December 1, 1997
By Bruce Landsberg
The ground collision between a Beech 1900 airliner and a Beech King Air A90 at Quincy, Illinois, in November 1996 perfectly illustrates the concept of the accident chain — change any one thing and the accident is unlikely to occur. This collision is unique; in the AOPA Air Safety Foundation records dating back to 1982, there has not been another ground collision between an airliner and a corporate GA aircraft at a nontowered airport.
The 1900 made a straight-in approach to Runway 13 and collided on the ground at the intersection of Runway 4 with the A90, which was on the takeoff roll. The collision occurred at 5:01 p.m. Central Standard Time at the nontowered Quincy airport, which is served by a common traffic advisory frequency (CTAF). A Piper Cherokee, flown by a new pilot, was also preparing for departure, was using the CTAF, and became a factor in the collision.
The weather was not a culprit. A special report issued just after the collision showed winds from 070 degrees at 9 knots, visibility 12 miles; a few clouds near the surface, ceiling 14,000 feet broken, 20,000 feet overcast; temperature 2 degrees Celsius; dew point minus 3 degrees C; altimeter setting 29.99; smoke near the ground. Ambient light conditions were nearly ideal for spotting traffic from the north. In the evening twilight, the 1900's landing and strobe lights were readily visible from several miles out on the approach to Runway 13, according to witnesses.
There were five qualified pilots involved in this collision scenario. The Beech 1900 captain, age 30, held an airline transport pilot (ATP) certificate and was type rated in the aircraft. She had upgraded to captain nine months earlier, with about 4,000 hours of flight time, and 700 as PIC in the 1900. She was handling the radio during the accident flight as the pilot not flying.
The first officer, 24, held a commercial certificate with instrument ratings for single- and multiengine aircraft. He had accumulated about 1,950 hours total time, with 800 as second in command of the Beech 1900. He was handling the controls at the time of the accident.
The King Air pilot, 63, was a retired TWA captain and pilot in the U.S. Air Force Reserve. He was type rated in the Boeing 377, 707, 720, and 747; Douglas DC-9, Lockheed 382 and 1011; and North American B-25. He had retired from TWA in 1992, flew part-time as a flight instructor at an Air Force aero club, and did some charter work. He held a first class medical certificate that required him to wear glasses and was seen wearing glasses when he boarded the aircraft just before the accident. The pilot had accumulated more than 25,000 hours of total flight time, with 22 hours in the accident airplane.
About six months earlier the King Air pilot had been involved in a gear-up landing accident while giving dual instruction in a Cessna 172RG. The FAA offered him a remedial training option instead of enforcement action. The training had not yet taken place. The FAA inspector who investigated the accident stated that the pilot had "expressed an extremely negative attitude toward the FAA's questioning him about his landing. His statements were to the effect that he was a retired U.S. Air Force colonel with almost 30,000 hours of flying time and that a gear-up did not mean anything." Additionally, TWA had demoted him in 1991 from captain to flight engineer because of flying deficiencies.
The 34-year-old pilot-rated passenger in the King Air A90 was employed by FlightSafety International Airline Center in St. Louis. She was a ground instructor and a part-time CFI at the same Air Force aero club as the other King Air pilot. She had accumulated nearly 1,500 hours and was working to build multiengine experience to prepare for an airline job. This was her first flight in a King Air, and she appeared to be receiving instruction, according to some prospective buyers of the King Air who had just gotten off the aircraft in Quincy. It could not be determined from the wreckage which seat she was sitting in or whether she was handling the controls.
The pilot of the Cherokee received his private pilot certificate in February 1996 and had 80 hours in a Piper Cherokee. A passenger in the Cherokee had just received his private certificate two weeks before the accident.
The only record of this accident came from the cockpit voice recorder on the Beech 1900. None of the aircraft had a flight data recorder, nor was one required. The transcript of the tape recounts the situation as it developed. Nonpertinent comments are omitted.
King Air A90 N1127D — 27D (identified as female voice of pilot passenger) Beech 1900 (Great Lakes Flight 251) external transmission — Lakes 251 Intracockpit — Capt (Captain), FO (first officer) Cherokee N7646J — 46J was on the taxiway and pulled up on the run-up pad behind the King Air.
1656:44 Capt: You're planning on [Runway] 13 still, right? 1656:46 FO: Yeah, unless it doesn't look good. Then we'll just do a downwind for [Runway] 4, but right now plan for 13. 1656:56 Lakes 251: Quincy area traffic, Lakes Air Two-Fifty-One is a Beech airliner currently 10 miles to the north of the field. We'll be inbound to enter on a left base for Runway 13 at Quincy. Any other traffic, please advise. 1657:45 Capt (running before-landing checklist): ...and the landing lights and logo lights? 1657:47 FO: They're on. 1659:04 27D: Quincy traffic, King Air One-One-Two-Seven-Delta holding short of Runway 4. Be uh, takin' the runway for departure and heading, uh, southeast, Quincy. [The King Air then moved onto the runway, pulled forward slightly, and stopped for about a minute, apparently to complete some last-minute items.] 1659:19 Capt: She's takin' Runway 4 right now? 1659:22 FO: Yeah. 1659:29 Lakes 251: Quincy area traffic, Lakes Air Two-Fifty-One is a Beech airliner currently, uh, just about to turn about a six-mile final for Runway, uh, 13. More like a five-mile final for Runway 13 at Quincy. 1700:16 Lakes 251: And Quincy traffic, Lakes Air Two-Fifty-One's on a short final for Runway 13. Um, the aircraft gonna hold in position on Runway 4 or you guys gonna take off? 1700:28 46J: Seven-Six-Four-Six-Juliet uh, holding, uh, for departure on Runway 4. 1700:34 At this point the ground proximity warning system in the Beech 1900 that provides warnings when the flight gets close to terrain mechanically called out "200 feet," interrupting the transmission from Cherokee 46J. That transmission concluded "...on the, uh, King Air." 1700:37 Lakes 251: OK, we'll, we'll get through your intersection in just a second, sir.... We appreciate that. 1700:42 Capt: Landing gear's down — three green; flaps are at landing. Your yaw damp is off. Final's complete. 1701:01 Capt: Max reverse. Oh (expletive). 1701:03 FO: What, oooh (expletive). 1701:07 FO: (Expletive). 1701:08: End of recording.
