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Opening Statement at the Roselawn Board Meeting, Washington, DC
Jim Hall
National Transportation Safety Board (NTSB), Board Meeting of the accident in Roselawn, IN on 10/31/1994, Washington, DC

Good morning. We are here today to consider a draft final report on the National Transportation Safety Board's investigation of the October 31, 1994 crash of an American Eagle ATR-72 in Roselawn, Indiana that took the lives of all 68 persons aboard.

This accident was a great tragedy. It was a tragedy not only for the 68 victims, but, like all accidents of this kind, it was a tragedy for the hundreds of loved ones they left behind. We have a large representation of those families here with us today, and I want to extend a special welcome to you.

My involvement in this accident began just hours after it occurred, when I stood in the muddy field in which flight 4184 came to rest. Through the rain and mist that dark night, I was able to make out what appeared to be the tailcone of the fallen aircraft, little knowing that in the morning light it would prove to be one of the largest pieces of the plane remaining.

Since then, I have met many of you who lost loved ones in that accident, and the Board has tried to keep you updated on the status of our investigation.

I would also like to acknowledge the presence and the good works of Mr. Doug Smith and others who have helped bring to the attention of the American public, the NTSB, and to Congress the important issue of how family members are treated after air disasters. The hearing held by Aviation Subcommittee Chairman Jimmy Duncan on June 19 was an important step in seeing that all family members are treated humanely. The good work that you are doing is making a difference and I commend you for it.

Because of the intense interest this meeting has generated in the public and press, as well as to accommodate the wishes of the family members to attend, we have moved our meeting to this ballroom in the Loews L'Enfant Plaza Hotel. We are making a video tape record of this meeting; copies may be purchased by contacting our contractor through the Board's Public Inquiries Branch at (202) 314-6551.

None of us at the Safety Board can truly understand what you have gone through these last 20 months, nor do we presume that by issuing a final report your grief will pass. However, I want to assure you that what you will witness today will be the culmination of an extremely exhaustive investigation. If in your minds we have taken too long to reach this point, I hope you understand that it is because we wanted to make sure no reasonable avenue of inquiry had been overlooked.

Let me briefly describe to you what you will be observing today. A few weeks ago, our investigative staff submitted for our consideration a draft final accident report on the crash of American Eagle flight 4184. Since then, each of us has had the opportunity to study the draft. While we have been able to meet individually with staff to discuss the draft, today is the first opportunity for all four of us to discuss among ourselves and collectively with staff the elements of the draft report.

During today's meeting, you will observe the Board Members go through the report section by section, soliciting staff comments and explanations on many points. Once we have completed that process, which will assuredly consume many hours, we will then consider the conclusions, probable cause determination, and specific safety recommendations proposed by staff in the draft report.

And let me take this opportunity to point out to you that there are only 4 of us taking part in this meeting because Vice Chairman Robert Francis has recused himself from the Roselawn investigation. Let me read from his February 2, 1996 recusal:

"After giving serious thought to my service with the FAA in France at the time of the accident, I have concluded that it would be prudent for me to decline participation in the determination of probable cause for Roselawn, Indiana. I do not believe, and am confirmed in this belief by agency counsel, that there is any legal requirement that I withdraw. Nevertheless, in order to avoid any possible misunderstanding or public confusion over NTSB independence, I believe that recusal is the sound course."

I think this is a good time to explain the party system to those of you who may not be familiar with our processes. The National Transportation Safety Board is funded by the taxpayers of the United States of America. We are a small agency; with just 350 employees, we investigation 2,000 aviation accidents and about 500 surface transportation accidents a year. We are able to accomplish this by leveraging our resources through the party system. In a major investigative effort like Roselawn, each of our investigators on the team heads a group of investigators in a particular specialty, such as engines, systems or human performance. Other organizations that can provide us with expertise we need are granted party status and provide investigators for these groups.

NTSB procedures safeguard the independence of our investigations. For example, all outside investigators report directly to NTSB investigators. Also, while the parties agree on the factual findings of the investigation, no parties -- with the exception of foreign parties covered by international agreements, which I will explain shortly -- are permitted to preview the Board's analysis and findings of probable cause.

In the case of the Roselawn investigation, those parties were:

  • The Federal Aviation Administration
  • Simmons Airlines/AMR Eagle
  • Air Line Pilots Association
  • Avions de Transport Regional (ATR)
  • National Air Traffic Controllers Association (NATCA)
  • National Weather Service
  • National Aeronautics and Space Administration (NASA), and
  • Honeywell, Inc.

I want to thank all of these organizations for their assistance to us in this major investigation.

One of the factors that added considerable time to this investigation is the fact that the aircraft was of foreign manufacture. Under international agreement, through the International Civil Aviation Organization, or ICAO, the country of manufacture may participate not only in the on-scene and follow-up investigative activities, but may review and provide comments on the Board's draft report before it is considered at a public meeting.

Because of this, the Bureau Enquetes-Accidents, or BEA, basically France's version of the NTSB, and the Direction General a l'Aviation Civile, or DGAC, which is basically France's FAA, participated in all phases of this investigation, had full access to our completed draft report and provided extensive comments. This process added more than 6 months to our investigation.

While some might wish to question the wisdom of this arrangement, I can assure you that if an American-made or U.S.-operated airliner were to crash in France, our government would be afforded the same rights. This process has proved extremely useful in the past and is a major benefit to aviation safety.

Let me turn to the investigation itself. While we never lost sight of the 68 people who lost their lives in this accident, we fully understood the importance of this accident to the aviation industry in general, and to ATR in particular. We also fully understood the consequences of our actions to the airlines that use this aircraft and to the travelling public that use those airlines.

As you know, just a week after this accident we issued urgent safety recommendations to the FAA to restrict the flight of ATR aircraft in icing conditions until a fix could be developed for what we believed to be undesirable airplane characteristics in icing conditions. When the FAA basically accepted those recommendations about a month later, it caused disruption for midwest travellers during the busy holiday season.

As an aside, the reason we were able to rapidly identify the undesirable characteristics that led to the crash -- and the reason we have as much information on the final moments of the flight -- was that the ATR-72 had a sophisticated flight data recorder, or FDR, with more than 100 parametersthat the investigators could examine. Contrast this to the 2 Boeing 737s that crashed in the last 5 years for which we still have been unable to determine the causes. Both had old recorders with very few parameters. The FAA and the industry have yet to take acceptable action on our recommendations to upgrade FDRs on many airliners.

I think that ATR should be commended for equipping its aircraft with modern recorders. The wealth of information we learned from the recorder expedited the industry's understanding of the problem and led to an equipment redesign, therefore benefiting air safety.

During the course of the Roselawn investigation, we spent considerable effort and resources on flight tests and on examining the certification history of the aircraft. And as I've said, we spent a lot of time considering the points and information provided by the French government.

The result is one of the largest draft reports in Safety Board history, 319 pages not counting appendices.

This is going to be a very long meeting, although I'm optimistic that we'll complete it by late today. Among the issues you'll hear discussed today are:

  • Methods for forecasting icing conditions;
  • ATR-72 flight characteristics with ice build up;
  • The FAA's certification of the ATR;
  • DGAC and FAA oversight of the continuing airworthiness of the ATR; and
  • The flight crew's actions during the flight.

In closing, let me remind you that this is a public meeting. Among our audience are not just family members of those aboard, but representatives of most if not all the parties to the investigation. I ask that while we are in session any conversations be conducted outside the ballroom, and I ask the members of the press to conduct any interviews out in the hall, as well. Thank you for your cooperation.

Mr. Jordan, would you please introduce the staff.


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