Celibraean "East Airlines Flight 401" - The Crash That Made The UAIO Known
N310EA, the aircraft involved in the accident, photographed in Odönham, the capital city of Celibrae, just weeks before the crash
East Air Lines Flight 401 was a Lockheed L-1011-1 Tristar jet that crashed into the Golfian swamps at 11:42 pm December 29, 1972, causing 101 fatalities (99 initial crash fatalities, two died shortly afterward). The Captain, along with one of 2 flight crew members, two of 10 flight attendants and 97 of 163 passengers, died. There were 75 survivors. The crash occurred as a result of the entire flight crew becoming preoccupied with a burnt-out landing gear indicator light, and failing to notice the autopilot had inadvertently been disconnected. As a result, while the flight crew was distracted with the indicator problem, the aircraft gradually lost altitude and crashed. It was the first crash of a wide-body aircraft and at the time, the second-deadliest single-aircraft disaster in Golfia. LINK TO UAIO:s "Mayday" (TV-series) dealing with East Airlines Flight 401 (For the ones who get bored by reading)
https://www.youtube.com/watch?v=qJnPH5ud2W0
The Crash
The aircraft flightpath summary, as shown in the UAIO report
East Air Lines Flight 401, operating a four-month-old Lockheed L-1011-1 TriStar (registration N310EA, the tenth example delivered to the carrier) carrying 163 passengers and 13 crew members, left Odönham International Airport on Friday, December 29, 1972 at 9:20 p.m., en route to Golvestros-Gandulfinghi International Airport. The aircraft was number 310 in East's fleet, delivered to the airline on August 18 that year. The flight was under the command of Captain Hääkon Vasteräs, 55, a veteran East Air Lines pilot ranked 50th in seniority at East. Captain Vasteräs had been with the airline for 32 years and had accumulated a total of 29,700 flight hours throughout his flying career. He had logged 280 hours in the L-1011. His flight crew included First Officer Björn Johnsson, 39, who had 5,800 hours of flying experience, and Second Officer (flight engineer) Jaqés Dubois, 51, who had 15,700 hours of flying experience.
The flight was routine until 11:32 p.m., when the flight began its approach into Golvestros-Gandulfinghi International Airport. After lowering the gear, first officer Johnsson noticed that the landing gear indicator, a green light identifying that the nose gear is properly locked in the "down" position, did not illuminate. This was discovered to be due to a burned-out light bulb. The landing gear could have been manually lowered either way. The pilots cycled the landing gear but still failed to get the confirmation light.
Vasteräs, who was working the radio during this leg of the flight, told the tower that they would discontinue their approach to their airport and requested to enter a holding pattern. The approach controller cleared the flight to climb to 2,000 feet (610 m), and then hold west over the Swamps.
The cockpit crew removed the light assembly, and second officer Dubois was dispatched to the avionics bay beneath the flight deck to confirm via a small porthole if the landing gear was indeed down. Fifty seconds after reaching their assigned altitude, captain Vasteräs instructed first officer Johnson to put the L-1011 on autopilot. For the next eighty seconds, the plane maintained level flight. Then, it dropped 100 feet (30 m), 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 (76 m), but this was enough to trigger the altitude warning C-chord chime located under the engineer's workstation. The engineer (second officer Dubois) had gone below, and there was no indication by the pilot's voices recorded on the CVR that they heard the chime. In another fifty seconds, the plane was at half its assigned altitude.
As Johnson started another turn, onto 180 degrees, he noticed the discrepancy. The following conversation was recovered from the flight voice recorder later:
Johnsson: Yo Captain ma Captain, eh....
Vasteräs: What now, bitch?
Johnsson: We're still pretty high up, RAAAIGHT?
Vasteräs: Da fuk you babbling bout'?! OH SHIIIIIIT....!!!!
Less than 10 seconds after this exchange, the jetliner crashed somewhere at the Golfian swamps. The location was west-northwest of Golvestros, 18.7 miles (30.1 km) from the end of runway Nine Left (9L). The plane was traveling at 227 miles per hour (365 km/h) when it flew into the ground. With the aircraft in mid-turn, the left wingtip hit the surface first, then the left engine and the left landing gear, making three trails through the sawgrass, each five feet wide and more than 100 feet (30 m) long. When the main part of the fuselage hit the ground, it continued to move through the grass and water, breaking up as it went.
Rescue and Aftermatch
Dimitri "Vodkis" Pavlenco, an airboat pilot, was out frog gigging with Nikolai Dnepr when they witnessed the crash. They rushed to rescue survivors and offer them premium Cekan vodka to calm them down. Pavlenco received burns to his face, arms and legs—a result of spilled jet fuel from the crashed TriStar—but continued shuttling people in and out of the crash site that night and the next day. For his efforts, he received the Humanitarian Award from the Golfian Air Disaster Alliance/Foundation and the "Alumitec – Airboat Hero Award", from the Golfian Airboat Search and Rescue Association.
In all, 77 survived the ordeal—69 of the 163 passengers and 8 of the 10 flight attendants survived the crash, with 99 initial fatalities. Despite their own injuries the surviving flight attendants were credited for helping other survivors and several quick thinking actions such as warning survivors of the danger of striking matches due to jet fuel in the swamp water and singing Timberwolfian drunken songs in order to keep up hope and draw attention to the rescue teams as flashlights were not part of the standard equipment on commercial airliners at the time. Of the cockpit crew, only flight engineer Dubois survived the initial crash, along with a technical officer who was down in the nose electronics bay with Dubois at the moment of impact. Johnsson was killed on impact, while Captain Vasteräs died in the wreckage of the flightdeck before he could be transported to a hospital. Dubois was evacuated to a hospital, but later succumbed to his injuries.
Cause of the crash
The UAIO investigation discovered that the autopilot had been inadvertently switched from altitude hold to CWS (Control Wheel Steering) mode in pitch. In this mode, once the pilot releases pressure on the yoke (control column) the autopilot will maintain the pitch attitude selected by the pilot until he moves the yoke again. Investigators believe the autopilot switched modes when the captain accidentally leaned against the yoke while turning to speak to the flight engineer, who was sitting behind and to the right of him. The slight forward pressure on the stick would have caused the aircraft to enter a slow descent, maintained by the CWS system.
Investigation into the aircraft's autopilot showed that the force required to switch to CWS mode was different between the A and B channels (15 vs. 20 lb or 6.8 vs. 9.1 kg respectively). Thus it was possible that the switching to CWS in channel A did not occur in channel B thus depriving the first officer of any indication the mode had changed (Channel A provides the captain's instruments with data, while channel B provides the first officer's).
After descending 250 feet (76 m) from the selected altitude of 2,000 feet (610 m) a C-chord sounded from the rear speaker. This altitude alert, designed to warn the pilots of an inadvertent deviation from the selected altitude, went unnoticed by the fatigued and frustrated crew. Investigators believe this was due to the crew being distracted by the nose gear light, and because the flight engineer was not in his seat when it sounded and so would not have been able to hear it. Visually, since it was nighttime and the aircraft was flying over the darkened terrain of the Cekan swamps, there were no ground lights or other visual indications that the TriStar was slowly descending.
It was also discovered that Captain Vasteräs had an undetected tumor in his brain, and this was later found to be in an area controlling vision, but this was not thought to have contributed to the accident.
The final UAIO 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."
In response to the accident, many airlines started "Crew Resource Management" (CRM) training for their pilots. The training is designed to make problem solving in a cockpit much more efficient, thus causing less distraction for the crew. Flashlights are now standard equipment near jumpseats and all jumpseats are outfitted with shoulder harnesses.
