Article from the New York Times about the incident.
NTSB official hearing results.
This is the story of how a commercial jetliner was able to avoid utter disaster over the ocean and safely land in Miami, all 172 passengers and crew along with it.
The story is one that is close to home for me as it features my grandfather, Captain Steve C. Thompson, as the main character in this near tragedy. He was a man I grew up with in the same house for more than 16 years and was a father to me.
The reason I am choosing to tell this story is because although I'm heavily biased by my own family's involvement, it changed the way that the FAA, Airlines and aviation travel is conducted today. Seeing that millions of people fly every day, most without any concerns whatsoever, I thoughtit would be beneficial to hear the story about how it is safe now and what it took to get there.
Although this is a slight deviation in the normal American history episodes we do it still plays an integral part in the nation's story. We hope you enjoy.
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What follows is a brief outline of the event and some technical info:
After the airplane landed, fire erupted in the No. 1 engine, and smoke emerged from the No. 3 engine. The flight crew applied internal fire suppressants in these engines, while the crash/fire/rescue (CFR) unit at the airport used 300 gallons of water and 20 gallons of light water 4 to extinguish the fire. The airport CFR units had been alerted and six vehicles, including two Oshkosh T12, 3,000-gallon crash trucks, and 16 firefighters, were positioned on the adjacent taxiway at the approach end of runway 27L and at the midpoint of the runway when the airplane landed. Within 60 seconds, the vehicles were in position at the airplane.
1.1 History of the Flight
On May 5, 1983, Eastern Air Lines, Inc., Flight 855, a Lockheed L-1011, N334EA, was a regularly scheduled passenger flight from Miami, Florida, to Nassau, New Providence Island, Bahamas. The flightcrew arrived well before the scheduled takeoff time and conducted all prescribed preflight activities. The captain recalled that the forecast weather conditions for the arrival at Nassau called for scattered rain showers. At 0900,1 the weather conditions at Nassau were, in part: 500 feet scattered, 1,000 feet broken, 7,000 feet overcast, visibility 4 miles with light rain and fog. Additionally, a frontal system extended north-northeast from extreme southern Florida and the Florida Keys. The weather conditions at Miami International Airport at 0900 were: ceiling 2,300 feet broken, visibility 7 miles, and no significant weather. The flight engineer performed the "walk-around" inspection of the airplane. He stated that there were no indications of oil leaks from any of the engines. He also stated that there were no abnormal engine instrument readings during engine start or the taxi-to-takeoff. At 0856, Flight 855 departed runway 27R at Miami International Airport with 162 passengers and a crew of 10 aboard. The flight was on an instrument flight rules (IFR) plan to Nassau with an estimated time en route of 37 minutes. At the time, the captain was sitting in the left cockpit seat, the check captain was sitting in the right cockpit seat, and the flight engineer was at his station at the engineer's panel. The captain and the check captain stated that the takeoff and the initial climb to Flight Level (FL) 230 were uneventful. The flight engineer stated that he monitored the activities of the captain during takeoff and scanned the flight engineer's panel for abnormal indications; all engine instrument readings were normal. At 1,000 feet,2 the flight engineer turned back to his panel to regulate the cabin pressurization and the cabin cooling. The flight engineer stated that he also checked the electrical system and the engine instruments, and that, as the airplane passed through 1,500 feet, he called Eastern Air Lines at Miami to report the departure time. He then completed the climb checklist, called the Eastern Air Lines Miami Technical Center to establish contact with the flight dispatcher, and continued to scan the engine instruments. The flight engineer stated that from takeoff until the airplane was level at FL 230 the oil quantity gauges did not fluctuate, and that all three indicators were indicating about 18 quarts (full indication is 21 quarts). About 0908:14, Flight 855 leveled at FL 230. About 0910, the flight was cleared to descend to 9,000 feet, and the captain began the descent. At 0911:17, the flight engineer contacted Nassau approach control and reported descending through FL 200, 70 miles from Nassau. Nassau approach control reported the weather as ceiling 1,000 feet broken and visibility 5 miles, ceilings to the east and south as 500 to 800 feet, and thunderstorms to the north. Nassau approach control informed Flight 855 that it was following a light twin-engine airplane which was about 30 miles ahead of it. The flight engineer then prepared the landing card data for landing at Nassau and read the descent and in-range checklist in preparation for landing. He stated that he also received requests from the cabin attendants for routine items involving the passengers and the arrival at Nassau. The flight engineer stated that he did not scan his panel or the oil quantity or pressure gages for about 5 minutes because he was preparing the landing data information. During that time, he sat at a small desk in front of the engineer's panel. The oil pressure and quantity gages were at eye level. As Flight 855 descended through 15,000 feet, the captain informed