9. Fatal Events in December Since 1975 ••
Provides information on a September 2000 bird strike involving a 737-400 at 10,000 feet near LaGuardia Airport.
  ... miles (seven km) from the runway threshold during an approach at night and in icing conditions. The flight crew incorrectly thought that an engine had ...
  ... unstabilzied ILS approach, improper air traffic control commands, and aircraft icing caused the aircraft to stall and crash short of the runway during ...
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31 October 1994; American Eagle (Simmons Airlines) ATR 72; Near Roselawn, IN: The aircraft inverted, dived, and crashed from holding pattern at 10,000 feet (3050 m) due to icing. The four crew and 64 passengers were all killed.
NTSB Accident Report Volume I  (Summary)
NTSB Accident Report Volume II  (Summary)

Continued story By Stephen J. Hedges; Peter Cary; Richard J. Newman

The ATR turboprop planes are industry favorites. They also have a very troubled past

Flight 4184 was stuck in a holding pattern late on Halloween afternoon, waiting to land at Chicago's O'Hare airport. The weather was lousy: drizzle at 10,000 feet, the temperature near freezing. In the cockpit of the ATR-72 twin turboprop, the pilots flipped on the wing de-icers, letting the autopilot guide the aircraft through a series of lazy turns. The plane had been circling for 30 minutes. Things were getting a little boring.

Then it happened. Suddenly, the autopilot popped off, and the plane flipped on its side in a 70-degree roll. The pilots grabbed the control wheels and fought it. The plane started to come around, but only for an instant. Then it rolled farther right, nearly turning over, its nose pitched down. Within seconds, the plane was inverted, turning a full spiral before it slammed into a muddy bean field near Roselawn, Ind. The pilots, two flight attendants and 64 passengers died. The whole thing took 25 seconds.

Planes just don't fall from the sky. For that reason alone, the demise of American Eagle Flight 4184 was more than a jarring tragedy. This week, the National Transportation Safety Board will convene hearings in Indianapolis to examine the causes of the crash. Explanations will be put forward, and there will be discussions of such things as pilot error and severe icing conditions. But this incident was far from unique.

Out of control. In the last 10 years, this airplane and its nearly identical sister ship, the ATR-42, experienced at least 12 unexpected rolls and stalls -- what the NTSB dryly calls "departures from controlled flight" -- related to ice buildup on its wings. On three different occasions -- in Detroit in 1986, in Italy in 1987 and last October 31 -- two ATRs flying through the same bad weather systems went out of control on the same day. Four of the six aircraft in those incidents survived; two, including Flight 4184, crashed. Some of the survivors were shaken. "I thought we were dead," said a first officer after recovering from an ice-induced roll in 1986.

The causes of those incidents remain in dispute. The manufacturer, the French-Italian consortium Avions de Transport Regional, says most were the result of unusually dangerous weather systems and pilot error -- not deficiencies in the ATR's design. "This is the most successful turboprop in the world," said Alain Brodin, president of ATR marketing. "There are 410 flying worldwide. A bad airplane doesn't last for long." Robert McCracken, an engineer with the Federal Aviation Administration responsible for ATR design issues in the late 1980s, says the sheer number of directives the FAA issued on the plane indicates "that this airplane has a higher sensitivity to flight in icing conditions than other airplanes."

On three occasions before Flight 4184's crash, the FAA restricted how the plane could be flown in icy weather. Each time, the agency lifted the restrictions after the manufacturer made mechanical fixes and changed pilot procedures. But did the company and the FAA do enough and soon enough? Could Roselawn have been prevented? Consider:

The FAA and ATR have known since just after the fatal crash in Italy seven years ago that a ridge of ice could form on the top of the plane's wings, making the aircraft more difficult to fly. That finding was first reported in a British study after the Italian accident. ATR says it tested its planes for that kind of icing problem; the company says the planes flew properly. Only now, however, after Roselawn, is the company installing bigger de-icers.

The ice buildup occurs because the de-icers currently in use do not fully protect the one part of the high-tech wing where ice could form and cause the plane to roll. In 1989, after an ATR-42 lost control in icy weather, the FAA approved a modification to the ATR's wings. Critics called the fix a "Band-Aid." Today, even ATR concedes the fix did not fully address the icy-ridge problem. Some believe an ice ridge caused the accident at Roselawn.

