/ PB97-910404

NTSB/AAR-97/04

DCA97MA009A/B

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

RUNWAY COLLISION

UNITED EXPRESS FLIGHT 5925

AND BEECHCRAFT KING AIR A90

QUINCY MUNICIPAL AIRPORT

QUINCY, ILLINOIS

NOVEMBER 19,1996
The National Transportation Safety Board is an independent Federal agency dedicated to

promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety.

Established in 1967, the agency is mandated by Congress through the Independent Safety

Board Act of 1974 to investigate transportation accidents, determine the probable causes of

the accidents, issue safety recommendations, study transportation safety issues, and evaluate

the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special

investigation reports, safety recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(202)314-6551

(800)877-6799

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Sprin~leld, Virginia 22161

(703)487-4600
NTSB/AAR-97/04 PB97-910404

NATIONAL TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

RUNWAY COLLISION

UNITED EXPRESS FLIGHT 5925

AND BEECHCRAFT KING AIR A90

QUINCY MUNICIPAL AIRPORT

QUINCY, ILLINOIS

NOVEMBER 19, 1996

Adopted: July 1, 1997

Notation 6793C

Abstract: This report explains the accident involving United Express flight 5925, a

Beechcraft 1900C, and a Beechcraft King Air A90 that collided at the intersection of

runway 13 and runway 04 at Quincy Municipal Airport, near Quincy, Illinois, on November

19, 1996. Safety issues 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.

Finding 15

In the findings list and the accident report text (Section 2.5, “Survival Aspects,” on

page 48, sixth paragraph), replaced “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” with “the occupants of the Beech 1900C did not escape because the air stair door

and the left overwing exit hatch were not opened for undetermined reasons.”

Finding 16

In the findings list, deleted “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.” Renumbered the remaining findings accordingly.

In the accident report text (Section 2.5.1, “Air Stair Door,” on page 49, fifth paragraph),

deleted “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.”

In the accident report text (Section 2.5.1, “Air Stair Door,” on page 49, sixth paragraph),

replaced “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” with “the Safety Board is further concerned that,

even though the impact forces from the accident were such that both airplanes came to

rest on their landing gear and the occupants of the Beech 1900C did not sustain blunt

force trauma injuries as a result, the door was not opened by any of the occupants for

undetermined reasons.”

September 5, 2000

 The National Transportation Safety Board adopted revisions

to the findings and probable cause for this accident, as

indicated below.

For more information, see Response to Petition for

Reconsideration 

a-1
a-2

Finding 17

In the findings list, deleted “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.” Renumbered the remaining findings

accordingly.

In the accident report text (Section 2.5.1, “Air Stair Door,” on page 50, second complete

paragraph), deleted “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.”

Finding 18

In the findings list, deleted “the FAA’s freedom from jamming certification standards

may be inadequate.” Renumbered the remaining findings accordingly.

In the accident report text (Section 2.5.1, “Air Stair Door,” on page 50, third complete

paragraph), deleted “further, because the air stair door on the accident airplane jammed as

a result of an impact that caused little or no injury to the occupants of the airplane, the

Safety Board concludes that the FAA’s freedom from jamming certification standards

may be inadequate.”

Probable Cause

Replaced “contributing to the severity of the accident and the loss of life were the lack of

adequate aircraft rescue and firefighting services, and the failure of the air stair door on

the Beech 1900C to open” with “contributing to the severity of the accident and the loss

of life were the lack of adequate aircraft rescue and firefighting services and the failure of

the air stair door on the Beech 1900C to be opened.”
This page intentionally left blank
iii

CONTENTS

EXECUTIVE SUMMARY............................................................................................................ vi

1. FACTUAL INFORMATION..................................................................................................... 1

1.1 History of Flight .................................................................................................................... 1

1.2 Injuries to Persons................................................................................................................. 4

1.3 Damage to Airplane............................................................................................................... 4

1.4 Other Damage........................................................................................................................ 4

1.5 Personnel Information ........................................................................................................... 4

1.5.1 Flight 5925 Flightcrew....................................................................................................... 4

1.5.1.1 Captain Information ........................................................................................................ 4

1.5.1.2 First Officer Information ................................................................................................. 7

1.5.2 King Air Occupants............................................................................................................ 7

1.5.2.1 King Air Pilot-in-Command............................................................................................ 7

1.5.2.2 King Air Pilot/Passenger................................................................................................. 8

1.6 Airplane Information............................................................................................................. 9

1.6.1 Beech 1900C ...................................................................................................................... 9

1.6.1.1 Beech 1900C Emergency Exit Door Certification – Freedom from Jamming.............. 10

1.6.2 King Air A90.................................................................................................................... 13

