Deadly Distractions - The Crash of Eastern 401
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.
How Are Your Margins?
When we hear “how are your margins” in business we often think of profit Margins and why wouldn’t we? All organizations want to be as efficient as possible so that they can return the most profit/ROI for its stakeholders. Business schools spend countless hours teaching us how different methods of how to achieve max profit and in a global economy it may mean mere survival. Most companies I have worked with have used Industrial Engineering, Six Sigma or other process improvement programs to become as efficient as possible, and that is a good thing. However, leaders must also keep an eye on their Safety Margins as well.
Today most organizations are very efficient and have taken out all of the “extra” and are operating at max efficiencies with little margin for error and the front line employees feel it.
Even the military, which has no profit motivation, has gotten in on the act and has been for some time. In the 80’s and 90’s we moved from two seat fighter Jets to single seat jets. As a single seat Hornet pilot we were told the engineers figured that to operate the airplane at its max capability actually required 1.2 pilots. Well, being .8 of a pilot on a good day, this made me nervous.
The Military spent many hours discussing safety and how to cope when you were feeling Overcome By Events (OBE). They said you are most likely to become OBE during irregular operations (something is not going as planned) and are feeling pressure to fix the issue and get back on track. During these times we were taught to Aviate, Navigate and Communicate, in that order. In other words, fly the plane, and then get it headed where you intend to go then tell someone what is going on. These simple steps saved countless lives in single seat fighter aviation as it predicted this feeling of being overwhelmed, said it was OK to feel that way and provided a strategy to cope.
As leaders it is important that we look ahead and try to predict when our employees may feel OBE and discuss what to do in those cases. Unfortunately many well-intentioned workers have been injured or killed trying to fix a problem while not costing production.
As Odie would say,” they were doing the wrong thing for the right reasons”. So, I encourage you to take the time to discuss with your employees the “what ifs” and how to handle them before they happen on the job.
Lets keep the Safety Margins High.
Lt. Col Wes “Dahmer” Sharp
Safety Speaker, Target Leadership
10 Reasons Why Smart People Do Dumb Things
I have compiled a Top 10 list of why I think smart people do dumb things. In no particular order…
1. Poor Perspective or Lack of Objectivity: Didn’t see the forest for the trees. Need to step back and get a view from 20,000 feet so to speak. Been there!
2. Pressure to Perform: It is usually from within ourselves or outside pressure from supervisor or company. Often happens when we feel the pressure to fix a problem, or get back on schedule. Been there!
3. Interruptions and Distractions: Things are often on our mind other than the task at hand. Not paying attention. Resuming work when going on/coming from vacation, or even lunch. Reminds me of Eastern flight 401 being distracted by a burned out light bulb. Been there!
4. Poor Situational Awareness: Where I think I am vs. where I actually am. We fight to be right, so we rationalize away hints and clues that keep trying to tell us, “Hey Dummy, you’re a smart person doing something dumb.” Been there!
5. Making Assumptions: We know what happens when we “ASS-U-ME”. When we make decisions based on one or a series of assumptions, the decision to act in a certain manner may seem perfectly logical. BUT, if the assumptions are wrong, the results of our actions may be disastrous. Been there!
6. Ego-Ability Exceeds Capability: Overconfidence in our ability to perform an action. It is usually prefaced with “Watch this” or “I’ll be careful”. Reminds me of the Bud Holland B-52 crash, or being a teenager again. Been there!
7. Snap Decisions: Are usually driven by panic or pure emotions. Acting without processing logical or rational thoughts. Slow down! Take a breath. Think. Communicate with others… then proceed. Been there!
8. Complacency: “The Silent Killer” has many facets, yet it has tagged many smart people. Reminds me of the Thunderbird accident. “Ho-hum” routine jobs hurt smart people every day. Pay attention. Been there!
9. Lack Of A Moral Compass: Bernie Madoff and Enron are examples of smart people or entities who did dumb things. I don’t steal from people, but I need to keep adjusting my moral compass when I run a yellow light… or speed… or “text and drive”… or… Been there!
10. Drugs & Alcohol: This certainly impairs ones ability to think or act smartly. Dumb acts have been committed by many smart people due to impaired thinking/ability. Been there, and, thank goodness, I don’t go there anymore!
What is interesting about each of these is… When a smart person is doing something dumb, they either do not realize it OR they don’t think they will get caught / hurt / killed!
Approachability — The Last Domino
Nearly every supervisor in the workplace feels they can be approached by others, but are they really “approachable?” What does “intervening” in the workplace mean to you as a supervisor or foreman? What does it mean to the one being supervised?
