All language subtitles for Mayday.S05E08.Fatal.Distraction.1080p.AMZN.WEB-DL.DD+2.0.H.264-playWEB_track3_[eng]

Pull down
and turn to your right.

If you force it,
you'll break it.

This won't come out, Bob.

Push the switch forward.

A single lightbulb

is preventing a modern jetliner
from landing.

Screwing around
with a 20-cent piece

of light equipment.
On this plane.

Struggling to fix
a minor problem,

a much more serious one occurs.

- We're still at 2,000, right?
- Hey, what's happening here?

Those who survived the crash
face a new danger.

The swamp has filled
with jet fuel.

No one light a match.

Eastern 401
was a pivotal accident
in aviation history.

The crash
would point investigators

to an astonishing danger lurking
in all commercial cockpits.

Mayday! Mayday!

December 29th,1972,

the dawn of the jumbo jet era.

On its way to Florida,
this L-1011 TriStar

is the most advanced
passenger jet in the world.

The Lucky TriStar
was a fascinating bird.

It was a beautifully
flying airplane.

It had a tremendous
amount of power

and a lot of innovation to it.

The cabin
of this Eastern Airlines jet

is large and quiet.

The service is first rate.

Bob Loft is the captain
for Eastern Airlines Flight 401.

He's been with the airline
for more than 30 years.

His first officer
is Albert Stockstill.

His second officer
is Donald Repo.

The jet has left the bitter cold
of New York behind

and is now descending
towards Miami.

Welcome to Miami.

The temperature's
in the low 70s,

and it's a beautiful night
out there tonight.

Go ahead and throw 'em out.

Angelo Donadeo is
an off-duty Eastern Airlines
maintenance expert.

He's catching a ride
back to Miami.

There are 176 people
on board tonight's flight.

Most are heading south
for New Year's.

Ron and Lilly Infantino

have been married
for only 20 days.

They've just spent Christmas
with his family.

The seatbelt sign
came on as normal.

We're in a final approach.

I look out the window there
and I could see lights

at the airport.

Close to midnight,
the plane begins its approach

to Miami International Airport.

Stockstill flies the plane,

while Repo performs
a landing checklist.

- Radar.
- Up. Off.

Hydraulic panels checked.

Thirty five, thirty three.

Gear down.

The captain
notices a problem.

Bert, is that handle in?

No nose gear.

The light showing
that the nose gear
is locked hasn't lit up.

I'm going to raise it back up.

The gear
might not be all the way down.

Loft tries again.

The sound of the landing gear
echoes through the plane.

It makes
a pretty loud grinding noise.

If you've flown very much,

you're familiar
with that sound, so...

they did that several times.

The pilots did that
several times,

and we weren't alarmed.

It's just one of those things
that happens sometimes, and...

We just kind of looked at
each other, and said,

"Great, we're going to be
late getting home."

Still no light.

Loft isn't sure if his front
landing gear is locked.

If it isn't,
landing could be disastrous.

Tower, this is Eastern 401.

Looks like we're going
to have to circle.

We don't have a light
on our nose gear yet.

Eastern 401, heavy, roger.

Pull up climb
straight ahead to 2,000.

Go back to
approach control, 1-28-6.

You want me to
test the lights or not?

Yeah. Check it.

Flight Engineer Repo
performs a test

nicknamed the Christmas tree.

It lights up every
warning light in the cockpit

to see if the bulbs
are working.

The nose gear indicator light
fails the test.

The bulb
is probably burned out.

But there's a slim chance
of a double failure.

Both the light bulb
and the landing gear
could be broken.

Bob, could you
just jiggle the light?

But the troublesome bulb
is out of the captain's reach.

On the ground,
Air Traffic Control
directs Flight 401

to climb to 2,000 feet...

and circle away from the airport
until the problem is solved.

- You want me to fly it, Bob?
- Uh...

Uh, what frequency
did he want us on, Bert?

- 1-28-6.
- I'll talk to him.

It's right above
that red one, isn't it?

Yeah, I can't
get at it from here.

Wow.

Yeah. I can't make it
pull out either.

It's a moonless night.

As the plane
veers away from Miami,

there's total darkness outside.

All of a sudden
it turned pitch dark again.

