The Crash of Eastern Air Lines Flight 401-Investigation

 

In the ensuing days, the NTSB conducted an investigation. They poked around the wreckage, interviewed survivors and witnesses and pored over the flight data. When investigators climbed into the crumpled hulk of the cockpit they found the control panel virtually intact. Loft's clock had stopped at 4:41:34 Greenwich time. (Calibrating to the nearest half second, the NTSB officially listed the moment of impact at 11:42:12.5 pm). The airspeed needle on Loft's side read 198 knots. The altitude select panel was set at two thousand feet. The nose gear light assembly was found jammed on its side and protruding a quarter of an inch out of its normal position. It contained two burned out light bulbs. All three throttles were in the full forward position, another indication that the pilots discovered the problem at the last moment and tried to pull out of it.

Angelo Donadeo, who had ridden in a cockpit jump seat was considered a crucial observer of what happened in the flight deck. He was interviewed on January 8th, while under heavy sedation in a Miami hospital. He signed the transcript of his testimony "reluctantly" because of his condition.

A peculiarity was discovered in the forward avionics bay; the two autopilot computers - those that controlled the plane's nose up and down attitude- were mismatched. One was a model 1-7, the other a Model 1-8. The difference between the two is that while one required 15 pounds of pressure on the control column to disengage the system, and the other required 20 pounds of pressure. Although the two computers were slightly different, both worked properly when tested, along with the five other computers that survived the crash. Eleven days after the crash, the NTSB loaded the surviving, mud stained autopilot computers into Aircraft N306EA, a sister ship to the one that crashed. Eventually all the evidence was presented in a public hearing held in the "Florida Room" of the Miami Springs Villas on March 5, 1973. By the time the meetings were over, the computer printouts from the Flight Data Recorder had been deciphered, and the voices of men now two months dead had been resurrected from the recording tapes. The evidence was abundant, and allowed investigators to develop a clear picture of what happened.

NTSB Map of the flight path of Flight 401

The flight had been normal until the final approach into Miami. When Stockstill had looked at the landing gear indicator, the green light that identifies that the gear is properly locked in the 'down' position didn't illuminate. This failure has two possible explanations: either the gear wasn't down, or the light wasn't working. The pilots recycled the gear. When the light still did not come on, they aborted the landing to examine the situation. The tower instructed the L-1011 to pull out of its decent, climb to two thousand feet, and then make a U-turn and flight west over the darkness of the Everglades. The cockpit crew removed the light assembly and the flight engineer was dispatched into the hell hole to visually check if the gear was down. Fifty seconds after reaching their assigned altitude and when the plane was halfway through its U-turn, the captain instructed Stockstill to put the L-1011 on autopilot. For the next eighty seconds the plane maintained level flight. Then it dropped one hundred feet, and then again flew level for two more minutes, after which it began a descent so gradual it could not be perceived by the crew. In the next seventy seconds, the plane lost only 250 feet, but this was enough to trigger the altitude warning C-note chime located under the engineer's work station. The engineer had gone below, and there was no indication by the pilot's voices that they heard the chime. In another fifty seconds, the plane was at half its assigned altitude. The plane's parabola was like that of a long line drive which finally expends its force and drops in an increasingly steep dive. At the moment when Stockstill's radio altimeter beeped the plane was passing through one hundred and one feet, the plane was dropping at fifty feet per second. The cockpit crew heard the warning, but it was too late.

The question remained: Why did an aircraft locked on autopilot dive into the swamp?

The answer came in fragments. First, an Eastern captain names testified to the NTSB on February 6th that he had noticed that the altitude hold function could be disengaged by bumping the control column. Many pilots doubted Gellert's testimony, but the incident was strikingly similar to a situation encountered by Thomas Oakes, another Eastern pilot. Oakes had been one of the first captains qualified to fly the L-1011. He had the altitude hold function disengage on a flight on January 8th, ten days after the crash of flight 401. He and the co-pilot noted the malfunction in their log book. Although these seemed to be freak occurrences, Eastern took it seriously to send a printed notice to all it's L-1011 pilots on January 15th.

(As a side note, on April 8, 1983, Daniel Gellert appeared on NBC Television's Today show. On the show, Gellert discusses his decision to report the L-1011 altitude hold malfunction to the NTSB. Gellert explains that after discovering the problem he went to Eastern management and had a meeting with an airline VP regarding this issue. He claims that the problem went uncorrected. He points out that when Flight 401 crashed into the Everglades because of an altitude hold malfunction, he decided to go to the NTSB. He adds that shortly afterwards he was grounded and ordered to undergo psychological testing. Gellert maintains that he is a competent pilot who has a responsibility to his passengers and believes Eastern had given him a lot of flack and ruined his personal life. Gellert had apparently sued Eastern Airlines for liable around the same time as the NBC interview. In Eastern Air Lines, Inc. v. Gellert, 438 So. 2d 923 (Fla. 3d DCA 1983), the Third District Court of Appeal analyzed whether Eastern Air Lines was liable for defamatory statements madeto the press by the director of Eastern Air Lines' news bureau. The court held that Eastern Airlines could not liable for punitive damages absent proof that it was independently at fault).

