1996 — Nov 19, Runway Collision, United Express 5925 and King Air, Quincy AP, IL– 14

1996 — Nov 19, Runway Collision, United Express 5925 and King Air, Quincy AP, IL–    14

 

–14  NTSB. AAR. Runway Collision, United…5925…Beechcraft…Quincy, IL, Nov 19, 1996.

–14  Sturkey. Mid-Air: Accident Reports and Voice Transcripts… 2008, p. 417.

 

Narrative Information

 

NTSB: Executive Summary

 

“On November 19, 1996, at 1701 central standard time, United Express flight 5925, a Beechcraft 1900C, N87GL, collided with a Beechcraft King Air A90, N1127D, at Quincy Municipal Airport, near Quincy, Illinois. Flight 5925 was completing its landing roll on runway 13, and the King Air was in its takeoff roll on runway 04. The collision occurred at the intersection of the two runways. All 10 passengers and two crewmembers aboard flight 5925 and the two occupants aboard the King Air were killed. Flight 5925 was a scheduled passenger flight operating under 14 Code of Federal Regulations Part 135. The flight was operated by Great Lakes Aviation, Ltd., doing business as United Express. The King Air was operating under 14 Code of Federal Regulations Part 91.

 

“The National Transportation Safety Board determines that the probable cause of this accident was the failure of the pilots in the King Air A90 to effectively monitor the common traffic advisory frequency or to properly scan for traffic, resulting in their commencing a takeoff roll when the Beech 1900C (United Express flight 5925) was landing on an intersecting runway.

 

“Contributing to the cause of the accident was the Cherokee pilot’s interrupted radio transmission, which led to the Beech 1900C pilots’ misunderstanding of the transmission as an indication from the King Air that it would not take off until after flight 5925 had cleared the runway.

 

“Contributing to the severity of the accident and the loss of life were the lack of adequate aircraft rescue and fire fighting services, and the failure of the air stair door on the Beech 1900C to open.

 

“Safety issues discussed in the report include the importance of emphasizing careful scanning techniques during flight training, Beech 1900C certification standards and compliance with requirements on door jamming, the certification of small airports used by scheduled commuter airlines, and aircraft rescue and fire fighting protection on scheduled commuter aircraft having 10 seats or more. Safety recommendations concerning these issues were made to the Federal Aviation Administration.”  (NTSB. AAR, vi.)

 

“….Time and distance data from an Aircraft Performance and Visibility Study conducted by the Safety Board indicated that the King Air began its takeoff roll about 13 seconds before flight 5925 touched down on the runway at 1700:59. According to the occupants of the Cherokee, the King Air had been in position on the runway for about 1 minute before beginning the takeoff roll. The Cherokee pilot stated that he heard no takeoff announcement from the King Air over the CTAF, and none was recorded on the Beech 1900C CVR.” ((NTSB. AAR, p.3.)

 

“At 1701, during flight 5925’s landing rollout, the airplane collided with the King Air at the intersection of runways 13 and 04…. Rescuers reported that they heard signs of life when they first reached the Beech 1900C, but they were unsuccessful in their attempts to open the air stair door….”  (NTSB. AAR, p.4)

 

“Quincy Municipal Airport is an uncontrolled airport owned and operated City of Quincy, Illinois, which is located about 10 miles away from the airport.”  (NTSB. AAR, p.15.)

 

“Both airplanes came to rest with their wings interlocked, along the east edge of runway 13, approximately 110 feet east of where the skid marks converged near the intersection of runways 04 and 13. According to witnesses, both airplanes came to rest on their landing gear after the impact….At the accident site, investigators observed that the grass was burned for approximately 10 feet beyond the perimeter of the wreckage, and that fuel had saturated the grass for about 40 feet beyond the perimeter. A 5- by 8-foot area of fuel residue was observed on the runway area where the aircraft skid marks converged.”  (NTSB. AAR, p.18.)

 

“Rescue Attempts

 

“A pilot employed by the airport’s fixed-base operator (FBO) and two Beech 1900C-qualified United Express pilots who had been waiting for flight 5925 to arrive were the first people to reach the accident scene. One of the United Express pilots remained some distance from the airplanes while the other United Express pilot and the FBO pilot approached the airplanes. They saw that the King Air and the right side of the Beech 1900C were engulfed in fire. The United Express pilot said that he opened the left aft cargo door of the Beech 1900C and black smoke poured out. The FBO pilot said that he could not see the interior of the cabin through the passenger windows because the cabin appeared to be filled with dark smoke. They then ran to the forward left side of the Beech 1900C fuselage where the FBO pilot said he saw the captain’s head and arm protruding from her window on the left. She asked them to “get the door open.”

 

“The FBO pilot stated that he found the forward air stair door handle in the 6 o’clock (unlocked) position.  He said that he attempted unsuccessfully to open the door by moving the handle in all directions and pulling on the door. He said that he did not see any instructions for opening the door, but he was able to rotate the handle upward to the 5 o’clock position but no further. The United Express pilot stated that he then intervened because he believed that the FBO pilot probably did not know how to open the door. The United Express pilot stated that he depressed the button above the handle while rotating the handle from the 3 o’clock position downward to the unlocked position. He stated that the handle felt “normal” as he rotated it. However, he was unable to open the door. The FBO pilot then tried again to open the door by rotating the handle upward, but he was again unsuccessful.

 

“On January 3, 1997, the Safety Board issued urgent Safety Recommendation A-97-1, which asked the FAA to do the following:

 

Immediately issue a telegraphic [Airworthiness Directive] (AD) directing all Beechcraft 1900 operators to (1) conspicuously identify the external air stair exit door button with highly visible markings, (2) indicate that the button must be depressed while the handle is rotated, and (3) include an arrow to show the direction that the handle must be moved to open the door.  (NTSB. AAR, pp. 20-21.)

 

“….The Quincy Airport has an ARFF truck, which is staffed by QFD firefighters 15 minutes before and 15 minutes after the arrival and/or departure of an air carrier aircraft with more than 30 passenger seats. The truck at the airport was not staffed at the time of the accident because no air carrier aircraft with more than 30 passenger seats were landing or taking off.  According to the fire chief, after the accident, the QFD and the City of Quincy began to investigate ways to staff the ARFF truck at the airport during periods beyond that required by the FAA.”

 

“The flightcrew made radio transmissions about 30 miles out, at 1652:07, (“any traffic in the area please advise”); 10 miles out, at 1656:56, (“we’ll be inbound to enter on a left base for runway one three at Quincy any other traffic please advise”); 5 miles out, at 1659:29, (“just about to turn, about a six mile final for runway…one three, more like a five mile final for runway one three at Quincy;”); and on short final, at 1700:16, (“aircraft gonna hold in position on runway four or you guys gonna take off?”) Although these callouts did not exactly match those recommended in the AIM and AC 90-42F, they were appropriate for the straight-in approach being flown.  Even though under 14 CFR Part 91.113, flight 5925, as a landing aircraft, had the right of way over aircraft on the surface, the captain took the precaution of asking whether the airplane on the runway was going to hold or take off. It would have been prudent for the captain to refer specifically to the “King Air,” to leave no doubt about which airplane she was addressing; however, her transmission was sufficiently specific that she could reasonably expect to be understood.

 

The Cherokee pilot’s transmission, at 1700:28, (“seven six four six Juliet uh, holding uh, for departure on runway four….on the uh, King Air”) immediately followed the captain’s inquiry, and appeared to be in response to her question. The transmission was interrupted by the GPWS alarm in the Beech 1900C. Although it would have been prudent for the captain to ask that the transmission be repeated, her reply, at 1700:37, (“OK, we’ll get through your intersection in just a second sir… we appreciate that”) made it clear that she believed she was communicating with the airplane that was to take off next on the runway, and it would have been reasonable for her to expect a clarification if that was not the case.”  (NTSB. AAR, p. 43.)

 

“The airplane touched down at 1700:59. The captain was recorded as calling for “Max reverse” at 1701:01; expletives from the flightcrew were also recorded beginning at 1701:01, indicating that the flightcrew saw the King Air at that time. Skid marks indicate that they applied maximum braking beginning 3 seconds later until the time of impact at 1701:09.

 

“The Safety Board concludes that the flightcrew of flight 5925 made appropriate efforts to coordinate the approach and landing through radio communications and visual monitoring; however, they mistook the Cherokee pilot’s transmission (that he was holding for departure on runway 04) as a response from the King Air to their request for the King Air’s intentions, and therefore mistakenly believed that the King Air was not planning to take off until after flight 5925 had cleared the runway.”  (NTSB. AAR, pp. 43-44.)

 

“Although he had been sitting on runway 04 for about 1 minute, the King Air pilot began the takeoff without making a takeoff announcement over the CTAF.  Because of the delay between the announcement from the King Air that the King Air was taking the runway and the commencement of its takeoff roll, an additional takeoff announcement would have been prudent, and would have been consistent with common and expected practice at uncontrolled airports. Such an announcement would have afforded the Beech 1900C flightcrew the opportunity to take evasive action. Because no pilot would take off knowing that another airplane was about to land on an intersecting runway, the occupants of the King Air must have been unaware at the time they began their takeoff roll that an airplane was about to land. The Safety Board concludes that the failure of the King Air pilot to announce over the CTAF his intention to take off created a potential for a collision between the two airplanes.

