plane
There is a viewing
window in the Hell-hole
which should let him see if the
front-wheels are locked in place.
'I don't see it down there'
'I cannot see it, it's pitch-dark,
I throw a little light and get nothing
Captain Loft has forgotten to
turn on lights outside the plane
that illuminate
the landing gear.
Now you try it
At Miami international,
controller Charley Johnson has just
finished dealing with another troubled jet.
He notices that Eastern Airlines Flight 401
seems to have dropped from 2000 ft to 900
But he is not overly concerned.
It is not unusual to get false readings
for several radar-sweeps in a row.
Captain Loft believes that he'll soon get
confirmation that his gear is locked
He wants to return to the airport
Eastern 401:
Turn left heading 180.
The plane is heading West, away from the airport
It will take several minutes
to get lined up for the landing.
Deep in the Everglades,
Bob Marquis is hunting frogs with a friend.
Eastern Airlines Flight 401 roars past.
I saw this light blinking...
...across the sky it was so black,
there was no horizon in the West and
You cannot tell how high the plane was.
Suddenly the pilots make an alarming observation.
Is there something with the altitude?
I see the lights in the cabin ON and OFF
I heard a noise,
There was a violent whipping sensation
Then, all of a sudden,
all hell broke lose.
Charley Johnson notices
that Flight 401's altitude now reads sea level.
I have lost you on the radar, there
What's your altitude now?
There is no response from Eastern 401
Another plane makes a disturbing report.
We just saw a big flash
It looked like it came out West
I don't know what it means,
but I want to let you know.
In a dark, remote swamp,
those who survived the crash,
find themselves in a nightmare.
Bob Marquis races towards the site of the crash.
I was going as fast as I could
It took me about 15 minutes
to get to the crash site.
Remarkably, Richard Pregluski is alive.
I knew I was badly injured,
because I could see my
clothes hanging from my body
I had almost no clothes
on my upper half of my body,
and I could see skin coming down my arms.
I also knew that, when you are in shock,
you feel no pain.
So I knew I really was seriously injured
I started thinking:
pain will come later
How do I keep calm?
and get out of there,
because the longer in that swamp,
the more danger I am in.
When the plane crashed,
a huge fireball tore through the cabin
I remember that fire come in to my face
I remember the flash.
I remember I tried breathing
I could not get my breath because
the fire took all the oxygen out of the air.
And that is the last thing I remember
until I got up in the swamp itself.
Ron Infantino was knocked out by the crash.
He wakes up in the swamp.
I was thrown quite a bit,
and I was away from everybody else,
nobody was even near me.
'Lily!'
He was badly wounded.
His new wife Lily was sitting next to him.
but now she is nowhere to be seen.
Swamp water dowse the initial flames.
But 20.000 kg of jet fuel has now leaked
into the swamp.
A single spark could start a deadly blaze.
'No one light a match.
We are covered in jet-fuel'.
What a sad thing to come through that crash
and then has somebody to something stupid...
...like strike a match
and have us all just blow up.
That was the real fear.
Hoping to help the survivors,
Bob Marquis jumps into the swamp.
He immediately feels
the sting of the jet fuel on his skin
It burned my legs.
The burns for about a week.
Marquis quickly spots a survivor,
who is in grave danger.
The badly wounded man
is still strapped to his seat
He is on the verge of drowning
He came up and said:
Help me!
'I can't hold my head up much longer'
and dropped back down in the water
I helped him, I pulled him up.
Bob Marquis saves dozens of lives,
preventing many people from drowning.
Isolated from the other survivors
and unable to move,
Ron Infantino now has a new reason
to fear for his life.
After a while, the alligators and snakes
could hear me in the reeds
I could hear the croaking of the alligators,
because they start to come back
to their natural habitat.
And as far as I am concerned I was dead meat
because I couldn't defend myself at all
And then I heard Christmas Carols
To rally the survivor-spirits,
Trudy Smith and others sing Christmas Carols
We knew instinctively
that we weren't get out of there in a hurry.
because nobody knew where we were
In the middle of the swamp,
midnight,
So, what else what you are going to do?
You got to picturize this,
in the dark, at night
while you hear singing in the wilderness.
It was like the Titanic going down
That type of thing, you know,
It was unbelievable
Within minutes,
coastguard helicopters are sent
out in search of the crash-site.
But in the pitch black night,
they can't find the wreckage.
Bob Marquis tries to signal
the distant helicopters
I could see where they were
and they were going the wrong direction.
I just waved the light at them
until I saw them turn
and head back towards us.
It seemed like we've been in
the swamps a really long time
when we heard a helicopter
It was such a welcoming sound
because that means somebody
knows that we were there.
Less than half an hour after the crash,
the coastguard arrives.
But the nearest landing site is a 100 meters away.
Marquis rushes to meet the helicopter
and ferries the rescuers back to the crash site
His first passenger is rescue worker Don Schneck.
I made it to the air boat
He asked me:
'where are all the rescuers?'
And I said:
'This is it, Let's go'
He took us out into the Everglades
to a point where he said:
This is as far as I want to go
because I don't want to run anybody over
And he said:
There are bodies down here all over the place.
Don Schneck starts searching for survivors
I approached the large objects
that I have seen at a small distance
I realized it was the nose-section of the aircraft
He is amazed to discover
that Captain Bob Loft has survived the crash
He was in bad shape.
He had lacerations,
so I know he had broken ribs
I can tell he was in shock
So I calmed him down,
told him I am the only one here right now
but they are coming.
'I am going to die'
He told me that.
It just made me feel so inadequate.
Because there was just me.
I turned around and I looked back towards Miami
And thinking:
Where in the heck is everybody?
And at that time when I looked
I must have seen 50 lights coming
Thank God!
First Officer Bert Stockstill was killed
during the crash.
Captain Bob Loft soon dies at the scene.
Angelo Donadeo and Don Repo have survived
and are taken to hospital.
In all, 77 people survived the crash
99 people are killed.
By dawn,
all the wounded have been
transported to Miami hospitals.
Ron Infantino is one of the many
who are struggling to survive.
The priest comes over and that is the last rights
So, right then I knew I was in bad shape
A scary thought
And of course at that time
I am still asking for Lily, you know
Had they seen her?
It was just a mad house there
more than you can imagine
Where is Lily?