Given this information, the NTSB hypothesized that Loft had probably bumped the control column when he turned to tell flight engineer Repo to "get down there and see if that goddamn nose wheel's down." The NTSB report continued: "If the captain had applied a force to the control wheel while turning to talk to the second officer, the altitude hold function might have been accidentally disengaged." The autopilot had apparently not turned off completely, but rather had switched into the "Control Wheel Steering" mode. The Whisperliner was no longer locked at two thousand feet, but would fly steadily at whatever level the pilots selected, purposefully or accidentally, by pressure on their control wheels. From this point on, even a slight nudge would be enough to edge the plane up or down.

An adjunct mystery which never really was solved was whether the altitude hold light extinguished when the function disengaged. In both Gellert's and Oakes' cases, they noted the autopilot light went out when they bumped the columns. But Stockstill might have been deceived by the mismatched autopilot computers on N310EA. There are two autopilot systems, an "A" and a "B." Because the computers were mismatched, Loft's side required 15 pounds of pressure to disengage, and Stockstill's side required 20 pounds of pressure. Had Loft bumped the column with more than 15, but less than 20 pounds of pressure, Loft's altitude hold light would have gone out, and Stockstill's light would remain on, giving him the erroneous impression that the autopilot was still engaged and holding the plane at two thousand feet. This could be the case, however, only if Stockstill had selected the "A" computer, which would be unlikely as the switch for the "A" computer is on Loft's side of the control panel. Either way, the NTSB did not believe that this was a critical factor in the accident.

Above, the autoflight control panel on the L-1011

The report cited the cause of the crash as pilot error, specifically: "the failure of the flight crew to monitor the flight instruments during the final four minutes of flight, and to detect an unexpected descent soon enough to prevent impact with the ground. Preoccupation with a malfunction of the nose landing gear position indicating system distracted the crew's attention from the instruments and allowed the descent to go unnoticed."

One hundred and three people died. The fifteen million dollar aircraft was destroyed. And it al began with two burned out light bulbs with a replacement value of twelve dollars.

The landing gear was found to be in the down and locked position.

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The following is a list of survivors and victims of Eastern Air Lines Flight 401. Thanks to Jim Kalafus for the corrected names of Flight 401 victims drawn from Dade Country death certificate files. Please email corrections, additions and/or memorial information to donuts13@yahoo.com. I can add your email address if you'd like other survivors to be able to contact you.

Survivors - Crew and Eastern Employees

Ann Connell, Barry Connell, Angelo Donadeo, Patricia R Georgia, Adrianne Ann Hamilton, Jennifer Larsen, Thomas Mulcahy, Mercedes V Ruiz, Beverly Jean Raposa, Trudy J Smith, Sue F. Tibbs, Sharon R Transue, Dorothy M Warnock.

The girls of Flight 401. Back row from the left: Mercy Ruiz, Sue Tebbs, Adrienne Hamilton, Trudy Smith. Front row from the left: Dottie Warnock, Pat Ghyssels, Beverly Raposa, Patty Georgia, Stephanie Stanich. This photo was taken hours before the crash while on board Flight 26 in Miami.

Survivors - Passengers

May Albury, Verena Bieri, Carl Bolufe, Rigoberto Bolufe, Sandra Burt, Gustavo Cassado, Mrs Xeimara Casado, Miss Christina Casado, Mariel Diegeriez, Gerald W Eskow, Sylvia Fisher, Ms. F. Frankin, Herbert Fresko, Molly Fresko, Alicia Garcia, Julia Garcia, Kathryn F.Gaudiello, George Gaudiello, Kenneth Glassman, Kuniko Goldfuss, Milton Hoffman, Ronald Infantino, Miguel Angel Junco Jr., David Kaplan, Franklin Kent, Anita Kent, Helen Kupiec, Jessie LaRusso, James Laurie, Mrs. Leone Levine, Cornelia Leya, Thomas McAvoy, Joseph Mazur, Rose Mazur, Luis Mejia, Richard N. Micale, Albert J Morris, Janice Minguzzi, Christina Ochoa, Allen Okanawsky, Oneida Pares, Aristides Pares, Martha Pares, Carlos Polanco, Lucino Polanco, Joseph Popson, Richard Pragluski, Goldez Quinico, Evelyn Ragalia, Marie Rego, Glen Remkus, Francoise Riette, Thomas Rothenberg, Martin Siminerio, Bonnie Silverman, Donna Smith, Millie Soberon, Jerald Solomon, Larry Sumpkins, Marilyn Taylor, Edward Ulrich, Jesse C. Walker, Alan Weiss, Lorenzo Zetlin.

