American Eagle Flight 4184 had been holding for 32 minutes in a chilly drizzle last October when air traffic controllers in Chicago cleared the pilots to make a routine descent from 10,000 to 8,000 feet.
Although the pilots did not know it, a dangerous ridge of ice had built up on the wings, and in a fraction of a second, to their complete and ultimately final terror, the pilots lost control of the ATR-72 turbo prop.
The plane’s controls moved on their own, tilting the right wing almost perpendicular to the ground. The pilots wrestled with the aircraft, but the wing tilted violently again, the plane flipped on its back and, without hope of recovery, the plane plunged toward earth.
All 68 people aboard were killed when the plane slammed into a soybean field near Roselawn, Ind.
It was a crash that did not have to happen.
A New York Times investigation has found that the Federal Aviation Administration had for years brushed aside repeated warnings from pilots, and experts, and from the behavior of the plane itself, that something was awry. The failure to heed those warnings raises troubling questions that go beyond the Roselawn crash, questions about the procedures and safeguards of the agency itself.
The agency does not routinely monitor crashes abroad of foreignmade planes operating in this country - as happened with the ATR. It also relies heavily on manufacturers’ evaluations of their own airplanes - as with the ATR rather than conducting independent tests. As a result, its own experts increasingly lack the hands-on knowledge to ask the right questions.
The FAA’s bureaucratic culture keeps it from being aggressive, as does its reluctance to impose costly safety modifications on airlines.
There have been assertions for years that issues like wind shear - and de-icing - become priorities only after a fatal crash brings them to public attention.