Crash of an ATR72-212 in Roselawn: 68 killed

Date & Time: Oct 31, 1994 at 1559 LT
Type of aircraft:
Operator:
Registration:
N401AM
Flight Phase:
Survivors:
No
Schedule:
Indianapolis - Chicago
MSN:
401
YOM:
1994
Flight number:
AA4184
Crew on board:
4
Crew fatalities:
Pax on board:
64
Pax fatalities:
Other fatalities:
Total fatalities:
68
Captain / Total flying hours:
7867
Captain / Total hours on type:
1548.00
Copilot / Total flying hours:
5176
Copilot / Total hours on type:
3657
Aircraft flight hours:
1352
Aircraft flight cycles:
1671
Circumstances:
American Eagle Flight 4184 was scheduled to depart the gate in Indianapolis at 14:10; however, due to a change in the traffic flow because of deteriorating weather conditions at destination Chicago-O'Hare, the flight left the gate at 14:14 and was held on the ground for 42 minutes before receiving an IFR clearance to O'Hare. At 14:55, the controller cleared flight 4184 for takeoff. The aircraft climbed to an enroute altitude of 16,300 feet. At 15:13, flight 4184 began the descent to 10,000 feet. During the descent, the FDR recorded the activation of the Level III airframe de-icing system. At 15:18, shortly after flight 4184 leveled off at 10,000 feet, the crew received a clearance to enter a holding pattern near the LUCIT intersection and they were told to expect further clearance at 15:45, which was revised to 16:00 at 15:38. Three minutes later the Level III airframe de-icing system activated again. At 15:56, the controller contacted flight 4184 and instructed the flight crew to descend to 8,000 feet. The engine power was reduced to the flight idle position, the propeller speed was 86 percent, and the autopilot remained engaged in the vertical speed (VS) and heading select (HDG SEL) modes. At 15:57:21, as the airplane was descending in a 15-degree right-wing-down attitude at 186 KIAS, the sound of the flap overspeed warning was recorded on the CVR. The crew selected flaps from 15 to zero degrees and the AOA and pitch attitude began to increase. At 15:57:33, as the airplane was descending through 9,130 feet, the AOA increased through 5 degrees, and the ailerons began deflecting to a right-wing-down position. About 1/2 second later, the ailerons rapidly deflected to 13:43 degrees right-wing-down, the autopilot disconnected. The airplane rolled rapidly to the right, and the pitch attitude and AOA began to decrease. Within several seconds of the initial aileron and roll excursion, the AOA decreased through 3.5 degrees, the ailerons moved to a nearly neutral position, and the airplane stopped rolling at 77 degrees right-wing-down. The airplane then began to roll to the left toward a wings-level attitude, the elevator began moving in a nose-up direction, the AOA began increasing, and the pitch attitude stopped at approximately 15 degrees nose down. At 15:57:38, as the airplane rolled back to the left through 59 degrees right-wing-down (towards wings level), the AOA increased again through 5 degrees and the ailerons again deflected rapidly to a right-wing-down position. The captain's nose-up control column force exceeded 22 pounds, and the airplane rolled rapidly to the right, at a rate in excess of 50 degrees per second. The captain's nose-up control column force decreased below 22 pounds as the airplane rolled through 120 degrees, and the first officer's nose-up control column force exceeded 22 pounds just after the airplane rolled through the inverted position (180 degrees). Nose-up elevator inputs were indicated on the FDR throughout the roll, and the AOA increased when nose-up elevator increased. At 15:57:45 the airplane rolled through the wings-level attitude (completion of first full roll). The nose-up elevator and AOA then decreased rapidly, the ailerons immediately deflected to 6 degrees left-wing-down and then stabilized at about 1 degree right-wing-down, and the airplane stopped rolling at 144 degrees right wing down. At 15:57:48, as the airplane began rolling left, back towards wings level, the airspeed increased through 260 knots, the pitch attitude decreased through 60 degrees nose down, normal acceleration fluctuated between 2.0 and 2.5 G, and the altitude decreased through 6,000 feet. At 15:57:51, as the roll attitude passed through 90 degrees, continuing towards wings level, the captain applied more than 22 pounds of nose-up control column force, the elevator position increased to about 3 degrees nose up, pitch attitude stopped decreasing at 73 degrees nose down, the airspeed increased through 300 KIAS, normal acceleration remained above 2 G, and the altitude decreased through 4,900 feet. At 15:57:53, as the captain's nose-up control column force decreased below 22 pounds, the first officer's nose-up control column force again exceeded 22 pounds and the captain made the statement "nice and easy." At 15:57:55, the normal acceleration increased to over 3.0 G. Approximately 1.7 seconds later, as the altitude decreased through 1,700 feet, the elevator position and vertical acceleration began to increase rapidly. The last recorded data on the FDR occurred at an altitude of 1,682 feet (vertical speed of approximately 500 feet per second), and indicated that the airplane was at an airspeed of 375 KIAS, a pitch attitude of 38 degrees nose down with 5 degrees of nose-up elevator, and was experiencing a vertical acceleration of 3.6 G. The airplane impacted a wet soybean field partially inverted, in a nose down, left-wing-low attitude. Based on petitions filed for reconsideration of the probable cause, the NTSB on September 2002 updated it's findings.
Probable cause:
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 while the airplane was in a holding pattern during which it intermittently encountered supercooled cloud and drizzle/rain drops, the size and water content of which exceeded those described in the icing certification envelope. The airplane was susceptible to this loss of control, and the crew was unable to recover. Contributing to the accident were:
1) 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;
2) the DGAC’s failure to provide the FAA with timely airworthiness information developed from previous ATR incidents and accidents in icing conditions,
3) 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,
4) the FAA’s inadequate oversight of the ATR 42 and 72 to ensure continued airworthiness in icing conditions; and
5) ATR’s inadequate response to the continued occurrence of ATR 42 icing/roll upsets which, in conjunction with information learned about aileron control difficulties during the certification and development of the ATR 42 and 72, should have prompted additional research, and the creation of updated airplane flight manuals, flightcrew operating manuals and training programs related to operation of the ATR 42 and 72 in such icing conditions.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Greensburg: 5 killed

