In the aftermath of 4184, we learned a great deal about the science of freezing rain and an entire fleet of aircraft not well suited to fly in it. We learned about warnings that went unheeded, and air traffic control procedures that would forever change. That was the technical stuff. Now we look back at the human factor.
On a quiet county road just south of Roselawn stand 68 crosses. Each bears the name of a life lost when Flight 4184 crashed into a soybean field a stone's throw away.
The Super ATR aircraft had been in a holding pattern for O'Hare. The pilots were unaware of a deadly ice build-up that would cause the plane to roll and plunge to earth. There was little left of the plane and passengers.
Victims' relatives- deep in grief and hungry for information could get little - from the airline or the government.
"Flight 4184 exemplified not only the tragic nature, but the utter confusion that existed during that time period," said Don Nolan, aviation law attorney.
The pilot's wife waited days for her husband's employer just to call her. Airline care teams visited victims' families and asked about their dead relatives medical histories.
Some of the unidentifiable human remains were laid to rest in a nearby cemetery. The airline conducted a service, but didn't tell the families.
"I was angry, I was upset," said Terri Severin.
Terri Severin lost her sister and her four year old nephew - the only child on the flight. Four months after the crash, Terri summoned the courage to go to the site. She was numbed by what she found.
"I actually walked away with bags full of plane wreckage, personal effects and human remains that were still just scattered at the site," said Severin.
Those discoveries - plane parts, body parts four months later - became, for the relatives, the ultimate indignity.
"There were unspeakable things that occurred," said Jim Hall.
Fifteen years ago, Hall was the chairman of the National Transportation Safety Board. The NTSB's singular mission then was to find out what went wrong, and to make recommendations so it doesn't happen again. But the families? That's for somebody else.
"I was told this isn't your business, and I said, 'well my goodness. If I'm being paid by the taxpayers and we're the agency that responds to these tragedies, it has to be our business,'" said Hall.
Hall wanted change. The families of 4184 demanded it, and in concert with families from other airline crashes, they pushed for it.
Two years later, the Aviation Disaster Family Assistance Act was signed into law.
Today when there is a disaster, the NTSB immediately takes the lead in dealing with the needs of families from information to crash site access.
"Today, the airlines are obligated to have a disaster plan in place. Those types of plans didn't exist 15 years ago," said Hall.
There are now protocols for airline employee training, grief counseling, the handling of remains and the return of personal effects.
"I am still healing and it will probably be a life long journey," said Severin.
Terry Severin has written a book and lectures on what happened after 4184. She says she learned long ago that corporations and government are not fail-safe resources in the wake of disaster.
"But I have learned that the average citizen can make a difference in turning a negative response into a positive outcome," said Severin.
This Saturday, Terri and other 4184 relatives will return to the memorial, as they do every year, to remember, to celebrate 68 lives and, perhaps, to contemplate what's changed since that tragic miserable night 15 years ago in a bean field just outside Roselawn, Indiana.
The NTSB's family response model is now used internationally. But responses to disaster will always be imperfect.
Terri Severin one day opened a letter saying that the airline had some unclaimed personal effects from 4184. It turned out that a couple of her nephew's toys were among them. Terri received that letter eight years after the crash.
For more information on Severin's book, visit www.inthewakeofthestorm.com.