And that means
we were going back out west

towards the Everglades.

Co-Pilot Stockstill
is flying the plane,

but Captain Loft needs his help
to solve the problem.

- Put the autopilot on here.
- All right.

The TriStar
is equipped

with the most sophisticated
autopilot in history.

It actually has the ability
to land the plane on its own.

Stockstill programs it
to fly at 2,000 feet.

Now, see if you can
get that light out.

Ah-ha!

The light
is finally removed.

Richard Pragluski
is an aviation engineer.

He takes this flight regularly

and can tell that
the plane is experiencing
technical problems.

He was heading out
towards the Everglades.

I knew there was something
wrong with the plane.

Because if if you have a delay,
they'll circle the plane.

The irritating problem
isn't getting better.

Now, Stockstill can't get
the light back in.

Now, push the switch
just forward.

Okay.
You got it sideways there.

Eastern 401, turn left,
heading 3-0-0.

Okay, 3-0-0, Eastern 401.

Hey. Hey, get down there

and see if that damn
nose wheel is down.

The electronics bay
on the plane

is underneath the cockpit.

The room, nicknamed
the Hell Hole,

is a unique feature
on wide-bodied jets.

The front landing gear mechanism
can be seen from there.

You got a handkerchief
or something?

So I can get a little better
grip on this?

Pull down
and turn to your right.

Anything I can do it with?

Now turn
to your left one time.

Get down there and see
if that damn thing...

This won't come out, Bob.

If I had a pair of pliers,
I could cushion it with
that Kleenex.

I can give you
a pair of pliers.

But if you force it,
you'll break it.

- Just believe me.
- To hell with it.

To hell with this!

Get down and see
if we're lined up with
that red line.

That's all we care.

Screwing around with a...

20-cent piece
of light equipment...

On this plane.

As the crew
struggles to fix the problem,

in the cabin, Richard Pragluski

sees something peculiar
out of his window.

I could see the tower
to my right in the distance,

and it looked like we were going
into a glide path...

which I found very strange.

Pragluski has noticed
something the pilots haven't.

The plane is
getting closer and closer
to the swamp below.

Eastern Airlines Flight 401

is flying over
the Florida Everglades.

Below it, nothing
but a dark, deserted swamp.

To passenger Richard Pragluski,

something doesn't seem right.

I felt it kind of strange

that they hadn't made
any announcements.

But again, he was still
fairly high off the ground...

and I figured they would
come out and tell us that

when they were
going to make the landing,

so I wasn't overly concerned.

Put it in the wrong way, huh?

Looks square to me.

Can't you get the hole lined up?

I don't know what the hell's
holding that damn thing
in there.

It's always something.

We could've made schedule.

Without a green light,
they still don't know

if their landing gear is locked.

Flight Engineer, Don Repo

is now in the belly
of the plane.

There's a viewing window
in the Hell Hole,

which should let him see

if the front wheels
are locked in place.

Damn.

- I don't see it down there.
- Eh?

- I don't see it.
- It's not lined up?

I can't see it. It's pitch dark,

and I throw the little light
and get nothing.

- Wheel well lights on?
- Pardon?

Wheel well lights on?

Captain Loft
has forgotten to turn on
lights outside the plane

that illuminate
the landing gear.

Now try it.

97-37-0-0-7-4.

At Miami International,

Controller Charlie Johnson
has just finished dealing

with another troubled jet.

National 607 has landed
without incident.

Fire trucks were deployed,
but they weren't used.

He notices
that Eastern Airlines Flight 401

seems to have dropped
from 2,000 feet to 900.

But he's not overly concerned.

It's not unusual
to get false readings

for several radar sweeps
in a row.

Eastern 401...

how are things
coming along out there?

Okay, we'd like to turn around
and come...

come back in.

Captain Loft believes
that he'll soon get confirmation

that his gear is locked.

He wants to return
to the airport.

Eastern 401,
turn left, heading...

1-8-0.

The plane is heading west,
away from the airport.

It will take several minutes
to get lined up for the landing.

Deep in the Everglades,

Bob Marquis is hunting frogs
with a friend.

Eastern Airlines
Flight 401 roars past.

I just saw the lights blinking

across the sky,
and it was so black.

