In-Flight Icing Encounter, Simmons Airlines, dba American Eagle Flight 4184, Avions de Transport

341 Pages·1998·4.43 MB·English

PB96-910402
NTSB/AAR-96/02
DCA95MA001
NATIONAL
TRANSPORTATION
SAFETY
BOARD
WASHINGTON, D.C. 20594
AIRCRAFT ACCIDENT REPORT
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
VOLUME II: RESPONSE OF BUREAU ENQUETES-ACCIDENTS
I
TO SAFETY BOARD’S DRAFT REPORT /
I
6486C
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Established in 1967, the agency is mandated by Congress through the Independent Safety
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the accidents, issue safety recommendations, study transportation safety issues, and evaluate
the safety effectiveness of government agencies involved in transportation. The Safety
Board makes public its actions and decisions through accident reports, safety studies, special
investigation reports, safety recommendations, and statistical reviews.
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490 L’Enfant Plaza, S.W.
Washington, D.C. 20594
[phone]
[phone]
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NTSB/AAR-96/02 PB96-910402
NATIONAL TRANSPORTATION
SAFETY BOARD
WASHINGTON, D.C. 20594
AIRCRAFT ACCIDENT REPORT
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
Adopted: July 9, 1996
Notation 6486C
l
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.

MINISTERE DE L’AMENAGEMENT DU TERRITOIRE, DE L'EQUIPEMENT ET DES TRANSPORTS
SECRETARIAT D’ETAT AUX TRANSPORTS
INSPECTION GENERALE DE L’AVIATION CIVIL Le Bourget. le 13 mai 1996.
ET DE LA METEOROLOGIE
BUREAU ENQUÊTES-ACCIDENTS j ‘1 ;:,,
COMMENTS OF THE BUREAU ENQUETES ACCIDENTS (FRANCE)
ON THE NATIONAL TRANSPORTATION SAFETY BOARD
DRAFT FINAL REPORT ON THE ACCIDENT
OF SIMMONS AIRLINES FLIGHT 4184
AT ROSELAWN, INDIANA ON OCTOBER 31, 1994
---------------------------------
SUBMITTED PURSUANT TO ANNEX 13 TO THE
CONVENTION ON INTERNATIONAL CIVIL AVIATION
Bâtiment 153- Aéroport du Bourget -93352 LE BOURGET cedex
Téléphone (33.1) 49 92 72 00 / Télécopie (33.1) 49 92 72 03
INTRODUCTION 6
EXECUTIVE SUMMARY 7
1. FACTUAL INFORMATION
23
1.1. History of the flight 23
1.2. Personnel information
47
1.2.1 the Captain 47
1.2.2 the First Officer 47
1.3. Airplane information 48
1.3.1. ATR 72 icing certification 48
1.3.2. ATR72 Anti-icing Advisory System 62
1.3.3. ATR 72 stick pusher Stall Protection System 66
1.4. ATR 72 icing operating procedures 68
1.4.1. AFM/FCOM and Manufacturer information 68
1.4.2. AMR EAGLE / SIMMONS, Flight Manual and
other pertinent documentation 77
1.5. ATR Flight Training 83
1.5.1. ATR Training Center 83
1.5.2. AMR EAGLE Training Centers
89
1.6. Meteorological information 90
1.7. Flight recorders 98
1.7.1. CVR 98
1.7.2. DFDR 99
1.8. Tests and research 101
1.8.1. previous ATR 42 incidents 102
1.8.2. post flight 4184 accident actions 120
1.8.3. Bilateral Airworthiness Agreement (BAA] 126
1.8.4. certification process between FAA, and DGAC
under the BAA 127
1.8.5. Continuing Airworthiness information exchanged
between FAA and DGAC under the BAA, and -
knowledge of the NTSB regarding icing related
incidents addressed in the NTSB’s Report 129
1.9. Air Traffic Control 136
1.10. Additional information worldwide fleet icing events 141
1.11. Additional pertinent documentation 148
1.12. Additional comments to NTSB factual section 154
2 ANALYSIS 173
2.1. Meteorological factors 174
2.2. History flight 176
2.2.1. Holding technique 176
2.2.2. Analysis of holding pattern sequences 177
2.2.3. Flight crew performance 180
2.2.4. Capacity of aircraft recovery 208
2.2.5. Crew response to roll upset 217
3
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2.3. Previous ATR icing incidents and adequacy of
DGAC/ATR actions 218
2.3.1. Mosinee incident 218
2.3.2. Air Mauritius and Ryan air incidents 224
2.3.3. Newark incident 226
2.3.4. Burlington incident 228
2.3.5. Conclusion 230
2.4. Air Traffic Control 233
2.5. The DGAC’s continuing airworthiness monitoring under
the bilateral airworthiness agreement 236
2.6. ATR operations in icing conditions 244
2.6.1. Certification 244
2.6.2. Flight characteristics 247
2.7. ATR dissemination of ice related information 250
2.7.1. The NTSB Report misrepresents facts and
ATR knowledge 250
2.7.2. ATR dissemination of icing information 255
2.7.3. ATR training for unusual attitudes 257
3. CONCLUSION 258
3.1. BEA findings 258
3.2. Probable cause 266
4
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4. RECOMMENDATIONS 268
4.1. Flight crew performance - sterile cockpit 268
4.2. Pre-flight and in-flight weather information 269
4.3. Pireps 269
4.4. Aircraft certification - freezing drizzle / rain 270
4.5. Certification and continuing airworthiness under
the BAA 271
4.6. ATR 272
4.7. AMR EAGLE 273
5. APPENDICES 274
5
INTRODUCTION
The BEA appreciates the invitation extended to it by the NTSB, as
required by Annex 13 to the Convention on International Civil Aviation, to
comment on the draft accident investigation Final Report. This will serve as
the BEA’s comments on that draft Final Report. We understand that the
Board, as required by Section 6.9 of Annex 13, will either amend the draft
Final Report to include the substance of these comments, or append these
comments to the Final Report.
However the BEA wishes to express its disappointement about its
absolute non participation to the investigation phase related to analysis,
findings, causes and safety recommendations, despite the initial
commitment from the NTSB and despite its repeated efforts to provide the
NTSB investigators with relevant views and documentation. This presently
leads to a major disagreement between two Investigative Authorities on
facts, analysis and on the accident causes, and, moreover, to the risk that
the safety recommendations will not be properly taken into account by all
the parties of the aviation community worldwide, because they will be based
.
on an arguable report.
.