This is a rare picture of the Lockheed L-1011, Ship# 310, that crashed into the Everglades. This picture was likely taken just weeks before the crash.
It is almost midnight, December 29, 1972, when Eastern Airlines ship #310 began her final approach to land at Miami International airport. The captain, called Miami tower on the radio: "Miami tower, Eastern 401, just turned on final."
The captain then instructed the copilot to lower the landing gear, ”Go ahead and throw ‘em out.”
When the landing gear handle was lowered, the pilots checked to make sure there were three green lights, indicating that all three landing wheels are safely down and locked (as shown).
In this case, the flight crew did not receive a green nose gear light. This means one of two things, either the nose wheel is not safely down and locked, or the bulb is burned out.
At 11:34 p.m. the captain spoke into the radio, "Well, ah, tower, this is Eastern 401, it looks like we’re gonna have to circle; we don’t have a light on our nose gear yet."
Miami tower responded, "Eastern 401 heavy, Roger, pull up, climb straight ahead to two thousand. Go back to approach control, 128.6."
No doubt, this is an unwanted distraction that interrupted the normal work routine of these Eastern pilots. Interruptions to our normal work flow can be deadly, and how we deal with these situations when they pop up can be the difference between life and death.
To work the nose gear problem, the ill fated Eastern crew decided to enter holding and allow the autopilot to maintain the racetrack pattern at 2,000 feet. On the surface, this is a good plan. However, the breakdown occurred when the pilots became so engrossed at diagnosing and fixing the burned out light bulb, that they failed to monitor the actions autopilot.
Investigators determined that during the struggle to properly re-install the light bulb, one of the pilots inadvertently bumped the control wheel with enough pressure, it changed the autopilot logic. It went into “descent mode.” The pilots failed to notice as the autopilot put the airplane into a very slow insidious descent towards the Everglades.
Sometime later, the copilot finally decided to check on the status of the autopilot. What he saw shocked him. He expected to see it holding steady at 2,000 feet, instead he saw less than 100 feet and slowly descending.
Both pilots stare in disbelief. This is the final exchange between two highly skilled, very competent pilots (operators) who became so distracted by a 20 cent burned out light bulb, they crashed into the Everglades.
"We did something to the altitude," said the copilot. "What?" answered the surprised captain. In complete bewilderment the copilot said, “We’re still at two thousand, right?” "Hey, what’s happening here?" These were the final words spoken from the captain as the cockpit area microphone picked up the sounds of Ship 310 flying itself into the Everglades. 101 fatalities.
The cockpit of Ship #310 is clearly visible is this picture
Science is clear, humans are not as good at multitasking as we think we are. When someone tells me they are good at multitasking, I know they are good at doing multi-jobs poorly. Unplanned interruptions and distractions in the workplace are common. Employees must recognize these as leading indicators that can lead up to an incident or accident. We are essentially being forced to multitask.
Discuss possible situations and scenarios of where you and your people are most likely to face unwanted distractions. Have a plan in place when something unplanned pops up. Hindsight is always 20/20, but having foresight is 20/20/20. That means every 20 minutes, take 20 seconds, and look 20 feet around you. You might be surprised at what you see.
For those of us who work in a high risk work environment, it is imperative we keep our situational awareness congruent with reality. There is nothing more dangerous than someone who is clueless and doesn’t know it - yet. As an operator (airline pilot), anytime an unplanned interruption comes my way, I use the acronym SLAP to help me remember to stay focused:
S top the current path / work / progression while using Foresight 20/20/20. L isten to others, gather information about the interruption. A ssess the distraction. Decide to either discount, delay, or redirect the issue. P roceed with the plan or rebrief a revised plan. Never assume everyone understands what you want. Be clear and concise. Ask probing questions.
By doing this, hopefully you will never allow a small distraction to become the main attraction.