Tests two months ago at Edwards Air Force Base in California confirmed that an ice-induced roll can occur, ATR officials concede. Even so, the company says the results "again demonstrated that performance of the ATR-42 and ATR-72 exceeds all FAA certification requirements, that the aircraft can operate safely even in extreme icing conditions."

When the FAA certifies a plane to fly in icing conditions, what it means in fact is that the plane has been tested only in light mist. Planes certified by the FAA for icing conditions are not tested in freezing drizzle and rain, the most hazardous conditions that pilots -- especially short-haul pilots -- experience. The FAA standard is 30 years old and, despite regular complaints, has not been changed. FAA officials say now that in the wake of Roselawn, they are considering a higher benchmark.

The ATR crashes illuminate an industry paradox: Big jets with the best de-icing equipment fly high, above bad weather. Smaller planes with less efficient de-icers fly at lower altitudes, where icing is more prevalent.

And those low altitudes are where ATRs mostly fly. In the early 1980s, newly deregulated U.S. air carriers were looking for a new airplane, one that could carry 30 to 60 passengers on short-haul routes. American aircraft manufacturers showed little interest. So French aviation giant Aerospatiale and the Italian firm Alenia formed a consortium. The result was ATR. The plane the new company came up with had a state-of-the-art cockpit, highly efficient Pratt & Whitney engines, a roomy fuselage and a sleek, metal-and-composite wing that produced less drag than older designs. That meant decreased fuel consumption and improved range, lowering operating cost.

The wings, mounted high on the fuselage, had three parts of importance to the icing issue. On the front edge of the wings are wide rubber strips, called boots, that automatically inflate and deflate to break off ice. At the wings' back edge are wide, movable flaps that help planes descend or take off. Out at the wingtips are control fins called ailerons. These are linked by cables and rods to the pilots' control wheels, and they operate in reverse tandem. For a right turn, for instance, the left aileron goes down, coaxing the left wing upward; at the same time, the right wing's aileron goes up, forcing that wingtip down.

There was something else that was special about the ATR's wings: They were thinner than old-style wings. That, says Porter Perkins, a leading U.S. expert on wing icing who recently retired from the National Aeronautics and Space Administration, could mean trouble: "On your old airfoils, getting some ice aft of the protected area didn't matter too much. But on these new airfoils, not enough attention was paid to potential ice contamination."

The new planes were a big hit. The ATR-42s passed their French certification tests in 1985. The FAA approved the plane a month later under a bilateral treaty that allows test data to be shared. The French and American standards on icing are almost identical. Both test only for flight in a light mist. By contrast, droplets hitting the ATR-72 that crashed in Roselawn were five times -- and possibly 50 times -- bigger. Eventually, 110 ATR-42s and 40 ATR-72s would enter the U.S. fleet.

But it was not long, federal records show, before the planes encountered ice -- and problems. In June 1986, an ATR-42 on a training flight pitched down unexpectedly. The FAA blamed the incident on ice on the plane's tail and issued an "airworthiness directive," warning pilots to avoid a certain flap setting.

Six months later, there were more problems. Within an hour of each other on Dec. 18, 1986, two ATR-42s experienced rolls as they were descending into Detroit. Both planes had run into heavy ice. Each was on autopilot. The first plane, Simmons Airlines Flight 2860, had 38 passengers on board. When the pilot called for the flaps to be lowered, the autopilot quit and the plane heaved over left, then right, then left again. Inside the cockpit, a "terrain" warning sounded. The plane had lost 500 feet in less than 20 seconds, leaving it just 500 feet above the ground when the pilots regained control. An hour later, Simmons Flight 2801 experienced a 30-degree roll on the same landing approach.

ATR blamed the first incident on the pilot's delay in turning on the plane's de-icers. But the next day, a concerned FAA telexed airlines forbidding them to fly ATR-42s into "known or forecast icing conditions" -- a grounding order similar to that imposed after Roselawn. French aviation authorities protested. Six months later, after ATR made improvements, the FAA lifted the restriction.

Stall warnings. But still the problems continued. Less than one year after the Detroit episodes, an Alitalia ATR-42 encountered severe icing during a late October storm over the northern Italian city of Como. In the cockpit, a horn sounded and the pilots' control sticks began to shake -- both warnings that the plane was about to stall -- a condition where the wing loses lift. Then came a series of pitching turns. The plane hit the ground at over 300 miles per hour.

As in the Detroit rolls, a second Alitalia ATR-42 had also experienced the same handling problems in the same weather that day. The difference, says ATR Vice President Robert Briot, a career test pilot, was that the pilots of the second plane acted correctly and recovered easily, while those in the plane over Como did not. The real problem, Briot says, was that Alitalia had not put instructions for flight in icy weather in the pilot handbook. In the aftermath, ATR put ice detectors on the plane's wings and connected them to a chime and warning light in the cockpit.

FAA officials who had handled the ATR's certification and subsequent icing problems sent an investigator to Como but issued no special warnings. The British Defense Ministry, however, ran tests on an ATR wing. They found that while the wing's de-icing boots worked well, they were "insufficient" to protect the wing from heavy moisture at freezing temperatures. When they replicated freezing drizzle, the entire wing was covered with ice. In the United States, the Air Line Pilots Association took the British test results to the FAA and argued that the ATR's boots needed to be expanded. ATR and a French aeronautical agency disagreed. The British test results, they said, were flawed and did not truly replicate the conditions that the planes fly in. Nevertheless, ATR took the wooden shapes that replicated the ice found in the British test, put them on a plane and reported no problems during flight tests. ATR made no changes.

Within a year of the Como crash and the British icing study, another ATR-42 rolled in flight. This time it happened in the United States -- and this time the FAA decided to act. The plane involved was another Simmons ATR-42, this one carrying 34 people into Mosinee, Wis. It was night, three days before Christmas, and the weather was rainy and near freezing. The plane had aborted one landing attempt and was making a second. The copilot, aware that the potential for icing was high, looked frequently for a buildup on the propeller caps -- the recommended procedure for recognizing ice -- and saw nothing. The autopilot was guiding the plane through a 27-degree right-hand turn when the plane leveled out and then began rolling left. At 27 degrees, the autopilot snapped off and the plane tipped on its left side to 80 degrees. The pilot slammed the throttles forward and, after several rolls, regained control -- 1,000 feet above the ground. The crew put the plane into a climb and went around again. The plane landed without further incident. On the ground, the two pilots chatted nervously, the cockpit voice recorder still running. "I want to get out of this airplane for a few minutes," the copilot said. "Damn, I've never been so scared in an airplane before."

Worried pilots. How much of a problem was there? "[The FAA's] principal maintenance inspector for Simmons was concerned that this was going to happen again," says Robert McCracken, the FAA engineer who was in charge of ATRs at the time. "Pilots were concerned, too." On March 6, 1989, FAA technical experts met with representatives of ATR and the French aviation authority, known by its acronym, DGAC. The FAA suggested that ATR pilots no longer use the autopilot in icing conditions. The French demurred: "DGAC and ATR do not feel there is an unsafe condition," the ATR representatives said, according to an official summary of the meeting. "It is their position that the latest incident occurred with the airplane operating in highly unusual weather conditions involving freezing rain."

This time, the FAA held firm. In April 1989 the agency issued a directive prohibiting the use of autopilots on ATR-42s in icing conditions. ATR quickly came up with a fix. Instead of bigger de- icing boots, it would put pieces of metal, called vortex generators, on top of the plane's wings. The VGs, as they are called, often can help when a wing's airflow is disturbed by channeling its energy back over the wing. The idea came from ATR's new, longer version of the plane, the ATR-72, on which VGs had been installed to improve handling. The FAA pronounced the VG solution satisfactory. The VGs, the agency said, would "significantly improve the effectiveness" of the ailerons in icing conditions. In October 1989, the FAA dropped its restriction on the ATR-42: Pilots could once again use the autopilot in icy weather.

Not everyone thought the fix was a good one. The Air Line Pilots Association protested. In a letter to the FAA, Harold Marthinsen, then director of the union's accident-investigation department, called the VGs "a Band-Aid type fix to an aircraft that was inadequately certified for operation in icing conditions." Other experts expressed similar doubts. "I would very much like to see the test data that established the effectiveness of the VGs on the ATR-42," said icing expert Porter Perkins.

Friction. So why did the FAA agree to the VGs? "They were shown to be quite effective in improving roll control," says Gary Lium, an FAA engineer now in charge of overseeing ATR design issues. Lium says other FAA-required changes also improved ATR crews' awareness of ice. But McCracken acknowledges pressure from the company: "We were being argued with pretty steadily" by ATR and the French aviation authority.

Despite complaints, it seemed for a while as if the VGs might be the answer. There were two severe roll incidents involving ATRs in icy weather in 1991, but both happened outside the United States. Next, two more occurred over Newark, N.J., and in New England in 1993 and 1994, but the causes were unclear. Then came Roselawn. Unknown to pilots Orlando Aguiar and Jeffrey Gagliano, their holding pattern at 10,000 feet likely put them in freezing drizzle. The droplets were far bigger than the mist the FAA certified the plane to fly in. For reasons that remain unclear, the pilots had their flaps extended 15 degrees -- ATR says it may have been to keep the airplane level for passenger comfort. When their flight was cleared to descend to 8,000 feet, the plane's speed increased and the flaps were retracted. That's when the roll began.

Why? "It was a very sad conjunction of facts," says ATR Vice President Robert Briot: The pilots were flying in freezing rain too long, and keeping the flaps down allowed ice to form on the wing. The pilots' fatal mistake, Briot says, was when they raised the plane's flaps. That changed the wing's shape and the air flowed in a new path that was disrupted by the built-up ice. "If you omit one of those things, there is no accident," Briot says. But he adds, "Everybody agrees that icing was the prevailing condition."

One theory is that the wing "stalled," or lost its lift, with the disrupted airflow. A more frightening scenario, experts say, was suggested by tests at Edwards Air Force Base after the accident. They showed that a 3/4-inch-high ridge of ice can form on the top of the wing, especially with flaps down. The interruption of the air flow by the ice could create a vacuum over one aileron that pulls it upward -- a phenomenon known as "aileron snatch." If that happens, the other aileron is automatically pushed down. That makes the plane roll. The plane's autopilot, if turned on, will fight the roll force without the pilot knowing it. When the roll forces -- that is the forces upon the ailerons -- become too great, the autopilot will suddenly disengage. The plane can then snap into a roll, from which the startled pilot must recover. "It would all be masked by the autopilot," says Pete Hellsten, an aeronautical engineer and a consultant to the FAA on icing.

A bigger boot. Since the Roselawn accident, ATR has done hundreds of tests with wooden ice shapes stuck on wings. Brodin, the president of ATR Marketing, concedes that ice just behind the de-icing boot can create roll forces, but he says the company's latest tests show the forces are not so high that a trained pilot cannot recover. And the ATR-72, he says, was put through more-rigorous icing tests when it was developed precisely because of icing concerns.

Immediately after Roselawn, the FAA grounded the ATR planes in cold weather. But it later relaxed those restrictions. ATR aircraft may now fly under a series of new pilot rules -- such as no autopilot in freezing rain or drizzle and more ice-flying training. And ATR has agreed to put a bigger boot on its airplanes, one it hopes will prevent the dangerous ridge of ice from forming. Those new boots will have to be tested, though, to see if they work as designed.

Is that enough? ATR says yes, and its executives point out that its planes now have been tested more than any similar aircraft for icy-weather flying, and exceed the FAA icing standard that the rest of the industry is held to.

Others, however, say it is time that the FAA started testing all planes for flight safety in conditions of freezing drizzle and rain. Critics of the agency say that it should require manufacturers to fix unsafe planes -- and stop blaming pilots for tragedies that are beyond their control. "It disturbs me that so many of these incidents have been categorized as pilot error," says icing expert Porter Perkins. "Yeah, it might have been pilot error if he had known all these things about the weather and the airplane, but, gosh, you're asking a lot of these people."

The fall of flight 4184
1. At about 4 p.m. on Oct. 31, 1994, the aircraft, an ATR-72-210,
is circling over Indiana waiting to land at Chicago. Freezing
drizzle is present, the plane's de-icing boots are operating. The
autopilot is on.
2. Flight 4184 is told to descend to 8,000 feet. The plane
descends, the pilots retract the flaps. The autopilot disengages
and the plane rolls 70 degrees  to the right.
3. The pilots fight the roll and bring the plane back to 50
degrees right.
4. The plane rolls right again, sending it into a full roll. The
pilots cannot recover.
5. The plane crashes into a field 3 miles south of Roselawn, Ind.
All 64 passengers and four crew members are killed.