The crash is headline-news around the world.
It is the first ever jumbo jet to crash.
And it produces the largest number of deaths
in U.S. civil aviation history.
There is tremendous pressure
on investigators from the NTSB
to find out what happened.
It was an enormous puzzle.
because this was the newest,
the most sophisticated, the best...
...of the airliners
that apparent was in perfect working condition.
So the NTSB proceed that this was going to be
a very long investigation.
with multi-level potential problems
The crash-site itself is an important clue
for investigators arriving at the scene.
The trail of debris is enormously long.
That suggests that the plane hit the swamp
almost in the same nose-up position
as it would while
landing at an airport
Its descend was clearly slow and gradual.
NTSB investigators have
documented the final settings
for many of the instruments in the cockpit.
They discover that the autopilot was set
to maintain an altitude of 2000ft.
So, why didn't it?
Maintenance expert Angelo Donadeo is interviewed.
All he can tell investigators is
the crew was trying to fix a light bulb
before the crash
Within days, the two black boxes are recovered
Investigators hope they will provide some answers.
Before they can extract the data...
..Flight engineer Donald Repo
dies in the hospital.
Ron Infantino is given some devastating news
of his own.
The body of his wife
Lily has been found
under the plane's wing.
It was a wonderful person,
I was just 27 years old
She was the same age and
it was actually my first love.
Infantino is haunted
by the memory
of switching seats with
Lily just before the crash
They have swapped seats,
quite casually earlier during the flight
when she had gotten up to the restroom
She was thrown into the swamp and drowned,
and he lived.
The swamp proves both a blessing and a curse
for survivors.
That was what saved most of the lives actually
because the plane broke up
and absorbed all the energy
and the mud absorbed it
and the plane just dispersed
The swamp water is so thick with mud,
it also clogs survivors wounds
preventing many from bleeding to death.
But there is a deadly new threat
facing some survivors.
Their wounds have become infected
contaminated by a deadly organism
found in the black mud of the Everglades.
The organism produces an infection
called gas-gangrene
It can kill a person in just two days.
Gas-gangrene can only be destroyed
in a hyperbaric chamber
It's a pressurized container
that gets filled with high levels of oxygen.
The oxygen gets forced into the wounds
and kills the bacteria.
Eight of the surviving passengers
are infected with gas-gangrene
Hyperbaric chambers must be found for all of them.
The only other way to save patients
is to amputate the infected limb.
Ron Infantino's arm is badly infected.
The doctor came in and says:
We diagnosed this gas gangrene.
He says:
We have to take your arm off immediately,
or have to get you to a hyperbaric chamber
Unfortunately he says
the only hyperbaric chamber is at Mercy Hospital
that is all been taking advantage of
Unless doctors can
find a chamber soon,
Infantino will lose his arm
While doctors search for a chamber for Ron,
investigators examine what is left of the plane.
They test its flight controls,
engines, instruments
and its electrical and hydraulic systems.
The plane was virtually new
It was in perfect condition
There was no mechanical reason found
that would have caused the crash.
In fact, some parts are in such good condition,
that the NTSB gives them back to Eastern Airlines
so that they can be installed
on other airplanes in its fleet.
An unused hyperbaric
chamber is finally found
for Ron Infantino at a
NAVY base in Panama city.
He spends 40 hours in the chamber
The pressurized oxygen kills the bacteria
and saves his life.
'Gentlemen,
we have three causes of the crash to explore.
A state of the art jet liner plunged 2000 ft
without the crew noticing.
Investigator know
the plane was mechanically sound.
They now focus on other possible reasons
for the unobserved descend.
At the top of the list,
is subtle incapacitation of the pilot.
The autopsy of Captain Bob Loft has yielded
a gruesome discovery.
Captain Loft had a large undetected tumour,
growing in his brain.
It pressed into the part of his brain,
responsible for sight.
Medical records reveal that
between ages of 50 and 52,
vision in the pilot's left eye
had rapidly deteriorated.
Doctors believe that the Captain may have had
reduced peripheral vision.
The tumour could have created blind spots.
As his attention became focussed
on a malfunctioning light,
he may not have noticed dire warnings
on his altimeter.
Investigators consider a stunning possibilty
An undetected medical ailment
may have contributed to the
worlds first Jumbo jet disaster
Investigators learn what they can
about Captain Bob Loft.
They interview people who knew him
and pour over his medical records
The investigators heard
that Captain Loft
as far as family and friends knew,
had perfect vision
He was an expert mark
He shot a very small target
Loft's records show that he
had recently passed a medical
in which he was issued
corrected glasses for flying.
But the evidence doesn't support the notion
that his vision was dangerously impaired.
He was 55 years old
and who gets to be 55 without
wearing reading glasses?
Not many.
Doctor Joe Davies who did the autopsy told me...
...that even though the tumour
was pressing on areas of his brain control vision,
there was no reason to think
that it had yet begin to affect that.
He felt it had nothing to do with the accident.
Investigators still don't know why Flight 401
started descending in the first place.
Could the autopilot,
which was supposed to keep the plane at 2000 ft,
have malfunctioned?
The plane's computers survived the crash.
They are removed and examined.
Eleven days after the crash,
the autopilot computers are
installed on another Tristar.
It flies the same route as Flight 401.
The autopilot holds that plane at 2000 ft.
So, why hadn't it on the night of the accident?
Investigators will need
to explore other leads to find out.
There is another question
that dogs this investigation.
Why didn't the Miami tower alert the crew
that their plane was dropping?
The worlds first 3-dimensional radar
had recently been installed there.
It meant that controller Charley
Johnson knew the location,
altitude and speed of Flight 401.
Investigators study recordings
of Johnson's conversations.
and discover that on the night of the crash,
it was another plane that
demanded most of his attention.
National Airlines Flight 607 was coming
in to land just ahead of Flight 401
That flight was having
its own landing gear problems.
As he focussed on the emergency,
Johnson handed Flight 401
over to another controller.
But just as National 607 came in
for its emergency landing
the other controller phoned Johnson
and handed Flight 401 back to him.
At the time Flight 401 was already over the swamp.
Johnson had 5 other planes to monitor.
He was also dealing with the aftermath
of his emergency landing.