1.7 Meteorological Information ................................................................................................ 14

1.8 Aids to Navigation .............................................................................................................. 14

1.9 Communications ................................................................................................................. 14

1.10 Airport Information ........................................................................................................... 15

1.11 Flight Recorders................................................................................................................ 15

1.12 Wreckage and Impact Information.................................................................................... 18

1.12.1 Beech 1900C Wreckage Information ............................................................................. 18

1.12.2 King Air A90 Wreckage Information............................................................................. 18

1.13 Medical and Pathological Information .............................................................................. 19
iv

1.14 Fire .................................................................................................................................... 19

1.15 Survival Aspects................................................................................................................ 19

1.15.1 Rescue Attempts............................................................................................................. 20

1.15.2 Passenger Briefing.......................................................................................................... 21

1.15.3 Beech 1900C Exits......................................................................................................... 22

1.15.3.1 Air Stair Door.............................................................................................................. 22

1.15.3.2 Overwing Exit Hatches ............................................................................................... 24

1.15.4 Pilot Evacuation Procedures and Training ..................................................................... 24

1.15.5 Previous Safety Board Recommendations on Emergency Exits.................................... 26

1.15.6 Emergency Response...................................................................................................... 27

1.15.7 Commuter Airline Study ................................................................................................ 28

1.16 Tests and Research ............................................................................................................ 30

1.16.1 Takeoff Distance and Accelerate and Stop Distance for King Air A90......................... 30

1.16.2 Visibility Tests and Study .............................................................................................. 30

1.16.2.1 Conspicuity/Visibility Tests........................................................................................ 30

1.16.2.2 Photographic Visibility Study ..................................................................................... 31

1.17 Organizational and Management Information................................................................... 32

1.17.1 Great Lakes Aviation, Ltd. ............................................................................................. 32

1.18 Additional Information...................................................................................................... 37

1.18.1 Operating Procedures at Uncontrolled Airports............................................................. 37

1.18.2 Previous Safety Board Recommendation on Scanning Techniques............................... 40

1.18.3 Postaccident Actions by the FAA .................................................................................. 40

2. ANALYSIS .............................................................................................................................. 42

2.1 General ................................................................................................................................ 42

2.2 United Express Flightcrew Performance............................................................................. 42

2.3 King Air Pilot and Pilot/Passenger Performance ................................................................ 44

2.4 Cherokee Pilot Performance................................................................................................ 47
v

2.5 Survival Aspects.................................................................................................................. 48

2.5.1 Air Stair Door................................................................................................................... 49

2.5.2 Emergency Response........................................................................................................ 51

3. CONCLUSIONS...................................................................................................................... 52

3.1 Findings............................................................................................................................... 52

3.2 Probable Cause.................................................................................................................... 54

4. RECOMMENDATIONS ......................................................................................................... 55

5. APPENDIXES ......................................................................................................................... 57

APPENDIX A—INVESTIGATION AND HEARING ................................................................ 57

APPENDIX B—COCKPIT VOICE RECORDER TRANSCRIPT.............................................. 58
vi

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.
NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

RUNWAY COLLISION

UNITED EXPRESS FLIGHT 5925

AND BEECHCRAFT KING AIR A90

QUINCY MUNICIPAL AIRPORT

QUINCY, ILLINOIS

NOVEMBER 19, 1996

1. FACTUAL INFORMATION

1.1 History of Flight

On November 19, 1996, at 1701 central standard time,1

 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 the provisions of Title 14 Code of Federal Regulations (CFR) Part 135. The

flight was operated by Great Lakes Aviation, Ltd., doing business as United Express. The King

Air was operating under 14 CFR Part 91.

On the day of the accident, the flightcrew of United Express flight 5925 checked

in for duty at Quincy Municipal Airport at 0415 for a 1-day trip, which was to consist of 8 legs

for a total of 5.36 flight hours. According to company records, the flightcrew performed routine

preflight duties and departed the gate at 0512 for the first leg to Burlington, Iowa. After the fifth

leg (Bloomington, Indiana, to Terre Haute), a mechanical problem required the flightcrew to

ferry the airplane to O’Hare, where the flightcrew changed to the accident airplane, N87GL, for

the remaining legs to Burlington and Quincy.

At 1500, the flightcrew departed O’Hare in N87GL as United Express flight

5925.2

 The flight departed 2 hours and 45 minutes late because of the earlier maintenance

problem at Terre Haute. According to flightcrew-reported times, the airplane landed at

Burlington at 1625 and departed at 1637 as combined flights 5925/5926 to Quincy.3

 1

All times are central standard time, based on a 24-hour clock, unless otherwise noted.