There was no horizon
in the West, and...

you couldn't tell
how high the plane was.

Suddenly, the pilots make
an alarming observation.

We did something
to the altitude.

- What?
- We're still at 2,000, right?

Hey, hey, what's happening here?

I see the lights
in the cabin

just flickering on and off,

and then I heard a noise.

There was a violent, I mean,
a violent whipping sensation.

And then all of a sudden,
all hell broke loose.

Charlie Johnson notices
that Flight 401's altitude

now reads as
coastal or sea level.

Eastern 401,

I've lost you
on the radar there,
your transponder.

What's your altitude now?

There's no response
from Eastern 401.

Another plane
makes a disturbing report.

Miami Approach,
this is National 611.

We just saw a big flash.
It looked like it came out west.

Don't know what it means,
but wanted to let you know.

In a dark, remote swamp,

those who survived the crash
find themselves in a nightmare.

Bob Marquis races
towards the site of the crash.

Oh, I was going
as fast as I could.

It took me about
15 minutes, I think,

to get to the crash site.

Remarkably,
Richard Pragluski is alive.

I knew
I was badly injured

because I could see my clothes
hanging from my body.

I had almost no clothes
on the upper half of my body

and I could see
skin coming down my arms.

And I also knew that
when you're in shock,
you feel no pain.

So I knew I really was
seriously injured.

And I started thinking...

I said, "Well, you know,
the pain will come later.

"But how do I keep calm

"and get out of there because
the longer I'm in that swamp

"in the condition I'm in,
the more danger I'm in."

When the plane crashed,

a huge fireball
tore through the cabin.

I remember that fire
coming to my face.

I remember the flash.

I remember
that I tried breathing.

I could not get my breath.

Of course, the fire took
all the oxygen out of the air.

And that's
the last thing I remember

until I got up
in the swamp itself.

Ron Infantino
was knocked out by the crash.

He wakes up in the swamp.

So I was thrown quite a bit.

And I was away from
everybody else.

Nobody was even near me.

Lilly.

Lilly.

He's badly wounded.

His new wife, Lilly,
was sitting next to him,

but now she's
nowhere to be seen.

Swamp water doused
the initial flames.

But 20,000 kg of jet fuel
has now leaked into the swamp.

A single spark
could start a deadly blaze.

No one light a match.

We're covered in jet fuel.

What a sad thing
to come through that crash...

and then have somebody
do something stupid

like strike a match
and have us all just blow up.

That was the real fear.

Hoping to help
the survivors,

Bob Marquis
jumps into the swamp.

He immediately feels the sting
of the jet fuel on his skin.

It burnt my legs,

and I had to treat my legs
for burns for about a week.

Marquis quickly spots a survivor

who's in grave danger.

The badly wounded man
is still strapped to his seat.

He's on the verge of drowning.

His head kept
dropping down in the water.

He came up and he said
"Help me.

"I can't hold my head up
much longer,"

and then dropped back down
in the water.

So I helped him,
I pulled him up.

Don't worry. I gotcha. I gotcha.

Bob Marquis
saves dozens of lives,

preventing many people
from drowning.

Isolated from
the other survivors
and unable to move,

Ron Infantino
now has a new reason
to fear for his life.

After a while,
the alligators and the snakes,

you could hear them
in the weeds...

coming by. And you could hear
the croaking of the alligators,

because they
started to come back
to their natural habitat.

And as far as I'm concerned,

if a 'gator came up to me
or a snake,

I was dead meat because
I couldn't defend myself at all.

And then I heard
Christmas caroling.

♪ Silent night

♪ Silent night

♪ Holy night

♪ All is calm... ♪

To rally
the survivors' spirits,

Trudy Smith and others
sing Christmas carols.

♪ Round yon virgin... ♪

We knew instinctively

that we weren't going
to get out of there in a hurry

because nobody knew
where we were.

In the middle of the swamp,
midnight...

So what else
are you going to do?

♪ Sleep in heavenly peace ♪

And you've got
to picture us this, I mean,

in the dark, at night,

all you hear is singing
in the wilderness.

♪ Sleep in heavenly peace ♪

It was like being on the Titanic
going down, type of thing,
you know?

It was unbelievable.

Within minutes,
Coast Guard helicopters

are sent out
in search of the crash site.