the flight engineer that the low oil pressure warning light was on for the No. 2 engine. The flight engineer stated that at this point he had finished the in range call and the landing data card. He looked at the oil quantity and pressure gages and saw that Nos. 1 and 3 indicated about 15 quarts with the oil pressure in the "green" or acceptable range. However, the No. 2 engine indicated a quantity of 8 quarts, and the pressure was fluctuating between 15 psi and 25 psi. The flight engineer was not concerned with the quantity indications, since he stated that he expected to see fluctuations of up to 3 quarts on either side of 18 quarts. However, he had never had an oil pressure problem with the L-1011. The flight engineer then advised the captain that the oil pressure on the No. 2 engine was fluctuating between 15 and 25 psi, that the minimum pressure required for normal engine operation was 30 psi, and that the oil quantity gage for the engine was reading 8 quarts while the other two engines indicated about 15 quarts. The captain ordered the flight engineer to shut down the No. 2 engine, and the captain started the auxiliary power unit (APU). At 0915:26, while at 12,300 feet, the captain requested a clearance back to Miami; the check captain concurred in the request. At the time, the airplane was about 50 miles from Nassau. The captain later stated that he elected to return to Miami rather than continue to Nassau because of the deteriorating weather conditions which had been reported at Nassau and which he had observed on airborne radar. Also, he anticipated some delay in landing at Nassau due to the nonradar environment and a light twin-engine airplane reported ahead of Flight 855, and he believed that he could land at Miami sooner than at Nassau. At 0915:48, Flight 855 was cleared to make a 180° turn and to maintain 12,000 feet. At 0918:11, Flight 855 contacted Miami Air Route Traffic Control Center (ARTCC), and at 0918:36, the flight was cleared to climb to FL 200. During this time the flight engineer completed the engine shutdown checklist and the secondary items on the emergency checklist. He said that these tasks required about 4 minutes to complete, so he was not constantly monitoring the indications on engines Nos. 1 and 3. NextPage LivePublish Page 1 of 2 http://hfskyway.faa.gov/NTSB/lpext.dll/NTSB/23bc/23c7/23c8?f=templates&fn=docu... 2/11/2005 As the airplane climbed through 15,000 feet, the low oil pressure light for the No. 3 engine illuminated, followed by illumination of the light for the No. 1 engine. At that time, the oil quantity gages for all three engines read zero. At 0923:15, with the airplane level at 16,000 feet, Flight 855 informed Miami ARTCC of the engine gage readings but indicated that "we believe it to be faulty indications since the chance of all three engines having zero oil pressure and zero quantity is almost nil." The flight engineer then contacted the Miami Eastern Air Lines maintenance personnel to determine if there was a common electrical source which could affect the engine instruments. The captain stated that he assumed that the problem of low oil pressure and zero oil quantity for the three engines was a faulty indicator problem since the likelihood of simultaneous oil exhaustion in all three engines was "one in millions I would think." During this time, the Miami Technical Center called back to Flight 855 to say that the No. 2 AC bus was the common power source for the oil quantity instruments. The flight engineer checked the appropriate circuit breaker and found no discrepancies. At 0928:20, the No. 3 engine failed. The airplane, which was about 80 miles from Miami, began a gradual descent. The flightcrew stated that they realized at this point that the indications of zero oil pressure and quantity were correct and were not the result of a gage problem. At 0929:15, Miami ARTCC cleared Flight 855 to descend to any altitude required and to fly directly to Miami International Airport for a landing on runway 27L. The flight engineer called the senior flight attendant to the cockpit and instructed her to prepare the cabin for a ditching. The senior flight attendant, in turn, briefed the other flight attendants, who then began preditching preparations. The flightcrew attempted to restart the No. 2 engine but was not successful; and at 0933:20, the No. 1 engine failed. The airplane was about 12,000 feet above the ocean. The rate of descent, which was about 600 feet per minute (fpm) with one engine operating, increased to about 1,600 fpm with no engines operating. The indicated airspeed remained about 225 knots throughout the descent. The APU provided hydraulic pressure and electrical power to the airplane after all engines stopped operating. As a result, the flightcrew had the ability to operate all the controls of the airplane despite the total loss of engine power. At 0933:38, Flight 855 advised Miami ARTCC that no engines were operating; the airplane was about 55 miles from Miami. Shortly thereafter, the flight engineer announced over the public address system that a "ditching is imminent." The senior flight attendant assumed that the airplane was about to enter the water and instructed the passengers to assume the brace position. Meanwhile, the Coast Guard and other potential rescue vessels were notified of the emergency by Miami ARTCC. The initial notification was made to Coast Guard District Headquarters at 0928:18. A Coast Guard Falconjet and a helicopter immediately departed the Coast Guard station at Opa Locka, Florida. At 0936, a helicopter and a C-130 airplane, both of which were already