2

The flight operated under a code-sharing agreement with United Airlines but used the

call sign “Lakes Air 251.”

3

Flight 5926 was scheduled to operate from Quincy by way of Burlington to O’Hare.

Because of flight 5925’s late departure from O’Hare, the decision was made to eliminate the Burlington
2

According to the cockpit voice recorder (CVR), at 1652:07, a female voice

identified as the captain4 of flight 5925 stated on the Quincy common traffic advisory frequency

(CTAF)5 that the airplane was about 30 miles north of the airport and that they would be landing

on runway 13; she also asked that “any traffic in the area please advise.” (See appendix B for a

complete transcript of the CVR recording.) No replies were received to this request.

At 1655:19, a female voice, identified as one of the occupants in the King Air,

announced, “Quincy traffic, King Air one one two seven Delta’s taxiing out...takeoff on runway

four, Quincy.” At 1655:40, the CVR recorded the voice of the male pilot of a Piper Cherokee,6

which was taxiing behind the King Air, announcing, “Quincy traffic, Cherokee seven six four six

Juliet back-taxi...taxiing to runway four, Quincy.” At 1655:48, the captain of flight 5925

commented to the first officer, “They’re both using [runway] four.” The captain then asked,

“you’re planning on one three still, right?” The first officer replied, “yeah, unless it doesn’t look

good then we’ll just do a downwind for four but...right now plan one three.”

At 1656:56, the captain of flight 5925 announced over the CTAF, “Quincy area

traffic, Lakes Air two fifty one is a Beech airliner currently ten miles to the north of the field.

We’ll be inbound to enter on a left base for runway one three at Quincy any other traffic please

advise.” There was no response.7

At 1659:03, the female occupant of the King Air announced, “Quincy traffic,

King Air one one two seven Delta holding short of runway four. Be ...takin’ the runway for

departure and heading...southeast, Quincy.” At 1659:19, the captain of flight 5925 commented,

“she’s takin’ runway four right now?” The first officer replied, “yeah.” According to the

Cherokee pilot, the King Air pulled up far enough on runway 04 to allow the Cherokee access to

runway 36, and when the King Air went into position on runway 04, he taxied the Cherokee into

the runup area short of the runway.

At 1659:29, the captain of flight 5925 announced, “Quincy area traffic, Lakes Air

two fifty one is a Beech airliner currently...just about to turn, about a six mile final for

 

stop of flight 5926. Therefore, passengers scheduled on flight 5926 from Burlington to O’Hare were

included on flight 5925 to Quincy from where they would have taken flight 5926.

4

Company personnel who listened to the CVR recording reported that all of the

communications were being made by the captain. Company practice is for the pilot not flying to handle

radio communications.

5

CTAF is a radio frequency designated for use by pilots operating near uncontrolled

airports. Pilots use this frequency to broadcast their positions or intended flight activities or ground

operations.

6

The pilot of the Cherokee received his private pilot’s license in February 1996, and had

80 hours of flight time in the Cherokee. His passenger had received a private pilot’s license about 2

weeks before the accident and had 44 hours of flight time.

7

In a postaccident interview, the Cherokee pilot indicated that when he heard this

broadcast, he saw the airplane. He also said that he remembered seeing lights on each wing of the

airplane on its final approach.
3

runway...one three, more like a five mile final for runway one three at Quincy.”8 At 1700:16, the

captain of flight 5925 reported that the airplane was “on short final for runway one three” and

asked, “the aircraft gonna hold in position on runway four or you guys gonna take off?”

The King Air did not respond to this request. However, at 1700:28, the pilot of

the Cherokee stated, “seven six four six Juliet...holding...for departure on runway four.” The

CVR then recorded an interruption in this transmission by a mechanical “two hundred” alert

announcement from the ground proximity warning system (GPWS)9 in the Beech 1900C. The

CVR then recorded the last part of the transmission from the Cherokee as “* on the uh, King

Air.”10 At 1700:37, the captain of flight 5925 replied, “OK, we’ll get through your intersection

in just a second sir * we appreciate that.”11

According to the Cherokee pilot and his passenger, as well as a pilot who saw the

approach and landing of flight 5925 as he was driving to the airport, flight 5925 had its landing

lights on. The passenger in the Cherokee said the airplane made a normal landing on runway 13.

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.12

 8

The Cherokee pilot indicated that he remembered hearing a call from the captain of

flight 5925 while he was waiting in the runup area. However, he recalled her saying that the airplane was

2 miles out on final.

9

The GPWS provides cautions, alerts, and warnings that indicate potentially hazardous

proximity to terrain. Callouts include “five hundred,” “two hundred,” and “minimums” above the terrain.