But in the pitch black night,
they can't find the wreckage.

Bob Marquis tries to signal
the distant helicopters.

But I could see
where they were and they were
going the wrong direction.

nd I just waved the light
at them until I saw them turn

and head back towards us.

It seemed like
we'd been in the swamps

for a really long time
when we heard...

a helicopter and...

it was such a welcoming sound

because that means somebody
knows that you're there.

Less than
half an hour after the crash,

the Coast Guard arrives.

But the nearest landing site
is 100 meters away.

Marquis rushes
to meet the helicopter

and ferry the rescuers
back to the crash site.

His first passenger
is rescue worker Don Schneck.

I made it
to the airboat.

He asked me,
"Where are all the rescuers?"

And I said,
"This is it. Let's go."

He took us out into the Glades

to a point where he said,
"This is as far as I want to go

"because I don't want
to run anybody over."

And he said, "There are bodies
out here all over the place."

Don Schneck
starts searching for survivors.

I approached the...

large object that I had seen
at a small distance

and realized it was the
nose section of the aircraft.

He's amazed
to discover that

Captain Bob Loft
has survived the crash.

He was in bad shape.

He had lacerations,
so I knew he had broken ribs.

I could tell he was in shock.

So I calmed him down, told him
I'm the only one here right now,

but they're coming.

Just hang in there.

I'm going to die.

He told me that,

and I argued with him.

Anything to keep his...

anything going.

It just made me feel
so inadequate.

Because it was just me.

I turned around and I looked
back towards Miami

and thinking,

"Where in the heck
is everybody?"

And at that time when I looked,

I must have seen
50 lights coming.

And I went, "Thank God."

First Officer
Burt Stockstill

was killed during the crash.

Captain Bob Loft
soon dies at the scene.

Angelo Donadeo and Don Repo

have survived
and are taken to hospital.

In all, 77 people
survived the crash.

99 people are killed.

By dawn, all the wounded
have been transported
to Miami hospitals.

Ron Infantino is one of the many
who are struggling to survive.

A priest comes over,
and does the last rites.

So right then I knew
I was in bad shape.

And it's a scary thought.

And of course, at that time,

I'm still asking for Lilly,
you know?

Have they seen her?

It was such a madhouse there
that night, you could imagine.

Lilly.

Where's Lilly?

The crash is headline news
around the world.

It's the first ever
jumbo jet crash,

and it produces the largest
number of deaths

in US civil aviation history.

There's tremendous pressure
on investigators

from the National Transportation
Safety Board

to find out what happened.

It was
an enormous puzzle,

because this was the newest,
the most sophisticated,

the best of the airliners,

that apparently was
in perfect working condition.

So the NTSB perceived
that this was going to be

a very long investigation

that involved multi-level
potential problems.

The crash site itself
is an important clue

for investigators
arriving at the scene.

The trail of debris
is enormously long.

That suggests that the plane
hit the swamp

almost in the same
nose-on position

as it would while landing
at an airport.

Its descent was clearly
slow and gradual.

NTSB investigators
have documented

the final settings
for many of the instruments
in the cockpit.

They discover that the autopilot

was set to maintain
an altitude of 2,000 feet.

So why didn't it?

Maintenance expert,
Angelo Donadeo is interviewed.

All he can tell investigators
is the crew was trying to fix

a light bulb before the crash.

Within days, the plane's
two black boxes are recovered.

Investigators hope
they will provide some answers.

Before they can
extract the data...

Flight Engineer,
Don Repo dies in hospital.

Ron Infantino is given some
devastating news of his own.

The body of his wife, Lilly,

has been found
under the plane's wing.

She's just a wonderful person.

I was 27 years old
and she was the same age, and...

she was actually my first love.

Infantino is haunted by the memory

of switching seats with Lilly
just before the crash.

They had swapped seats
quite casually earlier,

during the flight,
when she had gotten up

to go to the restroom.

She was thrown into the swamp
and drowned, and he lived.

The swamp
proves both a blessing

and a curse for survivors.

That's what saved
most of the lives, actually.

Because the plane broke up,
it absorbed all the energy.

You know, the mud absorbed it
and the plane just dispersed.