That is when he noticed
that Flight 401's altitude had dropped to 900 ft.
radar has worked still to
a certain extend happened
back then it was even worse
Coast mode was a very well known phenomena
you might lose the target for 2 or 3 minutes
in terms of the altitude reporting part of it
and it goes and gives you some
weird altitude and then boom,
it is right back
where it should be.
But the controller didn't stop there
and this was really to his credit
Johnson decided to make contact with Flight 401
Eastern 401,
how are things coming along?
'OKAY, we'd like to turn around and come back in'.
'Eastern 401, turn left heading 180'
After that brief exchange,
Johnson assumed that there was no problem
Eastern 401, how are things coming along?
Investigators conclude
that at that moment
controller Johnson was the only one
who could see that the plane was losing altitude.
Why haven't he passed that information
along to the crew?
U.S. government regulations
for air-traffic controllers provide the answer.
It simply wasn't part of the controller's job.
At the time of the crash,
the FAA required approach controllers to
maintain a separation of the airplanes
It did not give them a duty
to maintain the altitude of the
airliner with regard to the ground.
Now investigators try to determine
how the plane's own warning system failed
to alert pilots to their growing danger.
The L 1011 is equipped with an alarm
that sounds if the plane goes 250 ft
above or below the altitude
selected by the pilots.
As investigators replay the tape
from the black box,
they clearly hear that alarm
sounding in the cockpit
as the plane pass through 1750 ft.
Do you hear that?
How can they miss it?
Investigators closely examine
the cockpit transcript
to try to understand how
the alarm was missed.
Investigators notice that
just before the alarm sounded in the cockpit
warning the crew that the plane is too low
both pilots were completely absorbed
with the landing gear light.
The conversation also tells investigators
that the flight engineer
was below in the Hell-hole.
The warning chime came out of a speaker
at his workstation.
Investigators begin to realize
that the two pilots were unable
to hear a perfectly audible alarm
because they were focussed so entirely
on solving another problem.
That chime, which was clearly heard
on the cockpit voice recorder,
was not registering in the minds
of the flight deck.
not because they were trying to pay attention
but because they were tunnelled in
on this one problem.
That's what we do as humans.
Investigators now focus on crew-distraction
as a likely cause of this accident.
Several instruments would have displayed
the decreasing altitude.
The major question was:
Why were the pilots so preoccupied
that they were not looking at the instrument panel
They had to look at the human beings
They had to look at the interaction
They had to look at why no one was
paying attention to the airplane
as it begin to creep out of 2000 ft.
That was scary territory in 1972.
Investigators interview a number of pilots
and make a startling discovery
Pilots admitted that they
placed a lot of trust
in the modern new autopilots flying their planes.
They may have become overly dependant
on the technology
Investigators suspect that the Eastern crew
was so confident in their autopilot,
that they didn't monitor their instruments
as closely as they should have.
Once the autopilot was ON,
none of the pilots paid attention
to actually flying the plane.
We still got to find out why that plane went down.
Investigators still haven't determined
the most crucial piece of information.
If the autopilot was working,
why did the plane dive into the swamp?
The pilot's conversation clearly shows that
they haven't deliberately started descending.
So, why did it happen?
The answer comes in a dramatic form
when the NTSB conducts a public hearing in Miami,
two months after the crash.
Before the hearing,
an Eastern Airlines pilot named Daniel
Galleth wrote the chairman of the NTSB
offering to testify on his own behalf.
He had flown the Tristar L-1011
and notices some abnormalities.
The world of airline piloting in 1972 was hostile
to a pilot going around his
chief pilot and his airline
and raising his hand to
the NTSB and saying:
'Hey, wait a minute,
I've had an experience too
because airlines were far more insular
than they are today.
Galleth tells the hearing
that during a recent flight on a Tristar,
he had accidently dropped a map
on the cockpit floor.
As he bent down to pick it up,
he nudged his control column
He noticed immediately
that the autopilot had been affected.
The part of the autopilot,
controlling the altitude
had been turned OFF
The NTSB discovers that Galleth's experience
is shared by others.
In fact, 17 days after the accident,
Eastern Airlines tacked a notice
on to a company bulletin board.
and also mailed it to all of its Tristars pilots.
The bulletin warned against accidently
bumping the control wheel.
One of the things that we build
in to all the modern jet liners
and airliners is simply
a pressure switch
So, if you need take over right now,
you don't want to be wasting time down here
on the panel turning the autopilot OFF,
You just grab it and the autopilot goes away
The FDR tells investigators the precise moment
that the altitude started to drop.
It was 11:37 and 8 seconds PM
By studying the CVR transcript,
investigators can tell what
was happening in the cockpit
at that exact time.
By turning to speak to the Flight Engineer,
investigators believe
that Captain Loft bumped his control wheel.
He did it with just enough pressure to
disengage that part of the autopilot
that had been controlling the altitude.
Without anyone realizing it,
a simple nudge of the control wheel
started a gradual descend
On a dark, moonless night,
the pilots had no visual queues
to tell them they where falling
It was determined that occasionally,
with just a soft bump,
the autopilot has been disengaged.
Before the crash, it wasn't part of the training.
A training director for Eastern
Airlines eventually reveals
that before the Everglades-crash,
pilots were never taught
that a bump could disengage the autopilot.
The NTSB comes to a sobering conclusion
The plane crash was due to Pilot Error.
The crew was distracted.
They mishandled the sophisticated automation
and they hadn't been properly trained.
Eastern 401 was a pivotal accident
in aviation safety history
and we even didn't know this
for about 10 or 15 years
in terms of the true import
of what they did to us.
in focussing our attention on
the way we handle things in a cockpit,
was not only not correct, but it was dangerous.
Investigators also make a dishartning find
When the nose-gear-indicator-light assembly
is examined
They discover that a light bulb inside
is burned out.
Flight 401 's landing gear WAS locked.
The plane could have landed.
The only piece of the plane that failed,
was a $12 light bulb
The full legacy of Flight 401
will take years to unfold.
It will ultimately alter how pilots are trained
and how accidents are investigated.
But first,
the tail of Eastern Airlines Flight 401
will take a very bizarre twist.
As far as the NTSB is concerned,
the investigation into Flight 401 is over.
Several recommendations were laid out
to prevent similar accidents.
Those include new regulations,
instructing air traffic controllers
to warn pilots when they
getting to close to the ground.