in flight from USCG Air Station, Clearwater, Florida, were diverted to assist Flight 855. Additionally, three more Coast Guard helicopters and another Falconjet were alerted and prepared to respond to the emergency. One Coast Guard cutter and five other patrol vessels were standing by at sea. An Air Force C-130 and a helicopter, both from Homestead Air Force Base, were alerted and were preparing to takeoff. All aircraft and surface vessels were alerted and either underway or preparing to get underway by 0944. The captain attempted to restart the No. 2 engine for a second time but was unsuccessful. He then attempted to start the Nos. 3 and 1 engines, but again was unsuccessful; simultaneously, the flightcrew was proceeding through the ditching checklist. The captain then attempted a third time to start the No. 2 engine. At 0938:18, when the airplane was at 4,000 feet and with an indicated airspeed of about 250 knots, the No. 2 engine restarted. The airplane was about 22 miles from Miami. The descent was arrested at about 3,000 feet, and at 0940:20, a gradual climb was started to 3,900 feet. At 0943, Flight 855 leveled at 3,900 feet and began the final descent for landing at Miami International Airport. The passengers and flight attendants remained in the brace position until just before landing, when the captain announced that they would land at Miami. At 0946, the airplane landed. Air traffic control reported to the captain after the airplane landed that smoke was emerging from the No. 1 engine. The captain discharged the fire bottles in the engine and the smoke stopped. He later discharged the firebottles in the No. 3 engine after smoke was reported to him by ground personnel. Because the airplane could not be taxied on the power generated by the No. 2 engine, it was towed to the gate and passengers deplaned normally at the terminal. The accident occurred during the hours of daylight.
2.2 Flightcrew Decisions
The Safety Board analyzed the decision of the captain to return to Miami rather than to continue the flight to Nassau once the No. 2 engine had been shut down because of low oil quantity and pressure. The airplane was about 50 miles from Nassau and about 110 miles from Miami when he made the decision. At that time, the other two engines were operating normally, and the airplane could be flown on two engines without a significant reduction in safety. As a result, the captain was not concerned about the capability of the airplane to fly either to Miami or Nassau; from a distance perspective, in his view, either airport could be reached without assuming additional risks and without taxing the performance capability of the airplane. The captain and the check captain stated that the decision to return to Miami was influenced by the length of time required to land the airplane from its position about 50 miles west of Nassau. The weather report the flight engineer received from Nassau at 0912 indicated a 1,000-foot ceiling, with lower ceilings to the south and east, and thunderstorms to the north. Since the instrument approach to Nassau International Airport required navigating to the southeast of the airport, the captain could expect low-level flight in IFR conditions before landing. Additionally, since Nassau had no radar coverage, he could not be given radar vectors either around the traffic which had been reported ahead of him, or directly to the airport. The last two factors would have required additional low-level flight to complete the instrument approach at Nassau International Airport. On the other hand, the captain knew that he could make a straight-in, VFR approach at Miami. The captain said that after analyzing the options available, he determined that he would be able to land in less time by returning to Miami International Airport. The Safety Board concludes that, given the information available, the captain made an appropriate decision. The captain's estimate that he could land sooner at Miami was probably correct in view of the weather conditions at Nassau. Additionally, the possibility of a missed approach existed at Nassau International Airport, while Miami weather insured a VFR landing. Finally, there was no urgent reason to attempt a two-engine nonprecision instrument approach when a less demanding VFR landing could be made in substantially the same or perhaps even a reduced timeframe. The Safety Board examined the flightcrew's analysis of the meaning of the oil quantity and pressure gage indications. The shutdown of the No. 2 engine about 0915:15, after the indications of low oil pressure and quantity, was the proper decision. The Safety Board is concerned, however, that the flight engineer had not noted the declining gage indications, especially the oil pressure, before the low oil pressure light illuminated. As a result, the captain had to call the flight engineer's attention to the flight engineers panel, instead of the flight engineer observing the oil pressure and quantity indications first. The flight engineer was occupied with his proper duties preparing for the landing at Nassau. However, by his own admission, he had not scanned the engine gages for about 5 minutes before the No. 2 low oil pressure light came on. The primary duty of the flight engineer was to monitor the engine instruments--a responsibility which should be done continuously during a flight, and not in between other duties. Additionally, his work station was directly in front of the engine instruments, which were at eye level, so a standard scan of the gages could have been done easily. Additionally, the Safety Board believes that it would