The swamp water
is so thick with mud,

it also clogs survivors' wounds,

preventing many
from bleeding to death.

But there's a deadly new threat
facing some survivors.

Their wounds
have become infected,

contaminated by
a deadly organism

found in the black mud
of the Everglades.

The organism
produces an infection
called gas gangrene.

It can kill a person
in just two days.

Gas gangrene
can only be destroyed
in a hyperbaric chamber.

It's a pressurized container

that gets filled with
high levels of oxygen.

The oxygen gets forced
into the wounds
and kills the bacteria.

Eight of the surviving
passengers are infected
with gas gangrene.

Hyperbaric chambers
must be found for all of them.

The only other way
to save patients

is to amputate
the infected limb.

Ron Infantino's arm
is badly infected.

Doctor came in and says,
"Well, we've diagnosed it
as gas gangrene."

He says, "We've got to take
your arm off immediately,

"or have to get you
to a hyperbaric chamber."

"Unfortunately," he says,
"the only hyperbaric chambers

"at Mercy Hospital, that's all
been taken advantage of."

Unless doctors
can find a chamber soon,

Infantino will lose his arm.

While doctors search
for a chamber for Ron Infantino,

investigators examine
what's left of the plane.

They test its flight controls,
engines, instruments,

and its electrical
and hydraulic systems.

The plane was
virtually new.

It was in perfect condition.

There was no
mechanical reason found

that would have
caused the crash.

In fact,
some parts of the plane
are in such good condition,

that the NTSB gives them
back to Eastern Airlines

so they can be installed
on other airplanes in its fleet.

An unused hyperbaric chamber
is finally found

for Ron Infantino
at a Navy base in Panama City.

He spends 40 hours
in the chamber.

The pressurized oxygen
kills the bacteria

and saves his life.

Gentlemen, we have three causes
of the crash to explore.

A state of the art
jetliner plunged 2,000 feet

without the crew noticing.

Investigators know the plane
was mechanically sound.

They now focus
on other possible reasons
for the unobserved descent.

At the top of the list

is "subtle incapacitation
of the pilot."

The autopsy of Captain Bob Loft

has yielded
a gruesome discovery.

Captain Loft had a large,
undetected tumor

growing in his brain.

It pressed
into the part of his brain
responsible for sight.

Medical records reveal that
between the ages of 50 and 52,

vision in the pilot's left eye
had rapidly deteriorated.

Doctors believe that the captain

may have had
reduced peripheral vision.

The tumor could have
created blind spots.

As his attention became focused
on the malfunctioning light,

he may not have noticed
dire warnings on his altimeter.

Investigators consider
a stunning possibility.

An undetected medical ailment

may have contributed
to the world's first
jumbo jet disaster.

We're
still at 2,000, right?

Hey, hey, what's happening here?

Investigators learn what they can
about Captain Bob Loft.

They interview people
who knew him

and pore over
his medical records.

The investigators heard
that Captain Loft,

so far as his
family and friends knew,

had perfect vision.

He was an expert marksman.

He shot doves particularly,
which are a very small target.

Loft's records show that he had
recently passed a medical

in which he was issued
corrective glasses for flying.

But the evidence
doesn't support the notion

that his vision
was dangerously impaired.

He was 55 years old

and who gets to be 55
without wearing reading glasses?

Not many.

Dr. Joe Davis,
who did the autopsy, told me

that even though the tumor was
pressing on areas of his brain
that control vision,

there was no reason to think

that it had yet begun
to affect it.

He felt it had nothing to do
with the accident.

Investigators still don't know

why Flight 401
started descending
in the first place.

- Put the autopilot on here.
- All right.

Could the autopilot,

which was supposed
to keep the plane at 2,000 feet
have malfunctioned?

The plane's computers
survived the crash.

They're removed and examined.

Eleven days after the crash,
the autopilot computers

are installed
on another TriStar.

It flies the same route
as Flight 401.

The autopilot
holds that plane at 2,000 feet.

So why hadn't it
on the night of the accident?

Investigators will need
to explore other leads
to find out.

There's another question
that dogs this investigation.

Why didn't the Miami Tower
alert the crew

that their plane was dropping?

The world's first
three-dimensional radar

had recently
been installed there.