But four years later,
it became clear there was a bigger
lesson to be learned from Flight 401
In 1977 two 747's collided
on a runway in Tenerife on the Canary Islands.
It was the deadliest plane crash of all time.
And we are now at take off
That accident was caused by a string
of miss-communications in the cockpit.
'Jawel !'
Investigators established that 70% of crashes
were due to pilot error
Both of these accidents , Tenerife and 401,
what you see is crew's dedicated doing a good job
but not realizing that they are human.
Not realizing how many
things can go wrong
if you don't appreciate how human beings fail.
By the late 1970's,
NASA began to explore a new behavioural science,
designed to reduce pilot error.
It is called crew resource management
or CRM.
CRM means they were not going to have one pilot
leading and everybody else following
It means that the Captain
has to be a leader
and listen to and interact with
his subordinate crew members
They have to speak up.
Decades later,
Flight 401 is taught in aviation
courses around the world
as a textbook example
of poor Crew Resource Management.
The problem was that we
did not teach Bob Loft
or Stockstill
or any of these folks at that time,
that when something goes wrong,
the commander's first responsibility
is to maintain the aircraft control
and you do it himself or assign somebody.
On Flight 401,
Captain Loft did not clarify
who should be doing what.
Instead,
all 3 crew-members worked on the same problem.
It has got to come out a little bit
and then snap in.
With the co-pilot flying,
the Captain commanding from the left-seat,
you already had cross purposes here
'It is right above that red one'
I cannot get it out from here
And you had a lightquadron,
the Captain couldn't quite reach,
and the Co-pilot could,
but he was flying the airplane.
You just set them up for a major problem
and guess what?
We never taught them what to do
Today, Crew Resource Management
also trains flight crews
not to be intimidated by one crew member's mood.
Do you have a handkerchief or something
so I can get a little better grip on this?
Anything I can do it with?
Get down there and see if that dammed thing
So, if the leader is having a problem,
in this case a light bulb,
OKAY, you got it sideways, then.
and he is really irritated at it
and the co-pilot has now made the problem worse,
The co-pilot is not happy with himself
'What the hell is holding that thing in there?'
Don Repo is not going to be happy that he
got downstairs to try to solve the problem
and he couldn't see anything,
he has got to come up and report that
'I don't see it'
They are all tensed.
'It's not lined up?'
'I can't see it'
And when you get a crew like that tensed,
It is not to turn around to the Captain and say:
You shouldn't have done that
But this is part of the evolution of
what air-safety has now learned
and been able to teach so many other industries.
The enduring legacy of Flight 401
is the delegation of specific tasks
in the cockpit.
The result is fewer crashes.
There was also much more bizarre fallout
from this crash.
For a while,
it seemed that the crew of Flight 401 was
haunting other Eastern Airlines flights
For some time after the crash,
flight crews and passengers report seeing
lifelike apparitions of flight 401's crew.
Many of the ghost sightings were on aircraft,
fitted with recovered parts from Flight 401.
The ghost stories spread quickly.
One book devoted entirely to those stories
suggest that the ghosts were there to protect
passengers and crew from further mishap.
The official reaction of Eastern
Airlines to these ghost-stories
was one of absolute eye-rolling denial
in public and in private,
a certain bit of panic.
There are so many ghost-sightings
that eventually Eastern Airlines removes
Flight 401's cannibalized plane parts
from all other aircraft.
None of those who survived the crash
will ever forget the horror they
witnessed in the Everglades that night.
And 35 years after their ordeal
many of them returned to that swamp
to finally recognize
the heroic efforts
of Bob Marquis
'We are here today to recognize
and to say: thank you'
Many of the ones who lived
lived because Robert Marquis
was there with his air-boat
He saw them drowning
and decided that the thing he could do
would be to save the ones that he could save.
Robert Marquis was
the kind of person
that I hope that all of us alternatively would be
if we were confronted with that sort of thing
But he drew him some special courage
to do what he did.
He was one of the true heroes of the crash.
Narrator
Jonathan Aris
Subtitles
Rein Croonen
a modern jet liner from landing.
Struggling to fix a minor problem,
a much more serious one develops.
The plane crashes in a remote swamp
Those who survive the crash face a new danger.
The swamp has filled with jet-fuel.
Eastern 401 was a pivotal accident
in aviation history
The crash would point investigators
to an astonishing danger
lurking in all commercial cockpits.
Fatal distraction (Who's in Control)
December 29th, 1972.
the dawn of the Jumbo-Jet era.
On its way to Florida,
this L-1011 Tristar is the most
advanced passenger-jet in the world
The Lucky Tristar was a fascinating bird
It was a beautifully airplane that
had a tremendous amount of power
and a lot of innovation to it.
The cabin of this Eastern
Airline's jet is large and quiet.
The service is first rate.
Bob Loft is the Captain for
Eastern Airline's Flight 401
He has been with the airline
for more than 30 years.
His First Officer is Albert Stockstill
His Second Officer is Donald Repo
The jet has left
the bitter cold of New York behind
and is now descending towards Miami.
'Welcome to Miami
The temperature is in the low seventies
and it's a beautiful night until today'
Angelo Donadeo is an off-duty maintenance expert
He is catching a ride back to Miami.
There are 176 people on board tonight's flight.
Most are heading South for New Year's.
Ron and Lily Infantino have
been married for only 20 days.
They just spend Christmas with his family.
'The seatbelt-sign came on, that is normal,
We are in a final approach.
I looked out the window there
and I could see lights at the airport'.
Close to midnight, the plane begins its approach
to Miami International Airport
Stockstill flies the plane,
while Repo performs a checklist.
The Captain notices a problem
'No nosegear'
The light showing that the nosegear is locked,
hasn't lit up.
The gear might not be all the way down.
Loft tries again.
The sound of the landing gear
echoes through the plane
'It makes a pretty
loud grinding noise
If you fly much
you are familiar with that sound
The pilots did that several times
We weren't alarmed,
these are just one of those things
that happen sometimes.
We looked to each other and said:
"Great, we will be late getting home
Still no light!
Loft isn't sure
if his front landing gear is locked.
If it isn't, landing could be disastrous
You wanted to test the lights or not?
Yeah, check it
Flight engineer Repo performs a test,
nicknamed: the Christmas tree.
