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| Title: | In-Flight Icing Encounter and Loss of Control, Simmons Airlines, d.b.a. American Eagle Flight 4184, Avions de Transport Regional (ATR) Model 72-212, N401AM, Roselawn, Indiana, October 31, 1994, PART II |
| Micro summary: | This ATR-72 crashed after a severe icing incident. |
| Event Time: | 1994-10-31 at 1559 CST |
| File Name: | 1994-10-31-2-US.pdf |
| Publishing Agency: | National Transportation Safety Board (NTSB) |
| Publishing Country: | USA |
| Report number: | NTSB/AAR-96/02 |
| Pages: | 341 |
| Site of event: | |
| Latitude/Longitude: | N41 5'40", W87°19'20" |
| Departure: | Indianapolis International Airport, Indianapolis, Indiana, USA |
| Destination: | Chicago O'Hare International Airport, Chicago, Illinois, USA |
| Airplane Type(s): | ATR 72-212 |
| Flight Phase: | Cruise |
| Registration(s): | N401AM |
| Operator(s): | American Eagle (Simmons Airlines) |
| Type of flight: | Revenue |
| Occupants: | 68 |
| Fatalities: | 68 |
| Serious Injuries: | 0 |
| Minor/Non-Injured: | 0 |
| Other Injuries: | 0 |
| Executive Summary: | NTSB Abstract: Volume II contains the comments of the Bureau Enquetes-Accidents on the Safety Board’s draft of the accident report. The comments are provided in accordance with Annex 13 to the Convention on International Civil Aviation. Volume I of this report explains the crash of American Eagle flight 4184, an ATR 72 airplane during a rapid descent after an uncommanded roll excursion. The safety issues discussed in the report focused on communicating hazardous weather information to flightcrews, Federal regulations on aircraft icing and icing certification requirements, the monitoring of aircraft airworthiness, and flightcrew training for unusual events/attitudes. Safety recommendations concerning these issues were addressed to the Federal Aviation Administration, the National Oceanic and Atmospheric Administration, and AMR Eagle. (BEA) The BEA strongly disagrees with substantial portions of the Factual, and with the Analysis, Conclusions, and Probable Cause sections of the report. In the BEA's view, except for the Recommendations section, the present report is incomplete, inaccurate, and unbalanced, It appears to have been influenced by an a priori belief on the probable cause of this accident The BEA strongly believes that today one-sided approach is detrimental to the cause of international aviation safety. The Factual section selectively reports the facts of this accident. Some relevant facts are omitted and some other which are included are simply not accurate or their presentation is misleading. The BEA regrets it, since it had already advised the NTSB of a number of significant omissions, inaccuracies, and misrepresentations through his three sets of comments to the earlier drafts of this section, and since it was agreed that many of these errors would be rectified. The Analysis and Conclusions sections are hampered by the incomplete and inaccurate Factual section. “Many of the issues which are discussed are addressed in an incorrect or incomplete manner. Those sections also regrettably omit any discussion of several highly relevant issues for safety and for the understanding of this accident and fail to address a true combination of factors which has caused it. They clearly are inconsistent with the safety recommendations which follow. Given the facts of this accident, the current Probable Cause statement, which ignores critical causal factors, is unbalanced, not correct, and detrimental to the public concern for safety. Accordingly, the BEA considers that the report requires substantial reworking. Acknowledging the necessity, for achieving true aviation safety to take into consideration all relevant aspects of the aviation system, outside any national consideration or any a priori sharing of blame or liability, it has expended significant efforts to prepare in these comments such a substantial reworking of all or part of the quoted sections, to assist the NTSB in making the necessary revision and facilitate the inclusion of the comments. |
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