It meant that
Controller, Charlie Johnson

knew the location, altitude
and speed of Flight 401.

National 607
is declaring an emergency...

Investigators study recordings
of Johnson's conversations...

Fire and ambulance
sent out right away.

...and discover that
on the night of the crash

it was another plane that
demanded most of his attention.

National Airlines Flight 607
was coming in to land

just ahead of Flight 401.

That flight was having
its own landing gear problems.

Runway 9 will need
Fire and ambulances
sent out right away.

As he focused
on the emergency, Johnson
handed flight 401

over to another controller.

But just as National 607 came in
for its emergency landing,

the other controller
phoned Johnson

and handed Flight 401
back to him.

Eastern 401,
Heavy's coming back to you.

Unsafe nose gear.

Uh, no.

At the time, Flight 401
was already over the swamp.

Johnson had
five other planes to monitor.

He was also dealing with
the aftermath

of his emergency landing.

National 607 has landed
without incident.
Trucks were deployed...

That's when he noticed
that Flight 401's altitude

had dropped to 900 feet.

The way the radars work,

still, to a certain extent
this happens,

but back then it was even worse.

"Coast Mode" was
a very well-known phenomena.

I mean,
you might lose the target
for two or three minutes

in terms of the altitude
reporting part of it,

and it goes and gives you
some weird altitude.

And then, boom, it's
right back where it should be.

But the controller
didn't stop there,

and this was
really to his credit.

Johnson decided
to make contact with Flight 401.

Eastern 401,
how are things coming along?

Okay, we'd like to turn around
and come back in.

Eastern 401,
turn left, heading 1-8-0.

After that
brief exchange, Johnson assumed
there was no problem.

Eastern 401...

How are things coming along?

Okay...

Investigators concluded that at that moment,

Controller Johnson
was the only one

who could see that
the plane was losing altitude.

Why hadn't he
passed that information
along to the crew?

US Government
regulations for air traffic
controllers provide the answer.

It simply wasn't
part of a controller's job.

At the time of the crash,

the FAA required
approach controllers

to maintain a separation
of the airplanes.

It did not give them a duty

to maintain the altitude
of the airliner

with regard to the ground.

Now investigators
try to determine

how the plane's
own warning system

failed to alert pilots
to their growing danger.

The L-1011 is equipped
with an alarm that sounds

if the plane goes 250 feet,

above or below the altitude
selected by the pilots.

As investigators replay
the tape from the black box,

they clearly hear that alarm
sounding in the cockpit

as the plane
passed through 1,750 ft.

Did you hear that?

How'd they miss it?

Investigators closely examine
the cockpit transcript

to try to understand
how the alarm was missed.

- Put it in the wrong way, huh?
- Look's square to me.

Investigators noticed
that just before the alarm
sounded in the cockpit,

warning the crew
that the plane is too low,

both pilots were
completely absorbed

with the landing gear light.

The conversation
also tells investigators

that the flight engineer
was below in the hell hole.

The warning chime
came out of a speaker
at his work station.

Investigators begin to realize
that the two pilots

were unable to hear
a perfectly audible alarm,

because they were focused
so entirely on solving
another problem.

Their chime,
which is clearly heard
on the cockpit voice recorder,

was not registering
in the minds of all the men
on that flight deck.

Not because they weren't
trying to pay attention,

but because they were
tunneled in on this one problem.

That's what we do as humans.

Investigators now focus on crew distraction

as a likely cause
of this accident.

Several instruments
would have displayed
the decreasing altitude.

The major question was,
why were the pilots
so preoccupied

that they were not looking
at the instrument panel?

They had to look
at the human beings.

They had to look
at the interaction.

They had to look at why no one

was paying attention
to the airplane

as it began to creep
out of 2,000 feet.

That was scary territory
in 1972.

Investigators interview a number of pilots

and make a startling discovery.

Pilots admitted
that they placed a lot of trust

in the modern new autopilots
flying their planes.

They may have become overly
dependent on the technology.

- Put the autopilot on here.
- Okay.

Investigators suspect
that the Eastern crew was
so confident in their autopilot

that they didn't monitor
their instruments

as closely
as they should have.

Now see if you can get
that light out.

Once the autopilot was on,

none of the pilots
paid attention

to actually flying the plane.