It lights up every warning light in the cockpit
to see if the bulbs are working.
The nosegear indicator light fails the test.
The bulb is probably burned out.
But there is slim chance of a double failure:
Both the light bulb AND the landing gear
could be broken.
But the troublesome bulb
is out of the Captain's reach.
On the ground, Air Traffic Control
directs Flight 401 to climb to 2000 ft.
and circle away from the airport
until the problem is solved.
It is a moonless night.
As the plane veers away from Miami,
there is total darkness outside.
All of a sudden it turned out it is dark again.
And that means we are going West
towards the Everglades.
Copilot Stockstill is flying the plane,
but Captain Loft needs his help
to solve the problem.
Put the autopilot out here
The Tristar is equipped
with the most sophisticated autopilot in history
It has the ability to land the plane on its own
Stockstill programs in to fly at 2000 ft.
Now, see if you can get that light out
The light is finally removed.
Richard Pragluski is an aviation engineer.
He takes this flight regularly
and can tell that the plane is
experiencing technical problems.
It was heading towards the Everglades,
I knew there was something wrong
If you have a delay, they will circle the plane.
The irritating problem isn't getting better.
Now, Stockstill cannot get the light back in.
Get down and see if that nose wheel is down
The electronics bay is underneath the cockpit
The room, nicknamed the Hell-hole,
is a unique feature on wide-body jets.
The front landing-gear mechanism
can be seen from there.
Give a handkerchief or something
so I can get a little better grip on this.
As the crew struggles to fix the problem,
in the cabin Richard P.
sees something peculiar out of his window.
I could see the tower to my right,
in the distance,
and it looked like we are going to a glide-path
which I found very strange,
Pragluski has noticed something
the pilots haven't
The plane is getting closer and closer
to the swamp below.
Eastern Airlines Flight 401 is
flying over the Florida Everglades.
Below it, nothing but a dark deserted swamp.
To passenger Richard Pregluski,
something doesn't seem right.
I felt strange that
they haven't made any announcements
But again, it was still high of the ground
and I figured that they would come out and tell us
that when they make the landing
so I wasn't overly concerned
'You put it in the wrong way, huh?'
Without a green light,
they still don't know if
their landing gear is locked
Flight engineer Don Repo is now
in the belly of the plane
There is a viewing
window in the Hell-hole
which should let him see if the
front-wheels are locked in place.
'I don't see it down there'
'I cannot see it, it's pitch-dark,
I throw a little light and get nothing
Captain Loft has forgotten to
turn on lights outside the plane
that illuminate
the landing gear.
Now you try it
At Miami international,
controller Charley Johnson has just
finished dealing with another troubled jet.
He notices that Eastern Airlines Flight 401
seems to have dropped from 2000 ft to 900
But he is not overly concerned.
It is not unusual to get false readings
for several radar-sweeps in a row.
Captain Loft believes that he'll soon get
confirmation that his gear is locked
He wants to return to the airport
Eastern 401:
Turn left heading 180.
The plane is heading West, away from the airport
It will take several minutes
to get lined up for the landing.
Deep in the Everglades,
Bob Marquis is hunting frogs with a friend.
Eastern Airlines Flight 401 roars past.
I saw this light blinking...
...across the sky it was so black,
there was no horizon in the West and
You cannot tell how high the plane was.
Suddenly the pilots make an alarming observation.
Is there something with the altitude?
I see the lights in the cabin ON and OFF
I heard a noise,
There was a violent whipping sensation
Then, all of a sudden,
all hell broke lose.
Charley Johnson notices
that Flight 401's altitude now reads sea level.
I have lost you on the radar, there
What's your altitude now?
There is no response from Eastern 401
Another plane makes a disturbing report.
We just saw a big flash
It looked like it came out West
I don't know what it means,
but I want to let you know.
In a dark, remote swamp,
those who survived the crash,
find themselves in a nightmare.
Bob Marquis races towards the site of the crash.
I was going as fast as I could
It took me about 15 minutes
to get to the crash site.
Remarkably, Richard Pregluski is alive.
I knew I was badly injured,
because I could see my
clothes hanging from my body
I had almost no clothes
on my upper half of my body,
and I could see skin coming down my arms.
I also knew that, when you are in shock,
you feel no pain.
So I knew I really was seriously injured
I started thinking:
pain will come later
How do I keep calm?
and get out of there,
because the longer in that swamp,
the more danger I am in.
When the plane crashed,
a huge fireball tore through the cabin
I remember that fire come in to my face
I remember the flash.
I remember I tried breathing
I could not get my breath because
the fire took all the oxygen out of the air.
And that is the last thing I remember
until I got up in the swamp itself.
Ron Infantino was knocked out by the crash.
He wakes up in the swamp.
I was thrown quite a bit,
and I was away from everybody else,
nobody was even near me.
'Lily!'
He was badly wounded.
His new wife Lily was sitting next to him.
but now she is nowhere to be seen.
Swamp water dowse the initial flames.
But 20.000 kg of jet fuel has now leaked
into the swamp.
A single spark could start a deadly blaze.
'No one light a match.
We are covered in jet-fuel'.
What a sad thing to come through that crash
and then has somebody to something stupid...
...like strike a match
and have us all just blow up.
That was the real fear.
Hoping to help the survivors,
Bob Marquis jumps into the swamp.
He immediately feels
the sting of the jet fuel on his skin
It burned my legs.
The burns for about a week.
Marquis quickly spots a survivor,
who is in grave danger.
The badly wounded man
is still strapped to his seat
He is on the verge of drowning
He came up and said:
Help me!
'I can't hold my head up much longer'
and dropped back down in the water
I helped him, I pulled him up.
Bob Marquis saves dozens of lives,
preventing many people from drowning.
Isolated from the other survivors
and unable to move,
Ron Infantino now has a new reason
to fear for his life.
After a while, the alligators and snakes
could hear me in the reeds
I could hear the croaking of the alligators,
because they start to come back
to their natural habitat.
And as far as I am concerned I was dead meat
because I couldn't defend myself at all
And then I heard Christmas Carols
To rally the survivor-spirits,
Trudy Smith and others sing Christmas Carols
We knew instinctively
that we weren't get out of there in a hurry.
because nobody knew where we were
In the middle of the swamp,
midnight,
So, what else what you are going to do?