Above: Luis Mejia recovering from the crash in Palmetto Hospital.

Carlos Polanco

Lost - Passengers and Crew (Name and Birthdate)

Elise Grace Agate  9/3/42

Lourdes Albert  2/20/50

Renee Joaquin Albert  8/3/36

Muriel J. Ames  11/30/40

Luis Bancroft   10/10/48

Adelaide Geneve Bearman   9/21/22

Lloyd Irving Bearman   1/16/23

Darrylle Becker   3/16/43

Jerome Becker   6/27/39

Ernest F. Bloodgood   4/1/16

Loretta E. Bloodgood  10/13/15

Mary Carfizzi   11/3/19

Salvatore Carfizzi   7/15/15

Jose Carrasquillo   6/28/40

Paquita Carrasquillo   10/4/40

Donald Stanley Casadona   7/16/38

Maureen I. Chesler   10/12/47

Helen Marie Chestnut   4/17/39

Richard Childs   5/21/52

Dr. Aftabuddin Chowdhury   1/1/43

Lucille Cilles   1/30/24

Yetta Cohn   3/17/16

Braulio Corretjer   1/5/28

Silvia Crespo   11/30/32

Jana Dedek   6/24/53

Isell Delgado   1/23/25

Evelyn De Salazar   11/6/08

Susan Deutsch  10/21/42

Judy Ellenberg   2/27/53

Sara Escobar   8/ 7/31

Varujan Eskihanci   9/7/25

Solomon Fisher   7/18/11

Greta Foye   3/19/45

Jose Garcia   6/4/47

Pedro Garcia    2/10/26

Sharyn Noreen Gatti  3/21/48

Patricia A. Ghyssels  3/31/45

Bernard A. Goldfuss  11/2/22

Jorge Gonzales  1/16/38

Maria Elena Gonzales  9/3/51

Dennis Gordon  12/9/32

Diane Carol Greenblatt  5/5/52

AbbeyLynn Greenwald  9/18/52

Caridad Fermina Hernandez  10/11/32

Fara Infantino  12/7/46

Ethel L. Jackson  3/8/08

CarolSusan Jackter  9/26/52

Eduardo Jaramillo  8/2/32

Ronald Jaye  March 27, 1940

Carmen Jorge  7/7/46

Alina Junco  5/2/44

Miguel Junco  8/28/42

Jonathan Adam Kaminer  8/22/70

Michael Ann Kaminer 12/28/45

Selma Karpen  6/16/21

Silvan Karpen  5/23/28

Rose Kashman  9/22/15

Mildred Katz  1/8/34

Charles Kuchenbrod  7/16/30

Marc Leshay   11/28/51

Robert Albin Loft  3/17/17

Jesus Lorenzo  4/26/37

Rosa Losano  11/1/01

Susana Luna  8/29/29

Julia Lustig  5/30/25

Moe Lustig  7/16/23

Barry L. Mancuso  10/19/44

Rosemary Mancuso  10/31/49

Dale Ann Mazzone  5/19/51

Kenneth Michael Mazonne  3/27/44

Rosario Messina  2/29/26

Nicholas Minguzzi  8/5/68

AlanNachmias  5/16/50

Henry Nunez  8/18/23

Nery Palma  7/12/34

Roberto Palma  6/10/27

Elizabeth M. Pollack  12/10/17

Anne Ponte  1/7/16

Thomas Ponte  10/24/11

SamuelJ. Prager  12/23/03

Jose Rego  9/5/19

Donald Louis Repo  5/10/21

Elisa Ruth Romero  5/28/44

Rochelle Rubin  1/5/48 (she was the first victim discovered by the search team at 12:30 pm, December 30th)

Unborn son of Rochelle and Stefan Rubin

Stefan Jay Rubin  3/21/49

Barbara Ann Saal

Patricia Renee Shackelford  12/9/52

Klaus Schenck  9/5/39

Eugene Schenker  6/24/30

Richard J. Schulleri  1/3/43

Stephanie Rae Stanich  11/10/48

Allen M. Stark  8/11/49

Albert J. Stockstill   6/9/33

Warren Terry   2/16/34

Janice Testa   9/12/52

James Yandolino   3/7/52

Murray Yellin   6/9/11

Sadye Yellin   1/9/15

Rose Lina Zollo   7/13/43

NOTE - There is no official death certificates for the names "C. Carmichael" and "Mrs. McAvoy," which appeared in passenger lists released to the press at the time. It is suspected that "Mrs. McAvoy" was the name given to the traveling companion of Thomas McAvoy who may not have been his wife, but was one of the other passengers listed.

The Flight •Crash • Rescue and Aftermath • Investigation • Epilogue • Memoral • Discussion