We've still got to find out...

why that plane went down.

Investigators still haven't determined

the most crucial piece
of information.

If the autopilot was working,

why did the plane
dive into the swamp?

- We did
something to the altitude?
- What?

The pilots'
conversation clearly shows

that they hadn't
deliberately started descending.

We're still at 2,000, right?

Hey, hey, what's happening here?

So why did it happen?

The answer comes
in a dramatic form

when the NTSB conducts
a public hearing in Miami

two months after the crash.

Before the hearing,
an Eastern Airlines pilot

named Daniel Gellert
wrote the chairman of the NTSB,

offering to testify
on his own behalf.

He had flown the TriStar L-1011
and noticed some abnormalities.

The world of airline piloting
in 1972 was hostile to a pilot

going around his chief pilot
and his airline

and raising his hand
to the NTSB and saying,
"Hey, wait a minute,

"I've had an experience, too,"

because airlines
were far more insular
than they are today.

Gellert tells the hearing

that during a recent flight
on a TriStar,

he had accidentally dropped
a map on the cockpit floor.

As he bent down to pick it up,
he nudged his control column.

He noticed immediately
that the plane's autopilot
had been affected.

The part of the autopilot
controlling altitude

had been turned off.

The NTSB discovers
that Gellert's experience
is shared by others.

In fact, 17 days
after the accident,

Eastern Airlines tacked a notice
onto a company bulletin board

and also mailed it
to all of its TriStar pilots.

The bulletin warned against
accidentally bumping
the control wheel.

One of the things that
we built into

all the modern jetliners
and airliners,

is simply a pressure switch.

So if you if you need
to take over right now,

you don't want to be
wasting time down here

on the panel
turning the autopilot off.

You just grab it
and the autopilot goes away.

The Flight Data Recorder

tells investigators
the precise moment

that the plane's altitude
started to drop.

It was 11:37 and 8 seconds.

By studying
the voice recorder transcript,

investigators can tell
what was happening

in the cockpit
at that exact time.

Hey, hey, get down there

and see if that
damn nose wheel is down.

By turning to speak
to the flight engineer,

investigators believe
that Captain Loft
bumped his control wheel.

He did it with
just enough pressure

to disengage that part
of the autopilot

that had been controlling
the plane's altitude.

Without anyone realizing it,

a simple nudge
of the control wheel
started a gradual descent.

On a dark, moonless night,
the pilots had no visual cues

to tell them they were falling.

It was determined
that occasionally,

with just a soft bump,

an autopilot
had been disengaged.

So before the crash, it wasn't
part of their training.

A training director
for Eastern Airlines

eventually reveals that
before the Everglades crash,

pilots were never taught
that a bump could disengage
the autopilot.

The NTSB comes
to a sobering conclusion.

The plane crash
was due to pilot error.

The crew was distracted.

They mishandled the plane's
sophisticated automation,

and they hadn't been
properly trained.

Eastern 401
was a pivotal accident
in aviation safety history

and we really didn't know this
for about 10 or 15 years

in terms of the true import
of what it did to us.

In focusing
our attention on the fact

that the way we
handle things in a cockpit,

was not only not correct,
but it was dangerous.

Investigators also make a disheartening find.

When the nose gear indicator
light assembly is examined,

they discover that a light
bulb inside is burnt out.

Go ahead and throw 'em out.

Flight 401's
landing gear was locked.

The plane could have landed.

The only piece of the plane
that failed

was a $12 light bulb.

The full legacy of Flight 401
will take years to unfold.

It will ultimately alter
how pilots are trained,

and how accidents
are investigated.

But first, the tale
of Eastern Airlines Flight 401

will take a very bizarre twist.

As far as the NTSB is concerned,

the investigation into
Eastern Airlines Flight 401
is over.

Several recommendations
were laid out

to prevent similar accidents.

Those include new regulations

instructing air traffic controllers
to warn pilots

when they're getting
too close to the ground.

But four years later,
it became clear

there was a bigger lesson
to be learned from
Eastern Airlines Flight 401.

In 1977, two 747s collided

on a runway in Tenerife
on the Canary Islands.

It was the deadliest
plane crash of all time.

And we're now at take-off.

1736, report when runway clear.