You got to picturize this,
in the dark, at night
while you hear singing in the wilderness.
It was like the Titanic going down
That type of thing, you know,
It was unbelievable
Within minutes,
coastguard helicopters are sent
out in search of the crash-site.
But in the pitch black night,
they can't find the wreckage.
Bob Marquis tries to signal
the distant helicopters
I could see where they were
and they were going the wrong direction.
I just waved the light at them
until I saw them turn
and head back towards us.
It seemed like we've been in
the swamps a really long time
when we heard a helicopter
It was such a welcoming sound
because that means somebody
knows that we were there.
Less than half an hour after the crash,
the coastguard arrives.
But the nearest landing site is a 100 meters away.
Marquis rushes to meet the helicopter
and ferries the rescuers back to the crash site
His first passenger is rescue worker Don Schneck.
I made it to the air boat
He asked me:
'where are all the rescuers?'
And I said:
'This is it, Let's go'
He took us out into the Everglades
to a point where he said:
This is as far as I want to go
because I don't want to run anybody over
And he said:
There are bodies down here all over the place.
Don Schneck starts searching for survivors
I approached the large objects
that I have seen at a small distance
I realized it was the nose-section of the aircraft
He is amazed to discover
that Captain Bob Loft has survived the crash
He was in bad shape.
He had lacerations,
so I know he had broken ribs
I can tell he was in shock
So I calmed him down,
told him I am the only one here right now
but they are coming.
'I am going to die'
He told me that.
It just made me feel so inadequate.
Because there was just me.
I turned around and I looked back towards Miami
And thinking:
Where in the heck is everybody?
And at that time when I looked
I must have seen 50 lights coming
Thank God!
First Officer Bert Stockstill was killed
during the crash.
Captain Bob Loft soon dies at the scene.
Angelo Donadeo and Don Repo have survived
and are taken to hospital.
In all, 77 people survived the crash
99 people are killed.
By dawn,
all the wounded have been
transported to Miami hospitals.
Ron Infantino is one of the many
who are struggling to survive.
The priest comes over and that is the last rights
So, right then I knew I was in bad shape
A scary thought
And of course at that time
I am still asking for Lily, you know
Had they seen her?
It was just a mad house there
more than you can imagine
Where is Lily?
The crash is headline-news around the world.
It is the first ever jumbo jet to crash.
And it produces the largest number of deaths
in U.S. civil aviation history.
There is tremendous pressure
on investigators from the NTSB
to find out what happened.
It was an enormous puzzle.
because this was the newest,
the most sophisticated, the best...
...of the airliners
that apparent was in perfect working condition.
So the NTSB proceed that this was going to be
a very long investigation.
with multi-level potential problems
The crash-site itself is an important clue
for investigators arriving at the scene.
The trail of debris is enormously long.
That suggests that the plane hit the swamp
almost in the same nose-up position
as it would while
landing at an airport
Its descend was clearly slow and gradual.
NTSB investigators have
documented the final settings
for many of the instruments in the cockpit.
They discover that the autopilot was set
to maintain an altitude of 2000ft.
So, why didn't it?
Maintenance expert Angelo Donadeo is interviewed.
All he can tell investigators is
the crew was trying to fix a light bulb
before the crash
Within days, the two black boxes are recovered
Investigators hope they will provide some answers.
Before they can extract the data...
..Flight engineer Donald Repo
dies in the hospital.
Ron Infantino is given some devastating news
of his own.
The body of his wife
Lily has been found
under the plane's wing.
It was a wonderful person,
I was just 27 years old
She was the same age and
it was actually my first love.
Infantino is haunted
by the memory
of switching seats with
Lily just before the crash
They have swapped seats,
quite casually earlier during the flight
when she had gotten up to the restroom
She was thrown into the swamp and drowned,
and he lived.
The swamp proves both a blessing and a curse
for survivors.
That was what saved most of the lives actually
because the plane broke up
and absorbed all the energy
and the mud absorbed it
and the plane just dispersed
The swamp water is so thick with mud,
it also clogs survivors wounds
preventing many from bleeding to death.
But there is a deadly new threat
facing some survivors.
Their wounds have become infected
contaminated by a deadly organism
found in the black mud of the Everglades.
The organism produces an infection
called gas-gangrene
It can kill a person in just two days.
Gas-gangrene can only be destroyed
in a hyperbaric chamber
It's a pressurized container
that gets filled with high levels of oxygen.
The oxygen gets forced into the wounds
and kills the bacteria.
Eight of the surviving passengers
are infected with gas-gangrene
Hyperbaric chambers must be found for all of them.
The only other way to save patients
is to amputate the infected limb.
Ron Infantino's arm is badly infected.
The doctor came in and says:
We diagnosed this gas gangrene.
He says:
We have to take your arm off immediately,
or have to get you to a hyperbaric chamber
Unfortunately he says
the only hyperbaric chamber is at Mercy Hospital
that is all been taking advantage of
Unless doctors can
find a chamber soon,
Infantino will lose his arm
While doctors search for a chamber for Ron,
investigators examine what is left of the plane.
They test its flight controls,
engines, instruments
and its electrical and hydraulic systems.
The plane was virtually new
It was in perfect condition
There was no mechanical reason found
that would have caused the crash.
In fact, some parts are in such good condition,
that the NTSB gives them back to Eastern Airlines
so that they can be installed
on other airplanes in its fleet.
An unused hyperbaric
chamber is finally found
for Ron Infantino at a
NAVY base in Panama city.
He spends 40 hours in the chamber
The pressurized oxygen kills the bacteria
and saves his life.
'Gentlemen,
we have three causes of the crash to explore.
A state of the art jet liner plunged 2000 ft
without the crew noticing.
Investigator know
the plane was mechanically sound.
They now focus on other possible reasons
for the unobserved descend.
At the top of the list,
is subtle incapacitation of the pilot.
The autopsy of Captain Bob Loft has yielded
a gruesome discovery.
Captain Loft had a large undetected tumour,
growing in his brain.
It pressed into the part of his brain,
responsible for sight.
Medical records reveal that
between ages of 50 and 52,
vision in the pilot's left eye
had rapidly deteriorated.
Doctors believe that the Captain may have had
reduced peripheral vision.
The tumour could have created blind spots.
