NTSB Press Release

National Transportation Safety Board
Office of Public Affairs


FAILURE TO FOLLOW BASIC FLYING PRECAUTIONS LED TO FATAL RUNWAY COLLISION IN QUINCY, ILLINOIS

July 1, 1997

Washington, D.C. - Failure to follow basic flying precautions to "see and avoid" surrounding air traffic led to the fiery collision of two aircraft in Quincy, Illinois, the National Transportation Safety Board (NTSB) has determined.

All 14 people aboard the two aircraft were killed when a United Express Beech 1900C and a King Air A90 collided at a Quincy municipal airport runway intersection on November 19, 1996.

During a public meeting in Washington, the NTSB said the probable cause of the accident was the failure of the King Air pilots to effectively monitor the common traffic advisory radio frequency or to properly scan for traffic before commencing their takeoff while a commuter plane, United Express flight 5925, was landing on an intersecting runway. The NTSB said there was no evidence that the King Air had made a radio transmission or had heard the commuter plane's final radio call before it landed.

Contributing to the cause of the accident was an interrupted radio transmission from a third aircraft on the airport, a Piper Cherokee, which was waiting behind the King Air.

The Cherokee pilot radioed intentions to hold on the runway and that transmission, the NTSB concluded, led to a misunderstanding by the United Express pilots. They believed the transmission came from the King Air and believed 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, the NTSB said, was the lack of adequate aircraft rescue and firefighting services, and the failure of the airstair door on the Beech 1900C to open. All 14 people -- 12 in the commuter plane and two in the general aviation aircraft -- survived the impact of the ground collision, but died of effects of smoke and fire. The commuter's airstair door did not open, blocking escape. The most likely reason that the door could not be opened is that the accident deformed the door and created slack in the door control cable, the Safety Board said.

In other conclusions, the NTSB said:

It is likely that either the King Air occupants did not properly configure the radio receiver switches to the common traffic advisory radio frequency, or that they were preoccupied, distracted, or inattentive to their duty to "see and avoid" other traffic.

Flight 5925's crew made appropriate efforts to coordinate the approach and landing through radio communications and visual monitoring.

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.

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 postcrash fires as air carrier passengers on aircraft with more than 30 passenger seats.
As a result of this accident, the NTSB urged the Federal Aviation Administration to:

Develop ways to fund rescue and firefighting services for airports that are served by scheduled passenger operations with aircraft having 10 or more passenger seats, and require these airports to ensure that rescue and firefighting units with trained personnel are available during commuter flight operations and are capable of timely response.

Add a list of airports that have scheduled air service but do not have rescue and firefighting capabilities to the safety information section of the FAA's Internet home page.

Reiterate to flight instructors the importance of emphasizing careful scanning techniques during pilot training and biennial flight reviews.

Evaluate the propensity of the Beech 1900C door to jam when it sustains minimal permanent door deformation and, based on the results of that evaluation, require appropriate design changes; and establish clear and specific methods for showing compliance with the "freedom from jamming" certification requirements.

Develop 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 similar in severity to the Quincy accident.

Review and modify, as necessary, guidance for the principle maintenance inspectors to ensure that maintenance personnel are properly trained in accomplishing the maintenance tasks that they are assigned.
The NTSB's complete report, PB97-910404, may be purchased from the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161, (703) 487-4650.

Media Contact: Pat Cariseo (202) 314-6100

This press release and other NTSB information are available on the World wide Web: http://www.ntsb.gov

 

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The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.