That accident was caused

by a string of miscommunications
in the cock pit.

Investigators establish that 70% of crashes

were due to pilot error.

Both of these accidents,

Tenerife and 401,

what you see
is crews dedicated to
doing a good job

but not realizing
that they're human,

not realizing how many things
can go wrong

if you don't appreciate
how human beings fail.

By the late 1970s,
NASA began to explore

a new behavioral science
designed to reduce pilot error.

And pilots be on the lookout
for any different behavior...

It's called
crew resource management
or CRM.

Crew resource management
simply means that

we're not going to have
one pilot leading

and everybody else following.

It means that the captain
has to be a leader,

and listen to and interact with
his subordinate crew members

and the subordinate crew members
have to speak up.

Decades later,
Flight 401 is taught

in aviation courses
around the world

as a textbook example
of poor CRM.

The problem was that we did not
teach Bob Loft or Stockstill

or any of these folks
at the time,

that when something goes wrong,

the commander's
first responsibility

is to maintain aircraft control

and either do it himself
or assign somebody.

We're up to 2,000.

You want me to fly it, Bob?

Uh, what frequency
did he want us on, Bert?

- 1-28-6.
- I'll talk to him.

On Flight 401,

Captain Loft did not clarify
who should be doing what.

Instead, all three crew members
worked on the same problem.

Bob, could you
just jiggle the light?

It's gotta come out a little bit
and then snap in.

With the co-pilot flying,
the captain commanding
from the left seat,

you already had
cross purposes here.

It's right above that red one.

Yeah, I can't get at it
from here.

And you had
a light quadrant

the captain couldn't quite reach

and the co-pilot could,
but the co-pilot
is flying the airplane.

You've just set them up...

for a major problem.

And guess what? Systemically,
we never taught them what to do.

Today, CRM
also trains flight crews

not to be intimidated
by one crew member's mood.

You got a handkerchief
or something

so I can get a little better
grip on this?

Anything I can do it with?

Get down there
and see if that damn thing...

This won't come out, Bob.

So if the leader
is having a problem,

in this case, with a light bulb.

Okay,
you got it sideways then.

And he's
really irritated at it,

and the co-pilot has now
made the problem worse,

co-pilot's not going to be happy
with himself over that.

I don't know what the hell
is holding that
damn thing in there.

Don Repo
is not going to be happy
that he got downstairs

to try to solve the problem
and he couldn't see anything,

and he's got to come up
and report that.

I don't see it.

They're all tense.

- It's not lined up?
- I can't see it.

And when you get
a crew like that tense,

it's not time to turn around
to the captain

and say,
"You shouldn't have done that."

But this is part
of the evolution of what
air safety has now learned

and been able to teach
so many other industries.

The enduring legacy
of Flight 401

is the delegation of specific
tasks in the cockpit.

The result is fewer crashes.

There was also much more
bizarre fallout from this crash.

For a while, it seemed
that the crew of Flight 401

was haunting other
Eastern Airlines flights.

For some time after the crash,

flight crews
and passengers report

seeing lifelike apparitions
of Flight 401's crew.

Many of the ghost sightings
were on aircraft

fitted with recovered parts
from Flight 401.

The ghost stories
spread quickly.

One book devoted
entirely to those stories

suggests that
the ghosts were there

to protect passengers and crew
from further mishap.

The official reaction
at Eastern Airlines

to these ghost stories

was one of,
absolute eye rolling
denial in public,

and in private,
a certain bit of panic.

There are
so many ghost sightings

that eventually,
Eastern Airlines removes
Flight 401's

cannibalized plane parts
from all other aircraft.

None of those
who survived the crash

will ever forget the horror
they witnessed

in the Everglades that night.

And 35 years after their ordeal,

many of them
returned to that swamp

to finally recognize
the heroic efforts
of Bob Marquis.

We're here today to recognize

and to say thank you...

Many of the ones who lived,

lived because Robert Marquis
was there with his airboat.

He saw them drowning
and decided that the thing
that he could do

would be to save
the ones he could save.

Robert Marquis
was the kind of person

that I hope that all of us

ultimately would be
if we were confronted
with that sort of thing.

But he drew on
some special courage
to do what he did.

He was one of the true
heroes of the crash.