As his attention became focussed
on a malfunctioning light,
he may not have noticed dire warnings
on his altimeter.
Investigators consider a stunning possibilty
An undetected medical ailment
may have contributed to the
worlds first Jumbo jet disaster
Investigators learn what they can
about Captain Bob Loft.
They interview people who knew him
and pour over his medical records
The investigators heard
that Captain Loft
as far as family and friends knew,
had perfect vision
He was an expert mark
He shot a very small target
Loft's records show that he
had recently passed a medical
in which he was issued
corrected glasses for flying.
But the evidence doesn't support the notion
that his vision was dangerously impaired.
He was 55 years old
and who gets to be 55 without
wearing reading glasses?
Not many.
Doctor Joe Davies who did the autopsy told me...
...that even though the tumour
was pressing on areas of his brain control vision,
there was no reason to think
that it had yet begin to affect that.
He felt it had nothing to do with the accident.
Investigators still don't know why Flight 401
started descending in the first place.
Could the autopilot,
which was supposed to keep the plane at 2000 ft,
have malfunctioned?
The plane's computers survived the crash.
They are removed and examined.
Eleven days after the crash,
the autopilot computers are
installed on another Tristar.
It flies the same route as Flight 401.
The autopilot holds that plane at 2000 ft.
So, why hadn't it on the night of the accident?
Investigators will need
to explore other leads to find out.
There is another question
that dogs this investigation.
Why didn't the Miami tower alert the crew
that their plane was dropping?
The worlds first 3-dimensional radar
had recently been installed there.
It meant that controller Charley
Johnson knew the location,
altitude and speed of Flight 401.
Investigators study recordings
of Johnson's conversations.
and discover that on the night of the crash,
it was another plane that
demanded most of his attention.
National Airlines Flight 607 was coming
in to land just ahead of Flight 401
That flight was having
its own landing gear problems.
As he focussed on the emergency,
Johnson handed Flight 401
over to another controller.
But just as National 607 came in
for its emergency landing
the other controller phoned Johnson
and handed Flight 401 back to him.
At the time Flight 401 was already over the swamp.
Johnson had 5 other planes to monitor.
He was also dealing with the aftermath
of his emergency landing.
That is when he noticed
that Flight 401's altitude had dropped to 900 ft.
radar has worked still to
a certain extend happened
back then it was even worse
Coast mode was a very well known phenomena
you might lose the target for 2 or 3 minutes
in terms of the altitude reporting part of it
and it goes and gives you some
weird altitude and then boom,
it is right back
where it should be.
But the controller didn't stop there
and this was really to his credit
Johnson decided to make contact with Flight 401
Eastern 401,
how are things coming along?
'OKAY, we'd like to turn around and come back in'.
'Eastern 401, turn left heading 180'
After that brief exchange,
Johnson assumed that there was no problem
Eastern 401, how are things coming along?
Investigators conclude
that at that moment
controller Johnson was the only one
who could see that the plane was losing altitude.
Why haven't he passed that information
along to the crew?
U.S. government regulations
for air-traffic controllers provide the answer.
It simply wasn't part of the controller's job.
At the time of the crash,
the FAA required approach controllers to
maintain a separation of the airplanes
It did not give them a duty
to maintain the altitude of the
airliner with regard to the ground.
Now investigators try to determine
how the plane's own warning system failed
to alert pilots to their growing danger.
The L 1011 is equipped with an alarm
that sounds if the plane goes 250 ft
above or below the altitude
selected by the pilots.
As investigators replay the tape
from the black box,
they clearly hear that alarm
sounding in the cockpit
as the plane pass through 1750 ft.
Do you hear that?
How can they miss it?
Investigators closely examine
the cockpit transcript
to try to understand how
the alarm was missed.
Investigators notice that
just before the alarm sounded in the cockpit
warning the crew that the plane is too low
both pilots were completely absorbed
with the landing gear light.
The conversation also tells investigators
that the flight engineer
was below in the Hell-hole.
The warning chime came out of a speaker
at his workstation.
Investigators begin to realize
that the two pilots were unable
to hear a perfectly audible alarm
because they were focussed so entirely
on solving another problem.
That chime, which was clearly heard
on the cockpit voice recorder,
was not registering in the minds
of the flight deck.
not because they were trying to pay attention
but because they were tunnelled in
on this one problem.
That's what we do as humans.
Investigators now focus on crew-distraction
as a likely cause of this accident.
Several instruments would have displayed
the decreasing altitude.
The major question was:
Why were the pilots so preoccupied
that they were not looking at the instrument panel
They had to look at the human beings
They had to look at the interaction
They had to look at why no one was
paying attention to the airplane
as it begin to creep out of 2000 ft.
That was scary territory in 1972.
Investigators interview a number of pilots
and make a startling discovery
Pilots admitted that they
placed a lot of trust
in the modern new autopilots flying their planes.
They may have become overly dependant
on the technology
Investigators suspect that the Eastern crew
was so confident in their autopilot,
that they didn't monitor their instruments
as closely as they should have.
Once the autopilot was ON,
none of the pilots paid attention
to actually flying the plane.
We still got to find out why that plane went down.
Investigators still haven't determined
the most crucial piece of information.
If the autopilot was working,
why did the plane dive into the swamp?
The pilot's conversation clearly shows that
they haven't deliberately started descending.
So, why did it happen?
The answer comes in a dramatic form
when the NTSB conducts a public hearing in Miami,
two months after the crash.
Before the hearing,
an Eastern Airlines pilot named Daniel
Galleth wrote the chairman of the NTSB
offering to testify on his own behalf.
He had flown the Tristar L-1011
and notices some abnormalities.
The world of airline piloting in 1972 was hostile
to a pilot going around his
chief pilot and his airline
and raising his hand to
the NTSB and saying:
'Hey, wait a minute,
I've had an experience too
because airlines were far more insular
than they are today.
Galleth tells the hearing
that during a recent flight on a Tristar,
he had accidently dropped a map
on the cockpit floor.
As he bent down to pick it up,
he nudged his control column
He noticed immediately
that the autopilot had been affected.
The part of the autopilot,
controlling the altitude
had been turned OFF
The NTSB discovers that Galleth's experience
is shared by others.