These callouts refer to feet above the terrain.

10The asterisk from the CVR recordings found in this report indicates an unintelligible

word. According to the CVR transcript, this was the Cherokee pilot’s second radio call on the CTAF. In

a postaccident interview, the Cherokee pilot indicated that his recollection was that his second radio call

before departing Quincy followed a transmission that included the words “King Air...taxiing and

holding.” He stated that he did not hear the whole transmission but that at the time, he thought it came

from the King Air, and he thought that the King Air pilot might have been talking to him. He said that

after he asked his passenger whether he understood the transmission, and his passenger said that he did

not, he transmitted “King Air this is Cherokee 7646J...I am right behind you and am holding for your

departure.”

11The Cherokee pilot indicated that he did not recall hearing any transmission concerning

an intersection.

12A pilot waiting inside the FBO said he thought he remembered hearing a male voice

“stepping on” (transmitting at the same time as) a female voice shortly before the accident. None of the

other witnesses who were listening to the CTAF at the time reported hearing such a “stepped on”

transmission.
4

At 1701, during flight 5925’s landing rollout, the airplane collided with the King

Air at the intersection of runways 13 and 04. (See diagrams of accident site in figures 1 and 3

and photographs of accident site in figures 2a and 2b.) 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.

The Cherokee pilot later indicated that he did not know the two runways

intersected. The passenger in the Cherokee said he was watching the two airplanes, but he

thought they would miss each other.

The collision occurred in visual meteorological conditions about 15 minutes after

sunset at 39o

 and 56 minutes north latitude, and 91o and 11 minutes west longitude.

1.2 Injuries to Persons

Injuries Flightcrew Cabin Crew Passengers Other Total

Fatal 4 0 10 0 14

Serious 0 0 0 0 0

Minor 0 0 0 0 0

None 0 0 0 0 0

Total 4 0 10 0 14

1.3 Damage to Airplane

Both aircraft were destroyed by the impact and postcrash fire. The estimated

value of the Beech 1900C was $3 million. The estimated value of the King Air was $225,000.

1.4 Other Damage

The cost of repairs to the runway, runway light and turf, and environmental

decontamination of the area was $1,898.88.

1.5 Personnel Information

1.5.1 Flight 5925 Flightcrew

1.5.1.1 Captain Information

The captain, age 30, held an airline transport pilot (ATP) certificate, airplane

multiengine land, and was type rated in the Beech 1900. She held a first-class medical

certificate, with no limitations, dated September 26, 1996. She was hired by Great Lakes

Aviation on September 23, 1993, as a first officer, and she upgraded to captain on February 13,

1996. At the time of the accident, the captain had accumulated about 4,000 hours of flight time,

of which 700 hours were as pilot-in-command of the Beech 1900. Her last proficiency check


7

was in September 1996, and her last line check was in February 1996. Her total flying time in

the 30 and 90 days before the accident was 91 hours and 235 hours, respectively. A review of

Federal Aviation Administration (FAA) records revealed no prior accidents/incidents or

enforcement actions.

1.5.1.2 First Officer Information

The first officer, age 24, held a commercial pilot certificate with instrument

ratings for single-engine and multiengine airplanes. He held a first-class medical certificate, with

no limitations, dated June 18, 1996. According to his family, he had been hired and furloughed

by another commuter airline before he was hired by Great Lakes Aviation on September 27,

1995, as a first officer. At the time of the accident, the first officer had accumulated about 1,950

hours of flight time, of which 800 hours were as second-in-command of the Beech 1900. His last

proficiency check was in September 1996. His total flying time in the 30 and 90 days before the

accident was 103 hours and 223 hours, respectively. A review of FAA records revealed no prior

accidents/incidents or enforcement actions.

1.5.2 King Air Occupants

1.5.2.1 King Air Pilot-in-Command

The pilot of the King Air, age 63, was a retired Trans World Airlines (TWA)

captain. He was employed by TWA from 1965 until 1992, and was also a pilot in the U.S. Air

Force Reserves. From 1993 until the time of the accident, he was a part-time flight instructor at

the Scott Air Force Base Aero Club, Belleville, Illinois. In addition, he flew part-time as an ondemand, air taxi pilot for Prestige Air, Cape Girardeau, Missouri, and did some commercial

flying in a Beechcraft Baron BE-58P, based at Spirit of St. Louis Airport, Chesterfield, Missouri.