Ice and the ATR wing
1. Ideally, rubber de-icer boots expand and contract to break off
ice as it forms on leading edge. Air flows smoothly over the
wing, maintaining pressure over the aileron.
2. But freezing drizzle can slip past the boots and form an ice
ridge on top of the wing. That disrupts air flow, lifting it off
the wing, creating a low-pressure area over the aileron. The
aileron lifts up, and the airplane rolls.
3. Vortex generators can help when air separates slightly from
the wing. They take the energy of separated-but moving-air and
mix it with dead air that hugs the wing to re-create air flow.
4. But a high ridge of ice can push air over the top of the
vortex generators, reducing their effectiveness. The aileron
lifts and the plane rolls.

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A Pentagon spokesman said Thursday it was still not clear what caused two Army UH-60 Black Hawk helicopters to collide, killing six soldiers.

Palestinian dies in Gaza battle (15-Feb-01)
A Palestinian was killed by Israeli troops overnight, a day after eight Israelis were killed in a hit-and-run bus attack outside Tel Aviv.

Witness says he bought plane, made shipments for bin Laden (14-Feb-01)
Suspected terrorist Osama bin Laden wanted to ship Stinger anti-aircraft missiles to Sudan -- buying a private plane in 1993 to do the job, a government witness said Wednesday.

Investigators eye weather as Oklahoma State mourns players, staff killed in crash (29-Jan-01)
Investigators on Monday examined what role weather may have played in the weekend crash of a twin-engine plane east of Denver that killed 10 people, most affiliated with Oklahoma State University's basketball program.

Twenty-four killed in Venezuela air crash (26-Jan-01)
A DC-3 airplane crashed Thursday shortly after taking off from Ciudad Bolivar in Venezuela, killing all 24 people aboard, officials said.

Witness of Oklahoma State University plane crash describes 'ball of fire' (28-Jan-01)
The first person on the scene of a plane crash Saturday night that killed members of the Oklahoma State University basketball program said a ball of flame stopped him and his sons from trying to rescue anyone.

Alaska Airlines may replace ground crew contractor after wing incident (02-Feb-01)
Alaska Airlines said Thursday it had put one of its ground crew contracts up for bid because crew members failed to report wing damage to an Alaska Airlines' Boeing MD-80.

Plane not de-iced before fatal flight to Colorado, NTSB says (30-Jan-01)
Federal officials investigating the fatal crash of a twin-engine plane near Denver this weekend have determined the aircraft was not de-iced prior to takeoff, despite likely icing conditions.

Contact with OSU aircraft was lost before it went down, investigator says (28-Jan-01)
The small plane that crashed Saturday night, killing all 10 people aboard, lost radio contact and disappeared from controllers' radar screens before it went down in Colorado, a federal official told CNN Sunday.

Marines turn Osprey investigation over to Pentagon (24-Jan-01)
Under pressure from Congress for an independent investigation, the Marine Corps on Wednesday turned over its investigation of falsified maintenance records for the controversial MV-22 Osprey program to the Pentagon's inspector general.

U.N. workers among victims in Mongolian copter crash (15-Jan-01)
A helicopter carrying U.N. disaster relief officials crashed in Mongolia on Sunday, killing nine people.

Concorde flies again (18-Jan-01)
An Air France Concorde took to the skies on Thursday for the first time since one of the aircraft crashed in flames last July, killing 113 people.

Concorde flight gets green light (16-Jan-01)
An Air France Concorde has been allowed to fly to southern France amid hopes of returning the supersonic fleet to the sky.

France set to test fly Concorde (12-Jan-01)
Air France is reported to be preparing for the first test flight of one of its grounded Concorde jets since one of the supersonic aircraft crashed in July.

Concorde prepares for test flight (15-Jan-01)
An Air France Concorde will take to the skies on Thursday for the first test flight since one of the supersonic aircraft crashed last July.

Concorde to fly again (18-Jan-01)
An Air France Concorde is to take to the skies again on Thursday for the first time since one of the aircraft crashed in flames last July, killing 113 people.