Distraction in the Cockpit – Eastern Air 401: The Accident that Changed Aviation

On the evening of December 29, 1972, Eastern Air 401 (EA401) was on a routine flight from New York to Miami. Despite EA401 flying one of the most advanced aircraft at the time (the Lockheed L-1011), it crashed in the Florida Everglades killing 101 of its 176 passengers. Drawing from various first-hand accounts (cockpit voice recorder) and secondary evidence (news reports and online sources) of the tragedy, this teaching case provides a detailed account of the key events that took place leading up to the accident. The case describes how the pilots on EA401 were confronted with a simple scenario, a landing gear bulb not working in the cockpit, and through the distraction that ensued made a series of errors. Through many of the quotes in the text, readers gain an understanding of the impressions and perceptions of the pilots, including how they felt about many of the critical decisions and incidents during the last minutes of the flight. The case concludes by highlighting the main findings of the NTSB report. This case has five primary objectives. 1. Identify the problems that contributed to the tragedy of Eastern Air 401. 2. Reflect on limitations of the investigation’s conclusions. 3. Develop performance evaluation methods of flight crewmembers. 4. Recognize the benefits and drawbacks with CRM training design and the aviation industry. 5. Discuss how distraction leads to a degradation of situational awareness. Depending on individual course objectives, this case can take one or two days to debrief. Specifically, if this case is used in a strategy course, most of the case questions could be discussed in one day. However, if this case is used in a capstone Human Resource Management, Organizational Behavior, or MBA type course on teams and team training and performance, a second day could be used to develop documentation outlining training design or performance evaluation designs. The authors suggest that this works particularly well in an MBA setting, as students with work experience can see the links between the mistakes made by the crew members and their own workplaces. For the purpose of this note, the authors’ commentary will focus on the three-hour class structure for the teaching plan.