 

“Had the occupants of the King Air been monitoring the CTAF, they should have heard the four announcements from flight 5925 indicating that the airplane was inbound to Quincy and was planning to land on runway 13. Also, they would most likely have answered the question that was directed at them, or corrected the misunderstanding resulting from the Cherokee pilot’s transmission. Therefore, the Safety Board concludes that the occupants of the King Air did not hear the transmissions from flight 5925 on the CTAF.”  (NTSB. AAR, pp. 44-45.)

 

“Witnesses indicated that the approaching Beech 1900C was visible from at least 10 miles out, 4 minutes before it landed. Although the Safety Board’s visibility study indicated that the view of the landing airplane from the cockpit of the King Air would have been partially or momentarily fully obstructed by the cockpit side posts during much of the Beech 1900C’s final approach to landing and during the King Air’s takeoff roll, those obstructions could have been easily overcome if the King Air’s occupants had moved their heads and bodies while scanning. If they had done so at any point during the last 4 minutes of the airplane’s approach, they would have been able to see the incoming airplane and would not have commenced their takeoff roll when they did. Therefore, it is clear that neither occupant of the King Air properly scanned for traffic.” (NTSB. AAR, pp. 45-46.)

 

“The King Air pilot’s flying history suggests that he may not have placed sufficient importance on the basics of safe flying. His previous gear-up incident during an instructional flight suggests carelessness, and his subsequent comments to the FAA indicate that he did not consider the incident significant. The fact that he sat on an active runway for an extended time and comments from students indicating that he seemed to be rushing them are consistent with a careless attitude. Further, during his last year as a TWA pilot, the pilot had been downgraded from captain to flight engineer because of poor performance during recurrent training….

 

“The King Air pilot might have been in a hurry to get home after a long day of flying potential purchasers of the King Air on a demonstration flight to Tulsa. After the King Air pilot returned to Quincy, two of the passengers said that he seemed to be “in a hurry” or “anxious to get home.”

A combination of these factors (preoccupation with providing instruction to the pilot/passenger, careless habits, possible fatigue, and rushing) could explain why the King Air pilot did not properly scan for traffic.” (NTSB. AAR, p. 46.)

 

“The Safety Board concludes that the occupants of the King Air were inattentive to or distracted from their duty to “see and avoid” other traffic. In light of the circumstances of this accident, the Safety Board believes that the FAA should reiterate to flight instructors the importance of emphasizing careful scanning techniques during pilot training and biennial flight reviews.”  (NTSB. AAR, p. 47.)

 

“Both the Cherokee pilot and the passenger saw the two airplanes converging. The Cherokee pilot had the opportunity to alert the pilots in the Beech 1900C to the situation, and it would have been prudent for him to do so. It should have been apparent from the Beech 1900C’s approach path, which would have been about a 90-degree angle to runway 04, that the runways intersected. Nonetheless, the Cherokee pilot stated that he did not realize the runways intersected. The Cherokee passenger said that he thought the airplanes would miss each other.  The Safety Board concludes that because of the Cherokee pilot’s inexperience, he probably did not realize that a collision between the two airplanes was imminent, and therefore he did not broadcast a warning.”  (NTSB. AAR, p. 48.)

 

“The autopsy reports revealed that the occupants of both airplanes died of carbon monoxide intoxication from the inhalation of smoke and soot from the postimpact fire or inhalation of products of combustion. They did not sustain blunt force trauma injuries that would have impeded their mobility or ability to evacuate.

 

“The bodies of the King Air’s occupants were found behind the seats in the cockpit, indicating that they were overcome by the effects of the fire before reaching an exit.

 

“Witnesses who ran to the scene immediately after the collision stated that they heard sounds of life from within the cabin of the Beech 1900C and that the captain talked to them from the cockpit….

 

“The body of flight 5925’s first officer was found between the air stair door and the forward right overwing exit. The exterior air stair door handle was in the unlocked position when the first people reached the accident scene, suggesting that the first officer followed company evacuation procedures and initially tried to open the air stair door but was unable to do so. Because the right overwing exits were near the fire on the right side of the cabin, he most likely proceeded toward the left overwing exit but was overcome by the effects of the smoke and fire before he could reach it. The rescuers did not observe any smoke coming from the left overwing exit, indicating that it was not opened.