The pilot held an ATP certificate, with ratings for airplane multiengine land, and

commercial privileges for airplane single-engine land and sea. He was type rated in the B-377,

B-707, B-720, B-747, DC-9, L-382, L-1011, and N-B25. He also held a flight engineer

certificate for turbojet and reciprocating engine-powered airplanes. In addition, he was a

certified flight instructor for single-engine and multiengine airplanes with instrument ratings.13

He held a first-class medical certificate, dated June 11, 1996, with the restriction that he wear

corrective lenses. He was seen wearing glasses when he boarded the airplane before the accident.

According to the FAA, he had a waiver allowing him to use the tranquilizer/sedative, Ativan, (a

benzodiazepine that is generically known as lorazepam), so long as he used it no more than 2 to 4

times per month for sleep, and not within 18 hours of flying.

 13A logbook entry dated January 20, 1996, revealed that he received a multiengine

instructor endorsement from the female occupant on the accident flight.
8

The pilot had a total of 25,647.8 hours of flight time at the time of the accident, of

which 22 hours were in the accident airplane. His last Part 135 instrument proficiency check was

in July 1996. His logbook indicated that he was current in accordance with 14 CFR Part 91.

The pilot had been involved in a gear-up landing incident in a Cessna 172RG on

May 26, 1996, while giving instruction to a student commercial pilot. As a result of that

incident, the FAA initiated an enforcement action against him, but subsequently allowed him to

take remedial training in place of the enforcement action. That training had not been completed

at the time of this accident. The FAA inspector who investigated the gear-up incident said in a

written statement to the Safety Board that the pilot “expressed an extremely negative attitude

toward the FAA’s questioning him about this landing. His statements were to the effect that he

was a retired U.S. Air Force Colonel with almost 30,000 hour[s] of flying time and that landing

gear up did not mean anything.”

Safety Board investigators interviewed several pilots who had received flight

instruction from the King Air pilot, including the student who was involved in the gear-up

landing. This student indicated that in his opinion, a shortcoming of the instructor was that he

“seemed to be in a hurry when time was a factor,” and the student sometimes felt that the

instructor was rushing him. Two of the passengers who had flown with the King Air pilot just

before the accident14 commented that he seemed “to be in a hurry” or “anxious to get home”

when he left them after the return flight to Quincy.

TWA records indicated that on October 7, 1991, the pilot was transferred from the

status of captain to that of flight engineer. A TWA instructor involved in that action told Safety

Board investigators that the transfer was made because of flying deficiencies observed in the

pilot’s training, which resulted in a failed proficiency check and a failed special line check.

According to the pilot’s wife, he slept normally in the days before the accident but

awoke “at an early hour” to fly on the day of the accident. She said that she expected him to

return home that evening about 1745.

1.5.2.2 King Air Pilot/Passenger

The pilot-rated passenger, age 34, was employed by Flight Safety International

Airline Center, St. Louis, Missouri, as a ground instructor. She primarily taught orientation and

indoctrination classes to airline customers. She was also a part-time flight instructor at the Scott

Air Force Base Aero Club, Belleville, Illinois.

She held a commercial pilot certificate with ratings for airplane single-engine land

and sea, airplane multiengine land, instrument airplane. She also held a certified flight instructor

certificate for airplane single-engine and multiengine, instrument airplane; and a ground

 14On the day of the accident, beginning about 0830, the King Air occupants flew four

prospective buyers of the King Air on a demonstration flight from Quincy to Tulsa, Oklahoma, and back

to Quincy.
9

instructor certificate, with an advanced and instrument rating. Her first-class medical certificate

was issued on July 1, 1996, with no restrictions. Her logbook indicated that she had a total of

1,462.2 flying hours, and her last proficiency check was on June 28, 1996.

According to an acquaintance, who was also a flight instructor at Scott Air Force

Base Aero Club, the accident flight was the first time the pilot/passenger had flown in a King

Air. This flight instructor, and a passenger who had flown on the King Air before the accident,

stated that the pilot/passenger came along on the flight to increase her multiengine time. A

student pilot from the Scott Air Force Base Aero Club indicated that he understood the pilot had

instructed the pilot/passenger in multiengine airplanes, and had provided opportunities for her

and another flight instructor at the Aero Club to fly them. The pilot/passenger’s former husband

said that she wanted to become a commercial pilot with a commuter airline, and that she was

attempting to build her flying hours toward obtaining an ATP rating.

One of the passengers on the King Air’s earlier flight to Tulsa and back noted that

both the pilot and pilot/passenger had their hands on the controls when they left Tulsa,15 and

another passenger indicated that the pilot and the pilot/passenger appeared to have “an excellent

teacher/student relationship with [the pilot] as the teacher.” A third passenger stated that “[the

pilot] seemed to be telling [the pilot/passenger] how to fly the plane when we were in flight.”

