5.

What model (OTA, 5M or Reason's Model or combination of some) do you

think you would choose in assisting you in the final analysis of your investigation
report?

For the final analysis of the investigation report, the model that were used is OTA
model. OTA model is a office technology and assessment model(OTA model) that
divides its safety indicators into three categories which is primary, secondary, and
tertiary factors.

Primary safety factor were related with casual factors. First personnel capabilities which
is the entire crew fail to handle the situation properly. Second things that related to the
primary safety factors is aircraft capabilities which is have one source of the indicators
of landing gears. Next is unpredictable acts which is all the crew that supposed to
control the aircraft have been distract by the landing gear indicator problem. Lastly, air
traffic environment also led the aircraft to the accidents because of no light and dark
environment during the night. The crew did not noticed that the aircraft gradually lost
their attitude. The second officer was unable visually to determine the position of the
nose gear due to the dark environment.

Secondary factors is related to the commercial aviation operation which is the airlines
failed to provide adequate training regarding autopilot function to the flight crew.
Aviation manufactures design and production practices also lead to the accident, the
aircraft manufacturer did not prepared other indicators for the landing gears for
redundant. The aircraft just only have a light source to indicate the position of the
landing gear.

6. What were the analysis and recommendations made by the investigators in

this incident?
From the investigation and the data that have been obtained It was concluded that the
aircraft powerplants, airframe, electrical and Pitot static instruments, flight controls, and
hydraulic and electrical systems were not factors contributing to this accident.

The analysis discovered by NTSB state that the autopilot had been inadvertently
switched from altitude hold to control wheel steering (CWS) mode in pitch. Investigators
believe that the autopilot switched modes when the captain accidentally leaned against
the yoke while turning to speak to the flight engineer, who was sitting behind and to the
right of him. The slight forward pressure on the stick would have caused the aircraft to
enter a slow descent, maintained by the CWS system.

Investigation into the aircraft's autopilot showed that the force required to switch to CWS
mode was different between the A and B channels (15 vs. 20 lb or 6.8 vs. 9.1 kg,
respectively). Thus, the switching to CWS in channel A possibly did not occur in channel
B, thus depriving the first officer of any indication the mode had changed (Channel A
provides the captain's instruments with data, while channel B provides the first officer's).

After descending 250 feet (76 m) from the selected altitude of 2,000 feet (610 m), a C-
chord sounded from the rear speaker. This altitude alert, designed to warn the pilots of
an inadvertent deviation from the selected altitude, went unnoticed by the fatigued and
frustrated crew. Investigators believe this was due to the crew being distracted by the
nose gear light, and because the flight engineer was not in his seat when it sounded, so
would not have been able to hear it. Visually, since it was nighttime and the aircraft was
flying over the darkened terrain of the Everglades, no ground lights or other visual sign
indicated the TriStar was slowly descending.

Captain Loft was later found to have an undetected tumor in his brain, and this was later
found to be in an area controlling vision. However, the NTSB concluded that the
captain's tumor did not contribute to the accident.

The final NTSB report cited the cause of the crash as pilot error, specifically: "the failure
of the flight crew to monitor the flight instruments during the final four minutes of flight,
and to detect an unexpected descent soon enough to prevent impact with the ground.
Preoccupation with a malfunction of the nose landing gear position indicating system
distracted the crew's attention from the instruments and allowed the descent to go
unnoticed.

From the analysis by investigator, aircraft powerplants, airframe, electrical and pitot
static instrument, flight controls, and hydraulic and electrical system were not factors
contributing to this accident. The majority of survivors also from the larger fuselage
section because they remained with these section until the velocity was considerably
reduce or until these sections came to a stop.

Recommendation

1. Required the installation of a switch for the L-1011 ose wheelwell light near the
nose gear indicator Optical sight.
2. Required, near the optical sight, the installation of a placard which explains the
use of the system
3. Required that the altitude select alert light system on Eastern Air Lines
configured L-1011 airplanes be modified to provide a flashing light warning to the
crew whenever an airplane departs any selected altitude by +/-250 feet, including
operations below 2500 feet radar altitude