Original subtitles

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.