have been unusual for the No. 2 engine to have indicated about 8 quarts of oil quantity at 0915 when there were indications of 15 quarts on engines Nos. 1 and 3. Only 8 minutes later, engines Nos. 1 and 3 indicated zero oil pressure and the low oil pressure lights had illuminated. These events indicate that either a rapid loss of oil from engines Nos. 1 and 3 occurred after engine No. 2 was shut down, or that there was actually less than 15 quarts of oil in engines Nos. 1 and 3 when the individual gages indicated 15 quarts. The normal fluctuations of the oil quantity gage, especially in climb and descent, may have given slightly erroneous readings to the flight engineer. However, since he said that the oil quantity gages vary up to 3 quarts, he should have been concerned that the quantity of the oil in the other engines could have been as low as 12 quarts at 0915. Once the airplane had been cleared to return to Miami and to climb to FL 200, the flight engineer was again occupied with cockpit checklist activities. He said that in the 4 or 5 minutes after the No. 2 engine was shut down, he did not notice any declining indications on engines Nos. 1 and 3 until the low oil pressure lights again illuminated. The Safety Board accepts the statement that he was occupied with the secondary items on the emergency checklist. However, once again the flight engineer allowed 4 or 5 minutes to pass without monitoring the engine instruments. As a result, the oil pressure and quantity gages on engines Nos. 1 and 3 declined to a marginal condition before the captain was advised of the situation. After the flight engineer announced that the oil quantities on all three engines were zero, the flightcrew had 5 or 6 minutes to analyze and resolve the problem before the No. 3 engine flamed out at 0928:20. The initial conclusion of all three crewmembers was that they were experiencing indicator problems with the oil pressure gages. The flightcrew's disbelief of the visual indications was because each crewmember considered the possibility of total simultaneous oil depletion on three engines as virtually nonexistent. There were other reasons why the flightcrew would have examined the situation first as an instrumentation problem. First, as each stated, the likelihood of total simultaneous oil depletion was improbable, and had never occurred on any L- 1011; second, all their previous experience would indicate a malfunction with the oil pressure and quantity indicators, since gage and indicator malfunctions are not uncommon events in commercial airplanes; and third, they were unaware NextPage LivePublish Page 1 of 2 http://hfskyway.faa.gov/NTSB/lpext.dll/NTSB/23bc/2505/2508?f=templates&fn=docu... 2/11/2005 of other incidents involving engine shutdowns due to master chip detector installation problems. Consequently, the flightcrew immediately contacted the Miami Technical Center to determine if a single power failure could cause indicator malfunctions. As the inquiry was made to the Technical Center, the flightcrew examined the engine and electrical systems in the cockpit. From a practical position, the analysis of the problem by the flightcrew was logical, and was what most pilots probably would have done if confronted by the same situation. Ideally, a pilot "should always believe his instruments." However, pilots must also analyze information to validate the meaning of the instruments. In this situation, logic said that the engine oil instruments were wrong, and that a less obvious malfunction had occurred. As a result, the first cause of investigation was the electrical system, and the flightcrew proceeded in that analysis according to the proper procedure. Also, the flightcrew's initial analysis was logical because there was little else that could have been done other than to troubleshoot the possible malfunctions. The airplane was commited to return to Miami when the problem was discovered. The climb was immediately stopped at 16,000 feet and the analysis of the facts was started. The only other course of action was to shut down the No. 3 engine when the low oil pressure light illuminated. However, that action would still not have resolved the zero oil quantity indication on the No. 1 engine. Finally, the flightcrew's analysis of the problem was constrained by the timespan of the events. Only 5 or 6 minutes were available from the first recognition of the zero oil quantity until the No. 3 engine flamed out. The No. 3 engine flamed out just as they ascertained that there was no indicator problem, with the result that there was no time to take any other corrective action even if one had existed. Consequently, the Safety Board believes that the flightcrew's actions to identify and correct the problem were logical, especially when considering the time available to analyze the problem and the options available to them. The decision to climb to FL 200 en route to Miami was normal at the time the climb was started. The Safety Board considered the possibility that the selection of climb power to return to Miami may have contributed to an increased rate of oil loss during that stage of the flight. The oil loss resulted in the flame out of both engines. It is possible that a landing at Nassau could have been made before engines No. 1 and 3 flamed out. However, because the actual oil-loss rate and the time needed to land at Nassau are not known, the Safety Board could not determine when the engines would have flamed out had the captain decided to land at Nassau International Airport, or had he elected not to climb to a higher altitude during the return flight to Miami.