Date & Time: Nov 6, 1993 at 0851 LT
Registration:
N41010
Survivors:
No
Schedule:
Pontiac - Greensburg
MSN:
421B-0569
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2900
Captain / Total hours on type:
225.00
Aircraft flight hours:
2600
Circumstances:
The pilot reported ice accretion en route to his destination and subsequently requested, and received a lower altitude from ATC. The flight was issued a clearance for a VOR-A approach to the Greensburg Airport, and was observed by a witness north of the airport to fly for a short period down runway 18 about seven feet above the runway. The witness then observed the airplane began to climb and fly off in a southerly direction. Other witnesses saw the airplane flying in the vicinity of the airport beneath an overcast ceiling estimated between 300 feet and 1,000 feet AGL. One witness, located about two miles south of the airport, saw the airplane turn sharply left, drop nose low, recover, drop nose low, and then descend from sight behind trees. Investigators and rescue personnel discovered a large amount of ice debris along the flight path and outside the fire ring at the crash site.
Probable cause:
An inadvertent stall by the pilot in command. Factors associated with the accident are the icing conditions and low ceilings.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Greenwood: 5 killed

Date & Time: Sep 11, 1992 at 1457 LT
Type of aircraft:
Operator:
Registration:
N74FB
Flight Phase:
Survivors:
No
Schedule:
Greenwood - Columbus
MSN:
770
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
19473
Captain / Total hours on type:
9000.00
Aircraft flight hours:
4098
Circumstances:
The PA-32, N82419, had been receiving atc radar services en route to the Greenwood Municipal Airport. Radar services were terminated 3 miles from the airport. The MU-2, N74FB, had just taken off from the airport, and had reported to ATC in anticipation of receiving his IFR clearance. The flight had not yet been identified on radar. The two airplanes collided approximately 2 miles from the airport at 2,100 feet msl. The collision took place just outside and to the east of the Indianapolis airport radar service area (arsa). The MU-2 track was 066°, and the PA-32 track was 174°. The pax/pilot on the PA-32 took control of the airplane and was able to make a controlled landing. Guidance for traffic pattern operations and recommended arrival and departure procedures is found in the airman's information manual. All five occupants on board the MU-2 were killed.
Probable cause:
The inherent limitations of the see-and-avoid concept of separation of aircraft operating under visual flight rules that precluded the pilots of the MU-2 and the PA-32 from recognizing a collision hazard and taking actions to avoid the midair collision. Contributing to the cause of the accident was the failure of the MU-2 pilot to use all the air traffic control services available by not activating his instrument flight rules flight plan before takeoff. Also contributing to the cause of the accident was the failure of both pilots to follow recommended traffic pattern procedures, as recommended in the airman's information manual, for airport arrivals and departures.
Final Report:

Crash of a Piper PA-61-601P Aerostar (Ted Smith 601P) in Aurora: 1 killed

Date & Time: Sep 8, 1992 at 1540 LT
Registration:
N717BB
Flight Phase:
Survivors:
No
Schedule:
Vandalia – Memphis
MSN:
61-0825-8063433
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3100
Captain / Total hours on type:
1100.00
Aircraft flight hours:
1284
Circumstances:
The pilot was on second corporate flight of the day and complained to the avionics technician about the autopilot and asked him to adjust it. The technician said it would require a flight check. The pilot said he didn't have time for that, and got the technician to tell him how to perform the adjustment. Radar shows the airplane stable at 14,100 feet after departure. It then begins to deviate from cruise altitude between plus 100 feet to minus 200 feet. Center gives the pilot a 15° course change for traffic and the pilot acknowledges the instruction while the airplane is deviating off course. Radar contact was lost and no further radio transmissions were received from the pilot. Witnesses on the ground reported hearing a loud explosion followed by a muffled explosion, and seeing the airplane exit clouds vertically. The outboard six feet of both wings were found 1.25 miles from crash site. The pilot, sole on board, was killed.
Probable cause:
Exceeding the design stress limits of the airplane by the pilot in command.
Final Report:

Crash of a Lockheed C-130B Hercules in Evansville: 17 killed

Date & Time: Feb 6, 1992 at 1000 LT
Type of aircraft:
Operator:
Registration:
58-0732
Flight Type:
Survivors:
No
Site:
Schedule:
Evansville - Evansville
MSN:
3527
YOM:
1959
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
17
Circumstances:
The crew was completing a local training flight at Evansville-William H. Dress Airport on behalf of the Kentucky National Guard, consisting of touch-and-go maneuvers. On approach to runway 22, the crew was instructed by ATC to initiate a go-around for unknown reasons. The crew increased engine power and climbed to a height of 1,500 feet when the aircraft entered a nose down attitude, plunged and crashed onto an hotel located 4,800 feet short of runway 22 threshold. The aircraft, the hotel and a restaurant were destroyed. All five crew members as well as 11 people on the hotel/restaurant were killed. A police officer who was seriously injured in the accident died from his injuries 10 days later.
Probable cause:
It is believed that the loss of control was the consequence of negligences on part of the crew who maintained an insufficient speed while initiating a go-around procedure, causing the aircraft to suffer an aerodynamic stall.

Crash of a Piper PA-46-310P Malibu in Bristol: 3 killed

Date & Time: May 31, 1989 at 1606 LT
Operator:
Registration:
N9114B
Flight Phase:
Survivors:
No
Schedule:
Tullahoma – Kalamazoo
MSN:
46-8408046
YOM:
1984
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1619
Captain / Total hours on type:
17.00
Aircraft flight hours:
705
Circumstances:
After being cleared to descend to 12,000 feet and to deviate around a 'big cell', the aircraft entered an area of level two and three thunderstorms. Subsequently, an in-flight breakup occurred and wreckage was scattered over a four mile area. During the breakup, the right wing and empennage separated from the aircraft. The left wing and spar also failed at the same location as the right wing, but the left wing remained with the fuselage. No pre-accident failure, malfunction or metal fatigue of the aircraft was found drg the investigation. All three occupants were killed.
Probable cause:
Continued flight by the pilot into known adverse weather and his exceeding the design stress limits of the aircraft, which resulted in failure of the wing spars and separation of the right wing and empennage (stabilizers). Contributing factors were: continued flight by the pilot above the maneuvering speed (va), his lack of familiarity with the make and model of aircraft, and thunderstorms.
Final Report:

Crash of a NAMC YS-11A-300F in West Lafayette: 2 killed

Date & Time: Mar 15, 1989 at 0726 LT
Type of aircraft:
Operator:
Registration:
N128MP
Flight Type:
Survivors:
No
Schedule:
Terre Haute - West Lafayette
MSN:
2139
YOM:
1970
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7294
Captain / Total hours on type:
2097.00
Aircraft flight hours:
24088
Circumstances:
An IFR flight was terminated with a visual approach. Conditions were conducive to airframe icing. The aircraft was being positioned empty, with a cg at 22.1% mac. On short final, at approximately 400 feet agl, 35° of landing flap was selected. The aircraft was observed to pitch downward to an unusual attitude and to enter a steep descent. A partial recovery was observed before the aircraft impacted a dirt hill 500 feet short of runway 28. Examination of the airframe after the accident revealed 1/2 to 3/4 inch of rime ice adhering to the leading edge of the horizontal stabilizer. No ice was found on any other portion of the airframe. Evidence in the cockpit indicated that engine, pitot, and windshield anti-ice systems were on, but wing/empennage deice was off. No evidence of a powerplant or systems malfunction was found. Both pilots were killed.
Probable cause:
A loss of control due to the improper inflight decisions by the crew and the undetected accumulation of ice on the leading edge of the horizontal stabilizer, during flight in a forward center of gravity condition and exacerbated by the extension of full landing flaps.
Final Report:

Crash of a NAMC YS-11A-213 in Remington

Date & Time: Jan 13, 1987 at 1354 LT
Type of aircraft:
Operator:
Registration:
N906TC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Indianapolis - West Lafayette
MSN:
2154
YOM:
1970
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3913
Captain / Total hours on type:
1381.00
Circumstances:
The flight crew failed to adhere to appropriate procedures and directives when they failed to select the hp cock levers to the hswl (lock out) position while performing an approach to landing stall during a training/test flight. When stall recovery was initiated, both propellers 'hung up' when the high (cruise pitch) stops of each propeller failed to withdraw. As the power levers were advanced, turbine gas temperatures (tgt's) exceeded limitations; the left propeller auto-feathered, the right propeller was later feathered by the captain. Restart procedures were attempted without success, and a forced landing in a plowed cornfield ensued. Examination of the engines revealed that the turbines had been 'subjected to severe (and destructive) thermal degradation during operation' as a result of the propellers being constrained during low speed operations. Testing of the relays revealed that the high stop withdrawal relay for the right propeller functioned intermittently. All three crew members escaped uninjured.
Probable cause:
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: maneuvering
Findings
1. (c) procedures/directives - not followed - pilot in command
2. (f) inattentive - pilot in command
3. (c) powerplant controls - improper use of - pilot in command
----------
Occurrence #2: loss of engine power (total) - mech failure/malf
Phase of operation: descent - emergency
Findings
4. Turbine assembly - overtemperature
5. Emergency procedure - attempted - pilot in command
6. Propeller system/accessories, feathering system - engaged
7. Propeller feathering - performed - pilot in command
----------
Occurrence #3: forced landing
Phase of operation: descent - emergency
----------
Occurrence #4: gear not extended
Phase of operation: landing - flare/touchdown
Findings
8. Terrain condition - open field
9. (c) wheels up landing - intentional - pilot in command
10. Terrain condition - rough/uneven
Final Report:

Crash of a Piper PA-31T Cheyenne II in Merrillville: 1 killed

Date & Time: Dec 30, 1986 at 0254 LT
Type of aircraft:
Registration:
N74NL
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Louisville - Chicago
MSN:
31-7720010
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2170
Captain / Total hours on type:
140.00
Aircraft flight hours:
6888
Circumstances:
The aircraft was enroute to the Chicago Midway Airport. While letting down to 16,000 feet the pilot reported he was shutting down the right engine. ARTCC cleared the aircraft to 5,000 feet. Ten minutes later ARTCC lost radio transponder and mode C contact. 15 minutes later the aircraft descended out of the 1,800 feet overcast and struck a 170 feet utility tower at the 150 feet level. The aircraft then ground impacted and burned. Investigation revealed that the right engine had a bearing failure due to lack of lubrication. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: loss of engine power (partial) - mech failure/malf
Phase of operation: descent - normal
Findings
1. (f) engine assembly, bearing - distorted
2. (f) engine assembly, bearing - binding (mechanical)
3. Emergency procedure - inadequate - pilot in command
----------
Occurrence #2: airframe/component/system failure/malfunction
Phase of operation: descent - normal
Findings
4. (f) electrical system - failure, total
5. (f) lack of familiarity with aircraft - pilot in command
----------
Occurrence #3: in flight collision with object
Phase of operation: unknown
Findings
6. (c) proper altitude - not maintained - pilot in command
7. (f) flight/nav instruments - failure, partial
8. (f) minimum descent altitude - not maintained - pilot in command
9. Anxiety/apprehension - pilot in command
10. (f) light condition - dark night
11. (c) descent - misjudged - pilot in command
----------
Occurrence #4: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Rockwell Aero Commander 500 in Hagerstown

Date & Time: Dec 12, 1986 at 0324 LT
Registration:
N116CA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Akron - Mount Vernon
MSN:
500-1133-75
YOM:
1961
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3150
Captain / Total hours on type:
200.00
Aircraft flight hours:
11034
Circumstances:
The pilot was on the fourth leg of a night cargo flight cruising at approximately 500 feet agl enroute to Mt Vernon, IL, when the aircraft struck some trees and subsequently collided with the ground. The engines and propellers were both torn down and tested and no evidence of malfunction was discovered. The pilot stated he did not recall the crash sequence at all. The pilot was wearing a 'walkman' radio at the time of the accident. He stated it was to help keep him awake, because he had fallen asleep at times in the past while flying night cargo.
Probable cause:
Occurrence #1: in flight collision with object
Phase of operation: cruise
Findings
1. Object - tree(s)
2. (c) altitude - not maintained - pilot in command
3. Fatigue (flight schedule) - pilot in command
4. (f) light condition - night
5. (c) judgment - poor - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report: