American Eagle Flight 4184
An American Eagle ATR 72–212 similar to N401AM
|Date||October 31, 1994|
|Summary||Atmospheric icing, loss of control|
|Site||Near Roselawn, Indiana, U.S.
|Aircraft type||ATR 72–212|
|Operator||Simmons Airlines doing business as American Eagle|
|Flight origin||Indianapolis International Airport|
|Destination||Chicago O'Hare International Airport|
The aircraft, registration N401AM, was built by the French-Italian aircraft manufacturer ATR, and was operated by Simmons Airlines on behalf of American Eagle. American Eagle was the banner carrier regional airline branding program of AMR Corporation's regional system, prior to the formation of the fully certificated carrier named American Eagle Airlines.
The captain of Flight 4184 was Orlando Aguiar, 29. He was an experienced pilot with almost 8,000 hours of flight time. Colleagues described Aguiar's flying skills in positive terms and commented on the relaxed cockpit atmosphere that he promoted. The first officer of Flight 4184 was Jeffrey Gagliano, 30. He, too, was considered to be a competent pilot by colleagues and he had accumulated more than 5,000 flight hours. The two flight attendants were Amanda Holberg, 23, and Sandi Modaff, 27.
The flight was en route from Indianapolis International Airport, Indiana to O'Hare International Airport, Chicago, Illinois. Bad weather in Chicago caused delays, prompting air traffic control to hold Flight 4184 over the nearby LUCIT intersection at 10,000 ft (3,000 m). While holding, the plane encountered freezing rain, a dangerous icing condition where supercooled droplets rapidly cause intense ice buildup. Soon after, they were cleared to descend to 8,000 ft (2,400 m). After this descent the pilots were ordered to enter another hold. During the descent, a warning sound indicating an overspeed warning due to the extended flaps was heard in the cockpit. After the pilot took action by retracting the flaps, a strange noise was heard on the cockpit voice recorder, followed by an uncommanded roll excursion which disengaged the autopilot. Flight recorder data showed that the aircraft subsequently went through at least one full roll, after which Aguiar and Gagliano regained control of the rapidly descending aircraft. However, another roll occurred shortly thereafter. Fewer than thirty seconds later, at 3:59 p.m., contact was lost as the plane crashed into a soybean field near Roselawn, Indiana, killing all 64 passengers and 4 crew on board.
The disintegration of the plane indicated extreme velocity, and data recovered from the flight data recorder showed that the plane had 375 knots (694 km/h) indicated airspeed at impact. There was no explosion or post-impact fire, as the high speed of the impact caused the fuel to disperse before it could ignite. The bodies of all on board were fragmented by the impact forces, therefore the crash site was declared a biohazard.
Flight 4184 was the first loss of an ATR 72 aircraft, and remains the highest death toll of any aviation accident involving an ATR 72 anywhere in the world. Robert A. Clifford, a Chicago airplane accident attorney, represented 16 of the victims. As the trial was ready to begin, the defendants agreed to a record $110 million settlement and an apology from both the manufacturer and the airline in open court.
The National Transportation Safety Board (NTSB) issued its usual statement of "probable cause" near the end of its report. However, that statement was considerably longer than the norm for most other NTSB accident reports. The statement clearly blamed ATR (the manufacturer of that aircraft), the French DGAC (the French counterpart of the American FAA), and the FAA itself, as contributing to that accident, because they all failed in their duty to ensure the highest possible level of safety to the traveling public. The unabridged NTSB "probable cause" statement:
- 3.2 Probable Cause
- The National Transportation Safety Board determines that the probable causes of this accident were the loss of control, attributed to a sudden and unexpected aileron hinge moment reversal that occurred after a ridge of ice accreted beyond the deice boots because: 1) ATR failed to completely disclose to operators, and incorporate in the ATR 72 airplane flight manual, flightcrew operating manual and flightcrew training programs, adequate information concerning previously known effects of freezing precipitation on the stability and control characteristics, autopilot and related operational procedures when the ATR 72 was operated in such conditions; 2) the French Directorate General for Civil Aviation's (DGAC's) inadequate oversight of the ATR 42 and 72, and its failure to take the necessary corrective action to ensure continued airworthiness in icing conditions; and 3) the DGAC's failure to provide the FAA with timely airworthiness information developed from previous ATR incidents and accidents in icing conditions, as specified under the Bilateral Airworthiness Agreement and Annex 8 of the International Civil Aviation Organization.
- Contributing to the accident were: 1) the Federal Aviation Administration's (FAA's) failure to ensure that aircraft icing certification requirements, operational requirements for flight into icing conditions, and FAA published aircraft icing information adequately accounted for the hazards that can result from flight in freezing rain and other icing conditions not specified in 14 Code of Federal Regulations (CFR) Part 25, Appendix C; and 2) the FAA's inadequate oversight of the ATR 42 and 72 to ensure continued airworthiness in icing conditions.