 

“The Safety Board concludes that the impact forces were at a survivable level for the occupants of both airplanes. The Safety Board further concludes that the speed with which the fire enveloped the King Air and the intensity of the fire precluded survivability for the occupants of the King Air; however, the occupants of the Beech 1900C did not escape because the air stair door could not be opened and the left overwing exit hatch was not opened.”  (NTSB. AAR, 48.)

 

“The Safety Board concludes that the most likely reason that the air stair door could not be opened is that the accident caused deformation of the door/frame system and created slack in the door control cable. The Safety Board is concerned that the design and testing of the door did not account for minimal permanent deformation that could introduce slack into the door control system and ultimately disable the door. Therefore, the Safety Board believes that the FAA should evaluate the propensity of the Beech 1900C door/frame system to jam when it sustains minimal permanent door deformation and, based on the results of that evaluation, require appropriate design changes.”  (NTSB. AAR, p. 49.)

 

“The Safety Board is further concerned that even though the impact forces from the accident were so mild that both airplanes came to rest on their landing gear and the occupants of the Beech 1900C sustained little or no injuries as a result, those same forces were apparently sufficient to cause the Beech 1900C’s air stair door to jam, preventing the occupants from using it to escape. Because the airplane was certificated by the FAA as having met the freedom from jamming requirements, the Safety Board attempted to analyze the adequacy of those requirements….

 

“The Safety Board concludes that the methods for showing compliance with the FAA’s certification requirement that external doors be reasonably free from jamming as a result of fuselage deformation are not clearly defined. Therefore, the Safety Board believes that the FAA should establish clear and specific methods for showing compliance with the freedom from jamming certification requirements.”  (NTSB. AAR, pp. 49-50.)

 

“Emergency Response

 

“The Quincy Fire Department was 10 miles away, and it took about 14 minutes for its fire fighting units to arrive. In contrast, 14 CFR Part 139 requires that a certificated airport be capable of an immediate response time of 3 minutes by an on-site ARFF truck equipped with extrication tools and carrying extinguishing agent and properly trained firefighters. However, this requirement applies only when the airport is serving air carrier aircraft with a seating capacity of more than 30 passengers.

 

“Witnesses observed that the fire was burning on the right side of the Beech 1900C, about 1,800 feet from the airport’s ARFF truck. If properly staffed, that truck should have been able to reach the accident site in no more than 1 minute. Fire fighters might then have been able to extinguish or control the fire, thereby extending the survival time for at least some of the occupants of the Beech 1900C. Those occupants might then have had time to escape through the overwing exit hatch. Accordingly, the Safety Board concludes that if on-airport ARFF protection had been required for this operation at Quincy Airport, lives might have been saved.

 

“Therefore, the Safety Board reiterates Safety Recommendation A-94-204, which urges the FAA to do the following:

 

Permit scheduled passenger operation only at airports certificated under the standards contained in Part 139, “Certification and Operations: Land Airports Serving Certain Air Carriers.”

 

“The Safety Board concludes that although some communities may lack adequate funds to provide ARFF protection for small airports served by commuter airlines, commuter airline passengers deserve the same degree of protection from postcrash fires as air carrier passengers on aircraft with more than 30 passenger seats. Accordingly, the Safety Board believes that the FAA should develop ways to fund airports that are served by scheduled passenger operations on aircraft having 10 or more passenger seats, and require these airports to ensure that ARFF units with trained personnel are available during commuter flight operations and are capable of timely response….”  (NTSB. AAR, p. 51.)

 

Sturkey: “Synopsis: A Beechcraft 1900 Beechliner landed in clear weather at night. At the same time a Beechcraft A-90 King Air was taking off on an intersecting runway. The two aircraft collided at the runway intersection, and the post-crash fire killed all 14 people aboard both planes.” (Sturkey. Mid-Air: Accident Reports and Voice Transcripts from Military and Airline Mid-Air Collisions. 2008, p. 417.)

 

Sources

 

National Transportation Safety  Board. Aircraft Accident Report. Runway Collision, United Express Flight 5925 and Beechcraft King Air A90, Quincy Municipal Airport, Quincy, Illinois, November 19, 1996 (NTSB/AAR-97/04; PB97-910404).  Washington, DC:  NTSB, adopted July 1, 1997, 99 pages. Accessed at: http://www.ntsb.gov/publictn/1997/aar9704.pdf

 

Sturkey, Marion F. Mid-Air: Accident Reports and Voice Transcripts from Military and Airline Mid-Air Collisions. Plum Branch, SC: Heritage Press International, 2008.