1.6 Airplane Information

1.6.1 Beech 1900C

The accident airplane, N87GL, was owned by Raytheon Aircraft Credit

Association and was leased to Great Lakes Aviation on December 28, 1989. The airplane, which

contained 19 passenger seats, was manufactured by Beech Aircraft (now Raytheon Aircraft

Company) and received its airworthiness certificate on December 20, 1989. The airplane was

powered by two Pratt & Whitney (P&W) Model PT6A-65B turbopropeller engines. The two

Model HC-B4MP-3A engine propellers were manufactured by Hartzell. The airplane had four

emergency exits (viewed from the aft looking forward): the forward air stair door on the left,

which is the main boarding door, the overwing hatch on the left, and two overwing hatches on

the right.

At the time of the accident, the airframe had 18,446 hours total time and 26,797

total cycles. The left engine had 16,821.2 hours total time and 18,701 total cycles. The right

engine had 14,534.8 hours total time and 19,291 total cycles. No noteworthy discrepancies were

found in the airplane’s maintenance logs.

According to maintenance records, on April 27, 1996, Great Lakes performed a

detailed inspection (including opening) of the air stair door, the overwing exits, and the cargo

 15One of the passengers said that the pilot/passenger did some of the flying and that

around 50 feet above ground level (agl), she returned control to the pilot.
10

door. No discrepancies were noted. The air stair door was replaced by Great Lakes on

September 25, 1996, at its maintenance base in Spencer, Iowa, because of rivets pulling through

the door near the hinge attach areas. The records indicated that the door annunciator light (FWD

DOOR), which alerts the flightcrew of a possible unlocked door, had illuminated on October 1,

1996, October 10, 1996, and on November 7, 1996. Great Lakes maintenance personnel

reportedly fixed the illumination problem by adjusting the door’s microswitches.

According to Great Lakes, its maintenance department stocked about four air stair

door shells to support its fleet of 44 Beech 1900s. As air stair doors were needed, maintenance

personnel placed the rollers, locking mechanisms, and stops in the door shell, then secured the

door to the airplane, trimming the sheet metal around the door to ensure a proper fit. The

company’s records revealed that the air stair door was replaced by its maintenance personnel.

The person who inspected the door was a certified airframe and powerplant mechanic16 who had

attended formal Beech 1900 training. The mechanic who had assembled the locking mechanism

in the door shell was a certified mechanic who had not attended any formal Beech 1900 training.

A review of the inspection checklist for the air stair door did not indicate that there had been any

internal inspection of the door for the proper installation of the cable, routing, or other anomalies

associated with internal locking mechanisms.

1.6.1.1 Beech 1900C Emergency Exit Door Certification – Freedom from Jamming

The Beech 1900C received its initial type certification on November 22, 1983.

According to the FAA, the Beechcraft 1900C was type certificated under Part 23, Amendment

23-9, effective June 17, 1970, and Special Federal Aviation Regulation (SFAR) 41C, effective

September 13, 1982. According to the FAA, the emergency exits also complied with 14 CFR

23.807, Amendment 23-7, effective September 14, 1969.

According to the FAA, the Beech 1900C was type certificated pursuant to a

delegated option authorization (DOA), a process under which a type certificate is issued based in

part on the manufacturer’s self-certification that all applicable regulations have been met. (See

14 CFR Part 21, Subpart J).17 However, the FAA may choose to participate in and make specific

 16A mechanic who has been issued an airframe and powerplant certificate by the FAA

under 14 CFR Part 65.

1714 CFR 21.253 states that to obtain a type certificate for a new product under the DOA,

the manufacturer must submit to the FAA:

(1) An application for a type certificate...;

(2) A statement listing the airworthiness requirements...that the manufacturer considers

applicable;

(3) After determining that the type design meets the applicable requirements, a statement

certifying that this determination has been made;

(4) After placing the required technical data and type inspection report in the technical

data file required by 21.293(a)(1)(i), a statement certifying that this has been done;

(5) A proposed type certificate data sheet; and
11

findings of compliance with regard to certain regulatory requirements. As discussed below, in

certifying the Beech 1900C, the FAA observed testing and made a specific finding of compliance

with regard to the freedom from jamming certification requirement.

Regulatory requirements pertaining to door jamming applicable to the certification

of the Beech 1900C were set forth in 23.807(b)(4), which stated that each emergency exit must

“[h]ave reasonable provisions against jamming by fuselage deformation;” and SFAR 41,

subsection 5(e)(c), which stated that “[e]ach external door must be reasonably free from jamming

as a result of fuselage deformation in a minor crash.” Subsequent to the Beech 1900C’s

certification, the FAA promulgated a similar requirement in section 23.783(c)(5), stating that

each external passenger or crew door “must be reasonably free from jamming as a result of

fuselage deformation in an emergency landing.”18 (See 53 Federal Register 30802, 30807,

August 15, 1988).