In the years following this accident, AMR Corporation stopped using its American Eagle ATRs out of its northern hubs and moved them to its southern and Caribbean hubs at Dallas-Fort Worth International Airport, Miami, Florida, and San Juan, Puerto Rico to reduce potential icing problems in the future. Other U.S. former ATR operators, particularly the SkyWest, Inc. subsidiary and Delta Connection operator Atlantic Southeast Airlines, operated ATR 72 aircraft in areas where icing conditions were not common.
In April, 1996 the American FAA issued 18 Airworthiness Directives (ADs), in an apparent attempt to prevent further icing accidents in ATR aircraft. They included significant revisions of pilot operating procedures in icing conditions (higher minimum speeds, non-use of the autopilot, different upset recovery procedures) as well as physical changes to the coverage area of the de-icing boots on the airfoils.
While the ATR 42 and ATR 72 aircraft are now compliant with all icing condition requirements imposed by those 18 ADs, the de-icing boots still only reach back to 12.5% of the chord. Prior to the accident, they had extended only to 5% and 7%, respectively. The ADs still fail to deal with the findings of tests conducted by British regulators at MoD Boscombe Down, which demonstrated that ice could form as far back on the wing as 23% of the chord, and on the tail at 30% of the chord. Both percentages are well beyond the reach of the extended deicing boots installed in compliance with the FAA ADs. Those tests limited the size of the droplets to 40 micrometres, near the maximum limit of the FAA design certification rules for Transport Category aircraft (Part 25, Appendix C), still in effect at that time of the Roselawn crash. Extensive airborne testing following the accident revealed that airliners can encounter water droplets exceeding 200 micrometers in average diameter. It is likely that the lack of further ATR icing accidents is attributable to the changes in pilot operating procedures, as well as the moving of those aircraft to operating areas where severe icing is not a problem, rather than to the modest extension of the de-icer boots to 12.5% of the chord.
One week before the NTSB issued its Final Report on the accident, former American Eagle ATR pilot Stephen Fredrick released his tell-all book, Unheeded Warning - The Inside Story of American Eagle Flight 4184 [McGraw-Hill, July 1996]. The book was required reading by the Board Members prior to voting, and then NTSB Chairman James Hall congratulated Fredrick on telling a tale which needed to be told. Fredrick was terminated by American Eagle in July 1995 after speaking out publicly on the previous negative performance of the aircraft in icing conditions and lack of FAA or manufacturer changes to prevent the accident; the same reasons the NTSB would later find causal to the accident. The FAA moved to revoke Fredrick's medical one week after his termination from the airline which resulted in the pilot's 17 year hiatus from aviation. In 2012, Fredrick obtained his medical, returned to flying, and is now a captain for an airline operating in Hawaii. During his hiatus, Fredrick continued his writing endeavors, publishing two novels: Cassandra's Crossing in 2011 and Fortunate Son in 2012.
There are three designated memorials for Flight 4184. The first is a roadside memorial at the crash location just outside of Roselawn, Indiana. The second is located at Calumet Park Cemetery, in Merrillville, Indiana, where 18 caskets of unidentified remains were interred. The third is located at the Lincoln Township Fire Department in Thayer, Indiana, the station from which the first emergency responders came to the crash site.
This crash was featured on an episode of the Discovery Channel program The New Detectives. In the episode, entitled "Witness To Terror," the narrator gives an incorrect figure of 72 victims being killed on the flight. The crash was also featured in the theatrical production Charlie Victor Romeo.
The crash was also briefly mentioned in an episode of Modern Marvels (Sub Zero) on The History Channel.
- "Frozen in Flight". Mayday.
- "FAA Registry". Federal Aviation Administration.
- ASN Aircraft accident description ATR 72–212 N401AM – Roselawn, IN
- Fredrick, Stephen A. (1996). Unheeded warning: the inside story of American Eagle flight 4184. McGraw-Hill. ISBN 978-0-07-021951-9.
- "NTSB Report: American Eagle Flight 4184" (PDF).Pg. 210
- Steward, Danette; Boser, Robert J. (ed.) (September 2002). "Letter to the Editor – Unheeded Warning". AairlineSafety.com. Retrieved June 2014.
- Unheeded Warning: The Inside Story of American Eagle Flight 4184
- The Internet Movie Database – The New Detectives: Case Studies In Forensic Science (Season 2, Episode 11 – Witness To Terror) (1998)
- Accident description at the Aviation Safety Network
- PDF (3.58 MiB), 340 pages)
- PDF (4.42 MiB), 341 pages)
- PlaneCrashInfo.Com entry on Flight 4184
- Tv.Com – New Detectives: Witness to Terror (Details Flight 4184 investigation)
- Site for Families and Friends of 4184