Both airplanes came to rest along the east edge of Runway 13 with their wings interlocked, approximately 110 feet east of where the skid marks converged near the intersection of runways 4 and 13. According to witnesses, both airplanes remained on their landing gear after impact.
The Beech 1900 left continuous tire skid marks for 475 feet before converging with scuff marks left by the King Air's tires. The scuff marks veered to the right of Runway 4 for 260 feet before intersecting the 1900's skid marks.
Fire erupted, and while rescuers reached the aircraft almost immediately and were able to converse with the captain of the 1900, they were unable to open the cabin door.
National Transportation Safety Board investigators performed tests at the accident site to determine the visibility from a Beech 1900 on final and a King Air positioned on Runway 4. Additionally, they did some computer-model simulations to show the views fromthe various cockpit seats. From the King Air, the pilot's view of the Beech 1900 could have been fully or partially obstructed by the side window post. Likewise, the captain of the 1900 did not have a clear view of the King Air. The relative position of an aircraft on a collision course will not change, so if it was hidden behind a window post, that relationship would not change. The other airplane would just grow bigger until the point of impact.
The 1900's copilot could have seen the King Air right at the point of touchdown, but as the A90 accelerated it probably moved behind a windshield post. The first officer was very likely concentrating on the landing.
The only consistently clear view was from the right seat of the King Air. As mentioned earlier, it was impossible to tell who occupied which seat in the King Air, but a reasonable assumption is that the passenger was probably sitting on the right side, and she was definitely operating the radio. Since this was her first flight in the A90, her situational awareness would be relatively low.
The NTSB concluded that the 1900's flight crew made frequent radio broadcasts of its position during the approach and that the decision to land straight-in to Runway 13 was appropriate.
The King Air pilot was faulted for not announcing on the CTAF his departure from Runway 4. Both King Air pilots were also faulted for not listening to the CTAF for the transmissions from the arriving airliner — whether it was because of radio switch configuration, preoccupation, distraction, or inattentiveness. They failed to see, avoid, and yield right of way to landing traffic.
The Cherokee pilot's transmission in response to the 1900's request was unnecessary and inappropriate. It misled the 1900 crew to believe that they were communicating with the King Air. The Cherokee pilot, not being in the number one slot on Runway 4, had no reason to respond to the 1900's query to the King Air regarding his intentions.
After the crash, the fire spread so rapidly that the King Air occupants had little chance to survive. The airstair door jammed on the 1900 because of cabin deformation. Because of that and a lack of firefighting equipment at Quincy, the survivors of the relatively low-speed impact were denied any chance of ultimate survival. The Board has asked Beech to mark doors more clearly so that passengers and rescuers can get them open more easily.
Factors in this accident chain included a highly experienced King Air pilot with an "attitude" and a Cherokee pilot who was still learning. Taking position on the runway and holding at a nontowered airport is not a recommended practice. Communicating at the wrong time, even when well intentioned, can create serious misunderstandings. Most important, failing to clear the departure path when there is an intersecting runway is a sure recipe for trouble. This is basic airmanship.
The day after the accident, the ASF discussed with the FAA an education campaign to reach as many GA pilots as possible on the subject of operations at nontowered airports. This included sending a safety poster to 5,000 FBOs and flight schools, as well as creating a program for presentation by FAA aviation safety program managers. Additionally, a Safety Advisor detailing the safe way to operate in the nontowered environment was developed. So far, more than 100,000 copies of that Safety Advisor have been distributed through seminars, by mail, by the FAA, and by ASF volunteers. They have gone to regional airlines and some corporate flight departments, as well as pilots of light aircraft.
Single copies of the 16-page advisor are available free from ASF at safety seminars or by mail for $1 to cover shipping and handling; write to Nontowered Airport Safety Advisor, 421 Aviation Way, Frederick, Maryland 21701. It also can be downloaded from AOPA's Web site.
See also the index of "Safety Pilot" articles, organized by subject. Bruce Landsberg is executive director of the AOPA Air Safety Foundation.
Pilot Training and Certification
The FAA on Feb. 23 issued a special airworthiness information bulletin recommending preflight inspection of Robinson R44 and R44 II main rotors.
The FAA has released an eight-minute video providing aviation medical examiners with guidance on the agency's new obstructive sleep apnea policy, which takes effect March 2.
New legislation in both houses of Congress would allow thousands of pilots to fly without a third class medical and offer new protections for GA pilots.
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