Deadly Distractions - The Crash of Eastern 401
March 27, 2012 by Buck
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).
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.
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.