Safety Board investigators reviewed the Beech Model 1900/1900C Engineering

Structural Test reports, issued on September 3 and November 3, 1983, which detailed testing that

Beechcraft used for the type certification of the 1900C airplane. According to the reports,

fuselage static tests were conducted at Beech Aircraft in Wichita, Kansas, between December 14,

1982, and September 6, 1983, as part of the overall structural static test certification program for

the Beech Model 1900C forward fuselage and standard version 1900 fuselage. According to

 

(6) An Aircraft Flight Manual (if required) or a summary of required operating

limitations and other information necessary for safe operation of the product.

Section 21.257 provides:

An applicant is entitled to a type certificate for a product manufactured under a

DOA if the Administrator finds that the product meets the applicable airworthiness,

noise, fuel venting, and exhaust emission requirements (including applicable acoustical

change or emissions change requirements in the case of changes in type design).

18Emergency landing conditions are set forth in 14 CFR 23.561(b), which requires, in

part, that the airplane structure be designed to protect each occupant during emergency landing

conditions when “proper use is made of the seats, safety belts, and shoulder harnesses provided for in the

design” and,

(2) The occupant experiences the static inertia loads corresponding to the following

ultimate load factors –

(i) Upward, 3.0 G for normal, utility, and commuter category airplanes,...

(ii) Forward, 9.0 G;

(iii) Sideward, 1.5 G; and

(iv) Downward, 6.0 G when certification to the emergency exit provisions of

23.807(d)(4) is requested; and

(3) The items of mass within the cabin, that could injure an occupant, experience the

static inertia loads corresponding to the following ultimate load factors -

(i) Upward, 3.0 G;

(ii) Forward, 18.0 G; and

(iii) Sideward, 4.5 G.
12

Raytheon officials, Beech personnel at that time asked the FAA’s Aircraft Certification Office

(ACO) in Wichita for guidance on how to show compliance with the freedom from jamming

requirements of SFAR 41, paragraph 5 (e)(c).

According to Raytheon, the ACO did not provide Beech with specific test criteria,

but indicated that compliance could be shown by demonstrating that the doors were free from

jamming after undergoing the tests that were already established as part of the Beech structural

static test certification program. Under that program, side loads were applied during the side

shear and side bending torque tests. (Other tests involved up bending and up shear; down

bending and down shear; shear between spars; side shear between spars; and ultimate fuselage

pressure.) According to Beech’s test data, 2,970 pounds of static side pressure were applied for 3

seconds at 90o

 at fuselage station 30.13, and water line 34.48, near the right and left sides of the

nose gear. The tests measured 194,592 inch pounds of torque and 430,264 inch pounds of

bending moment at fuselage station 175.0 with the following results: a 3.70-inch crack in the

lower aft corner of the air stair frame at fuselage station 175; buckling of the aft lower corner of

the right-hand nose door, door frame, and floor frame at fuselage station [1]82;19 wrinkling of the

fuselage skin at fuselage station 290; loosening of the sealer, the forward spar; and the shearing

of two raised rivet heads at the forward spar.

In a letter to Beech dated April 25, 1983,20 the FAA indicated that “Beech must

show that application of the inertia loads in FAR 23.561 to the stair/door combination, while

closed, will not prevent subsequent opening of the door.” The FAA also asked that Beech

“provide...any information or data which you consider appropriate” to assure that a landing with

both main gears collapsed and the airplane resting on its nose gear and aft fuselage would not

result in an “unsafe feature.”21

After the completion of fuselage static tests which included the side shear and side

bending torque tests described above (but did not simulate loads resulting from a landing with

both main gears collapsed and the airplane resting on its nose gear and aft fuselage), FAA

representatives visited the Beech test facility and witnessed the opening of the forward air stair

door and overwing emergency hatches on the two test fuselages (a 1900 and a 1900C). The

doors opened without jamming or structural failure.

 19According to Raytheon, the test data entry for fuselage station 182 was written in error.

The right-hand nose door on the Beech 1900C is located at fuselage station 82 rather than 182.

20The letter primarily addressed Beech’s proposed methods for showing compliance with

SFAR 41, paragraph 5(e)(g), relating to design of the stair installed on the door, and did not specifically

refer to the freedom from jamming requirement in paragraph 5(e)(c). However, Beech’s correspondence

to the FAA discussing its proposed means for showing compliance, to which the FAA’s April 25 letter

responded, also referenced the freedom from jamming requirement in paragraph 5(e)(c).