In this article, we will examine the final moments of three aviation accidents in an attempt to get at what makes approachability in the field so difficult. How can we become more approachable from the bottom up, from the top down, and peer to peer?
When the dominoes begin falling, accident investigations often reveal that someone on the job could have intervened with a critical piece of information but either did not speak up or was not listened to.
Our purpose here is to not pick apart each falling domino, but simply to look at the final moments, the end game, “the last domino” — Approachability.
Reflect inward and ask yourself, what does “approachability” really look like, sound like, or feel like in the field? What you may find is that being approachable and intervening on the job is not as clear cut as you might think.
- Air Florida Flight 90 – crashed into the icy Potomac River January, 1982 (74 fatalities).
- Comair Flight 5191 - departed from the wrong runway in Lexington KY on August, 2006 (49 fatalities)
- PanAm & KLM 747 crash on the island of Tenerife – worst aviation accident in history (583 fatalities).
Rescue attempts by news helicopter of Air Florida Flt 90 passengers from the icy Potomac River.
In each exampe, the pilots (workers) had the power to stop the work before disaster, but failed to do so. Why?
Air Florida Flight 90
Let’s look at the final dominos of Air Florida Flight 90. Just as they begin the work, the takeoff roll:
Cockpit Voice Recorder Transcripts
Co-Pilot : God, look at that thing. That don’t seem right, does it? Uh, that’s not right. (Referring to engine gauges)
Captain: Yes it is, there’s eighty. (Referring to airspeed)
Co-Pilot: Naw, I don’t think that’s right. Uhhh, maybe it is.
Captain: Hundred and twenty. (Referring to accelerating airspeed)
Co-Pilot: I don’t know?
NOW BARELY AIRBBORNE, THE SOUND OF THE “STICKSHAKER” (warns pilots of impending stall) HEARD CONTINOUSLY UNTIL IMPACT
Active Listening Builds Trust and Saves Lives
After personally interviewing Capt. Bob Bragg, the last surviving pilot involved in what still stands today as the “worst aviation accident in history.”, I am reminded that active listening saves lives. Capt Bragg was the copilot on board a Pan American 747 jumbo jet when a KLM 747 jet collided with him on the runway on the island of Tenerife in 1977.
The runway was shrouded in fog as the captain of the KLM aircraft advanced the throttles for takeoff. He refused to listen to his crew members when they first protested by saying, “we don’t have clearance,” then followed up by asking, “is the Pan Am clear?”
The KLM captain emphatically stated that Pan Am was clear. History clearly shows otherwise as Copilot Bob Bragg saw the KLM abruptly appear out of the fog, and attempt to fly over the top of his aircraft. They didn’t make it, and 583 people lost their lives as a result.
Time and again we see errors in communication, misunderstanding, and assuming.
In complex operations, changes in work activity happen all the time, yet hazards abound.
At the top of the list is having a leader in charge who refuses to listen to others before making a decision that directly affects other people lives. These leaders feel their situational awareness is good, yet their perceptions of reality vs actual reality is incongruent. Only by actively listening to others can these leaders make correct decisions.
The Tenerife disaster has clearly taught us that everyone, no matter their rank or experience, has a piece of information that might be the critical piece, the last chain link, or final domino in a chain of events that prevents disaster.
As an airline copilot, I had the pleasure of working with a senior airline captain who embodied active listening. When the flight operation was being hampered by bad weather, or mechanical problems, or passenger issues, before he made final decisions that affected the lives of others, he employed these three active listening techniques in sequential order, to solicit information from his team:
1) “What I Heard You Say Is….”
2) “Did I Get That Right?”
3) “Is There More?”
For example, when the captain finished listening to critical information, he made the statement, “What I Heard You Say Is…” and he would proceed to parrot back the information without putting his spin, thoughts, or opinion on the subject. The captain then followed up with, “Did I get that right? “. Once the captain heard the answer to number 2 as, “Yes,” he would move on to number 3 by asking, “Is there more?”
I witnessed many amazing transformations in body language and tone of voice when he employed this methodical listening process. It was especially effective with upset passengers.
As a safety professional, anytime communication is turning from conversation to confrontation, try using this captain’s proven listening technique before making critical decisions. This technique even works well with teenagers. Although they may not like your decision, they are far more likely to support you because they have been heard, and being heard builds trust with leadership.
Odie uses his background in both commercial and military aviation to motivate and inspire individuals to embrace a zero-accident safety culture. 