In fact, 17 days after the accident,
Eastern Airlines tacked a notice
on to a company bulletin board.
and also mailed it to all of its Tristars pilots.
The bulletin warned against accidently
bumping the control wheel.
One of the things that we build
in to all the modern jet liners
and airliners is simply
a pressure switch
So, if you need take over right now,
you don't want to be wasting time down here
on the panel turning the autopilot OFF,
You just grab it and the autopilot goes away
The FDR tells investigators the precise moment
that the altitude started to drop.
It was 11:37 and 8 seconds PM
By studying the CVR transcript,
investigators can tell what
was happening in the cockpit
at that exact time.
By turning to speak to the Flight Engineer,
investigators believe
that Captain Loft bumped his control wheel.
He did it with just enough pressure to
disengage that part of the autopilot
that had been controlling the altitude.
Without anyone realizing it,
a simple nudge of the control wheel
started a gradual descend
On a dark, moonless night,
the pilots had no visual queues
to tell them they where falling
It was determined that occasionally,
with just a soft bump,
the autopilot has been disengaged.
Before the crash, it wasn't part of the training.
A training director for Eastern
Airlines eventually reveals
that before the Everglades-crash,
pilots were never taught
that a bump could disengage the autopilot.
The NTSB comes to a sobering conclusion
The plane crash was due to Pilot Error.
The crew was distracted.
They mishandled the sophisticated automation
and they hadn't been properly trained.
Eastern 401 was a pivotal accident
in aviation safety history
and we even didn't know this
for about 10 or 15 years
in terms of the true import
of what they did to us.
in focussing our attention on
the way we handle things in a cockpit,
was not only not correct, but it was dangerous.
Investigators also make a dishartning find
When the nose-gear-indicator-light assembly
is examined
They discover that a light bulb inside
is burned out.
Flight 401 's landing gear WAS locked.
The plane could have landed.
The only piece of the plane that failed,
was a $12 light bulb
The full legacy of Flight 401
will take years to unfold.
It will ultimately alter how pilots are trained
and how accidents are investigated.
But first,
the tail of Eastern Airlines Flight 401
will take a very bizarre twist.
As far as the NTSB is concerned,
the investigation into Flight 401 is over.
Several recommendations were laid out
to prevent similar accidents.
Those include new regulations,
instructing air traffic controllers
to warn pilots when they
getting to close to the ground.
But four years later,
it became clear there was a bigger
lesson to be learned from Flight 401
In 1977 two 747's collided
on a runway in Tenerife on the Canary Islands.
It was the deadliest plane crash of all time.
And we are now at take off
That accident was caused by a string
of miss-communications in the cockpit.
'Jawel !'
Investigators established that 70% of crashes
were due to pilot error
Both of these accidents , Tenerife and 401,
what you see is crew's dedicated doing a good job
but not realizing that they are human.
Not realizing how many
things can go wrong
if you don't appreciate how human beings fail.
By the late 1970's,
NASA began to explore a new behavioural science,
designed to reduce pilot error.
It is called crew resource management
or CRM.
CRM means they were not going to have one pilot
leading and everybody else following
It means that the Captain
has to be a leader
and listen to and interact with
his subordinate crew members
They have to speak up.
Decades later,
Flight 401 is taught in aviation
courses around the world
as a textbook example
of poor Crew Resource Management.
The problem was that we
did not teach Bob Loft
or Stockstill
or any of these folks at that time,
that when something goes wrong,
the commander's first responsibility
is to maintain the aircraft control
and you do it himself or assign somebody.
On Flight 401,
Captain Loft did not clarify
who should be doing what.
Instead,
all 3 crew-members worked on the same problem.
It has got to come out a little bit
and then snap in.
With the co-pilot flying,
the Captain commanding from the left-seat,
you already had cross purposes here
'It is right above that red one'
I cannot get it out from here
And you had a lightquadron,
the Captain couldn't quite reach,
and the Co-pilot could,
but he was flying the airplane.
You just set them up for a major problem
and guess what?
We never taught them what to do
Today, Crew Resource Management
also trains flight crews
not to be intimidated by one crew member's mood.
Do you have a handkerchief or something
so I can get a little better grip on this?
Anything I can do it with?
Get down there and see if that dammed thing
So, if the leader is having a problem,
in this case a light bulb,
OKAY, you got it sideways, then.
and he is really irritated at it
and the co-pilot has now made the problem worse,
The co-pilot is not happy with himself
'What the hell is holding that thing in there?'
Don Repo is not going to be happy that he
got downstairs to try to solve the problem
and he couldn't see anything,
he has got to come up and report that
'I don't see it'
They are all tensed.
'It's not lined up?'
'I can't see it'
And when you get a crew like that tensed,
It is not to turn around to the Captain and say:
You shouldn't have done that
But this is part of the evolution of
what air-safety has now learned
and been able to teach so many other industries.
The enduring legacy of Flight 401
is the delegation of specific tasks
in the cockpit.
The result is fewer crashes.
There was also much more bizarre fallout
from this crash.
For a while,
it seemed that the crew of Flight 401 was
haunting other Eastern Airlines flights
For some time after the crash,
flight crews and passengers report seeing
lifelike apparitions of flight 401's crew.
Many of the ghost sightings were on aircraft,
fitted with recovered parts from Flight 401.
The ghost stories spread quickly.
One book devoted entirely to those stories
suggest that the ghosts were there to protect
passengers and crew from further mishap.
The official reaction of Eastern
Airlines to these ghost-stories
was one of absolute eye-rolling denial
in public and in private,
a certain bit of panic.
There are so many ghost-sightings
that eventually Eastern Airlines removes
Flight 401's cannibalized plane parts
from all other aircraft.
None of those who survived the crash
will ever forget the horror they
witnessed in the Everglades that night.
And 35 years after their ordeal
many of them returned to that swamp
to finally recognize
the heroic efforts
of Bob Marquis
'We are here today to recognize
and to say: thank you'
Many of the ones who lived
lived because Robert Marquis
was there with his air-boat
He saw them drowning
and decided that the thing he could do
would be to save the ones that he could save.
Robert Marquis was
the kind of person
that I hope that all of us alternatively would be
if we were confronted with that sort of thing
But he drew him some special courage
to do what he did.
He was one of the true heroes of the crash.
Narrator
Jonathan Aris
Subtitles
Rein Croonen