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B190 / BE9L, Quincy IL USA, 1996

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Summary
On 19 November 1996, a Beech 1900C which had just landed and a Beech King Air A90 which was taking off collided at the intersection of two runways at the non-Towered Quincy Municipal Airport. Both aircraft were destroyed by impact forces and fire and all occupants of both aircraft were killed. The Investigation found that the King Air pilots had failed to monitor the CTAF or properly scan visually for traffic. The loss of life of the Beech 1900 occupants, who had probably survived the impact, was attributed largely to inability to open the main door of the aircraft.
Event Details
When November 1996
Actual or Potential
Event Type
Airworthiness, Fire Smoke and Fumes, Human Factors, Runway Incursion
Day/Night Day
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BEECH 1900
Operator Great Lakes Aviation
Domicile United States
Type of Flight Public Transport (Passenger)
Origin Chicago/O'Hare International Airport
Intended Destination Quincy
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Landing
LDG
Flight Details
Aircraft BEECH 90 King Air
Operator Private
Type of Flight Private
Origin Quincy
Take off Commenced Yes
Flight Airborne No
Flight Completed No
Flight Phase Take Off
TOF
Location - Airport
Airport Quincy
General
Tag(s) Flight Crew Training,
Aircraft-aircraft collision,
Inadequate Airworthiness Procedures,
Ineffective Regulatory Oversight,
Inadequate Airport Procedures
FIRE
Tag(s) Post Crash Fire
HF
Tag(s) Distraction,
Procedural non compliance,
Ineffective Monitoring - SIC as PF
GND
Tag(s)
RI
Tag(s) Incursion pre Take off,
Incursion after Landing,
Intersecting Runways,
Ground Collision
EPR
Tag(s) RFFS Procedures
AW
System(s) Other
Contributor(s) Damage Tolerance
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Non-aircraft damage Yes
Fatalities Most or all occupants (14)
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Aircraft Airworthiness,
Airport Management
Investigation Type
Type Independent

Description

On 19 November 1996, a Beech 1900C (N87GL) being operated by Great Lakes Aviation on a scheduled passenger flight from Chicago O'Hare to the non-Towered airport at Quincy as United Express 5925 under call sign Lakes Air 251 was completing its landing roll on runway 13 when it collided at the intersection of two runways with a Beech King Air A90 (N1127D) which had begun a take-off on the intersecting runway 04. Both aircraft were destroyed by the impact and post-crash fires and all 14 occupants of the two aircraft were killed. The accident happened in daylight conditions and with normal ground visibility. The runway and runway lighting were damaged in the vicinity of the collision.

Investigation

An Investigation was carried out by the National Transportation Safety Board (USA) (NTSB). The Beech 1900C was not fitted with an FDR and was not required to be. Data from the CVR which was installed was, although readable, found to be of poor quality and especially so during incoming or outgoing radio transmissions. It was noted that between October 1994 and January 1997, the Board had "investigated five other accidents/incidents involving Beech 1900 airplanes in which the CVR poorly recorded the incoming or outgoing radio transmissions" and had concluded "that the problem originated in the isolation amplifiers installed in the airplanes rather than in the actual CVR units".

The 30 year old Captain of the Beech 1900C had accumulated approximately 4,000 hours total flight time which included 700 hours in command on type since gaining her command nine months earlier. The 24 year-old Beech 1900C First Officer, who had been PF for the accident flight, had accumulated approximately 1,950 hours total flight time which included 800 hours on type. The 63 year-old King Air pilot was a retired airline pilot with 25,674 hours total flight time who since retirement had undertaken some air taxi work and part time pilot instruction. He had recently been involved in a wheels up landing in a Cessna 172RG whilst giving instruction to a student commercial pilot and had not yet completed the re-training required in place of FAA enforcement action. The Investigation was told by the FAA Inspector who had investigated the Cessna occurrence that the pilot had “expressed an extremely negative attitude toward the FAA’s questioning him about this landing" and stated that to a pilot of his background and experience, "landing gear up did not mean anything". His airline records also showed that one year before his 27 year period of flight crew employment by TWA ceased in 1992, he had been demoted to the rank of Flight Engineer "because of flying deficiencies observed in the pilot’s training, which resulted in a failed proficiency check and a failed special line check".

The departing King Air flight was being used to provide informal aircraft familiarisation to a less experienced 34 year-old pilot who, whilst employed on the ground, had gained a commercial pilot certificate for single engine aircraft and was a part time flight instructor on such aircraft at a local aero club with 1,462 total flying hours. It was reported that on the day of the accident flight, she had also accompanied the pilot on an demonstration flight from Quincy to Tulsa and back for potential purchasers of the King Air who had observed her being 'taught' by the Pilot with hands on the controls and also that these flights had been her first experience in a King Air.

It was established that with VMC prevailing across the area, the Beech 1900C Captain had made an initial call on the Quincy Common Traffic Advisory Frequency (CTAF) about eight minutes prior to landing stating that the aircraft was about 30 miles north of the field and would be positioning for a landing on runway 13. She also asked that any traffic in the area should please advise but no replies were received to this request. Just over three minutes later, the King Air passenger/pilot broadcast on the CTAF that the King Air was taxiing out for a take-off from runway 04 and this was followed by a recently-qualified PPL in a Piper Cherokee making a similar call. The Beech 1900C Captain then commented to her First Officer that both were using 04 and asked him if he still intended to land on 13 to which he responded yes, unless it didn't look good in which case he would join downwind for runway 04. The Captain then announced on the CTAF that they were "a Beech airliner currently ten miles to the north of the field" and that "we’ll be inbound to enter on a left base for runway one three at Quincy, any other traffic please advise” to which there was no response.

Two minutes later, the pilot/passenger in the King Air broadcast that the aircraft was "holding short of runway 4… be takin' the runway for departure and heading southeast" which was heard by both Beech 1900C pilots. The King Air then taxied onto runway 04 to a position clear of runway 36 (see the diagram below). The Beech 1900C Captain then made a further call that their aircraft was "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". Then, 45 seconds later, she broadcast that they were “on short final for runway one three” and asked if “the aircraft gonna hold in position on runway four or you guys gonna take off?” to which there was no reply from the King Air. However, the Cherokee pilot then began transmitting "7646Juliet…holding…for departure on runway 4” which on the Beech 1900C CVR was then interrupted by the GPWS automatic callout of "200" followed by “(unreadable word) on the uh, King Air".

The Beech 1900C Captain, believing this transmission was from the King Air responded with "OK, we’ll get through your intersection in just a second sir (unintelligible word) we appreciate that". Several witnesses reported that the Beech 1900C had its landing lights on and a normal touch down was subsequently made near the beginning of runway 13. The Investigation estimated that the King Air had begun its take-off roll about 13 seconds before this touchdown after having been in position on runway 04 for about a minute. There was no evidence that the King Air had broadcast that it was taking off on the CTAF and shortly afterwards the collision occurred at the intersection of runways 13 and 04.

The aerodrome layout in the area where the landing was continued. [Reproduced from the Official Report]

Both aircraft remained on their landing gear as they came to rest after which fuel fed fires immediately began in both damaged aircraft, initially affecting the right hand side of the Beech 1900C and all of the King Air. Three pilots, two of whom were Beech 1900 qualified were the first people to reach the accident site but were unable to open the Beech 1900 main passenger door in response to a request from the aircraft Captain even with the handle in the unlocked position and after it had been cycled correctly back to that position. Despite the fact that most if not all 12 occupants appeared to have survived the collision without sustaining "blunt force trauma" as a result, the inability to open this door and the non-opening of the two over-wing exits meant that everyone on board soon succumbed to the effects of "inhalation of smoke and soot" and other "products of combustion".

It was noted that the airport had no RFFS nor was this required and that the local Fire Department was ten miles away and its equipment had not reached the site until "about 14 minutes" after the accident. It was also noted that although a similar but certificated airport would have been required to facilitate a 3 minute response time with on-airport equipment and specially trained personnel, this would only apply if an airport was served by air carrier aircraft with more than 30 passenger seats. Nevertheless, it was considered that "lives might have been saved" had on-airport fire cover been available.

This accident led to a discussion as to why the main door could not be opened which was unable to come to a definite conclusion. The Investigation noted that the FAA Type Certification process for the Beech 1900C had assessed the main door "as having met the freedom from jamming requirements" but found that there was "apparently no clear guidance indicating how a manufacturer should demonstrate compliance with these requirements" and in particular "no clear written guidance from the FAA specifying the degree of fuselage deformation contemplated by those regulations" or any explanation of what is meant by the expression "reasonably free" from jamming. It was therefore concluded that "the propensity of the Beech 1900C door/frame system to jam when it sustains minimal permanent door deformation" should be re-evaluated by FAA and, subject to the results of that evaluation, appropriate design changes should be made. The possibility that the accident aircraft door operating cable might have been misrouted was also considered but no supporting evidence for this was found.

The formally-documented Conclusions of the Investigation included the following:

  • Given the Beech 1900C flight crew’s frequent radio broadcasts of the airplane’s position during the approach, and the lack of any prohibition on straight-in approaches to uncontrolled airports, the flight crew’s decision to fly a straight-in approach to runway 13 was not inappropriate.
  • The flight crew 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.
  • The failure of the King Air pilot to announce over the common traffic advisory frequency his intention to take off created a potential for collision between the two airplanes.
  • The occupants of the King Air did not hear the transmissions from flight 5925 on the common traffic advisory frequency; it is likely that either the King Air occupants did not properly configure the radio receiver switches to the common traffic advisory frequency, or that they were preoccupied, distracted, or inattentive.
  • The occupants of the King Air were inattentive to or distracted from their duty to see and avoid other traffic.
  • The Cherokee pilot’s transmission in response to flight 5925’s request was unnecessary and inappropriate and, combined with the lack of any correction to the flight crew's misunderstanding, misled the flight crew into believing that it had been communicating with the King Air, and that the King Air would continue holding.
  • 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.
  • Although some communities may lack adequate funds to provide aircraft rescue and fire fighting protection for small airports served by commuter airlines, commuter airline passengers deserve the same degree of protection from post-crash fires as air carrier passengers on aircraft with more than 30 passenger seats.

It was determined that the Probable Cause of the 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”.

In addition, a Contributory Factor in respect of Cause was identified as "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".

Also a Contributory Factor in respect of the Severity of the accident and the loss of life was identified as "the lack of adequate aircraft rescue and fire fighting services, and the failure of the air stair door on the Beech 1900C to be opened".

At the conclusion of the Investigation, seven Safety Recommendations were made as follows:

  • that the Federal Aviation Administration should reiterate to flight instructors the importance of emphasising careful scanning techniques during pilot training and biennial flight reviews. [A-97-102]
  • that the Federal Aviation Administration 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. [A-97-103]
  • that the Federal Aviation Administration should establish clear and specific methods for showing compliance with the freedom from jamming certification requirements. [A-97-104]
  • that the Federal Aviation Administration should consider the circumstances of the November 19, 1996 Quincy, Illinois accident when developing methods for showing compliance with freedom from jamming requirements, and determine whether it is feasible to require that doors be shown to be free from jamming after an impact of similar severity. [A-97-105]
  • that the Federal Aviation Administration should review and improve, as necessary, guidance for principal maintenance inspectors to use in ensuring that maintenance personnel are properly trained in accomplishing the maintenance tasks that they are assigned. [A-97-106]
  • that the Federal Aviation Administration 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 aircraft rescue and fire fighting units with trained personnel are available during commuter flight operations and are capable of timely response. [A-97-107]
  • that the Federal Aviation Administration should add to the Safety Information Section of the FAA’s Internet Home Page a list of airports that have scheduled air service but do not have aircraft rescue and fire fighting capabilities. [A-97-108]

In addition, a previously-made Safety Recommendation was re-iterated:

  • that the Federal Aviation Administration should permit scheduled passenger operation only at airports certificated under the standards contained in Part 139, “Certification and Operations: Land Airports Serving Certain Air Carriers”. [A-94-204]

The Final Report of the Investigation was adopted by the Board on 1 July 1997 and subsequently published. Amendments were subsequently made to the wording of four of the Findings and to the Probable Cause and to the wording of text on the air stair door of the Beech 190C on pages 49 and 50 of the Report. The amended version was approved by the NTSB on 5 September 2000 and references in this summary take account of these where relevant. Also, the version of the Final Report referenced here includes a short (two page) Appendix with details of the changes made to the original text immediately prior to the 'Executive Summary' at the beginning.

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