21In an earlier letter, Beech had indicated that in this emergency landing configuration

(both main gear collapsed and nose gear extended) it “would definitely expect at least nonpermanent

fuselage deformation.” In an internal memorandum dated April 20, 1983, the FAA Aircraft Certification

Division indicated concern that such deformation might result in door jamming, and recommended that

the ACO “investigate the condition...and assure that no unsafe condition will result.”
13

In a letter to Beech Aircraft Corporation dated September 12, 1983, the ACO

stated that the findings from this demonstration showed compliance with SFAR 41, section

5(e)(c). It further stated that, based on the results of an “unofficial static test conducted at Beech

on January 25, 1983,...[which ] show the entry door to be reasonably free from jamming when

the fuselage is loaded corresponding to the most critical condition of landing gear collapse (both

mains collapsed),” the ACO “is satisfied that no unsafe condition is identified with regard to

entry door jamming.”

After the Beech 1900C had been certificated, the FAA set forth guidance in

Advisory Circular (AC) 25.783-1 (dated December 10, 1986) for complying with the door design

standards in 14 CFR 25.783. In 1988, in connection with its promulgation of section

23.783(c)(5), the FAA indicated that the guidance in AC 25.783-1 for complying with the

freedom from jamming requirement of 25.783 could also be used to demonstrate compliance

with what the FAA referred to as the “substantively equivalent” freedom from jamming

requirements of 23.783.

22 Specifically, the AC states the following:

8. Door Jam Condition.

An external door, exit, or hatch which may be used for emergency exit in a

crash should be designed to allow for fuselage distortion likely to result

from a minor crash. This is usually achieved by allowing sufficient

clearance between the door and surrounding fuselage support structure to

accommodate likely distortions. Also, the possibility of distortion in the

door cutout should be minimized by designing the door cutout frame with

more strength than that of the surrounding structure.

1.6.2 King Air A90

The King Air A90 was manufactured by Beech Aircraft on January 16, 1967. The

airplane was powered by two P&W Model PT6A-20 turbine engines. The two Model HC

B3TN-3B engine propellers were manufactured by Hartzell. The airplane had two exits (viewed

from the aft looking forward): the air stair door in the aft cabin on the left, and the overwing

emergency exit on the right.

The airplane’s maintenance records revealed 11,391.8 total flight hours. A 150-

hour primary inspection was made on July 15, 1996, and the total airframe time was noted as

11,359.4 hours at that time. On that date, the left engine had accumulated 9,278.4 hours total

time and 2,809.9 hours since the engine was overhauled in March 1978; and the right engine had

9,368.3 hours total time and 2,932.7 hours since that engine was overhauled in March 1978. The

engine cycles were not recorded in the maintenance records.

 2253 Federal Register 30802, 30807 (August 15, 1988).
14

The examination of the airframe logbooks did not reveal any abnormalities or

entries concerning the airplane’s communication equipment. However, the last transponder and

pitot static inspections reflected in the airplane maintenance records were on July 1, 1992. Such

inspections are required every 2 years under 14 CFR Parts 91.411 and .413.23

1.7 Meteorological Information

An FAA contract weather observing station is located at the Quincy Municipal

Airport. Weather observations are made each hour by contract weather observers employed by

Midwest Weather. An automated weather observing system at the airport automatically

generates visibility, pressure, ceiling, wind, temperature, and dew point values. The surface

weather observations are recorded by the weather observers and transmitted on the voice channel

of the local nondirectional beacon.

The following surface weather observation for Quincy was provided on the day of

the accident at 1650:

Winds 060o at 10 knots; visibility 12 miles; ceiling 13,000 feet broken,

15,000 feet broken, 20,000 feet overcast; temperature 2o

 C; dew point -3o

C; altimeter setting 30.00 inches of Hg.

After seeing the smoke and flames from the accident, the surface weather observer

made the following special surface weather observation for Quincy at 1709:

Winds 070o at 9 knots; visibility 12 miles; few clouds near the surface,

ceiling 14,000 feet broken, 20,000 feet overcast; temperature 2o C; dew

point -3o C; altimeter setting 29.99 inches of Hg.; smoke near the ground;

aircraft mishap.

The weather observer stated that at the time of the accident, all weather equipment

was operating satisfactorily, and the visibility was uniform.

1.8 Aids to Navigation

There were no known difficulties with aids to navigation.

1.9 Communications

On the King Air’s earlier flight from Tulsa to Quincy, the ground controller at

Tulsa reportedly commented about the quality of one of the King Air’s radios, and the clearance

delivery controller was unable to receive transmissions made by the pilot/passenger. However,

 23The mechanic who performed the last annual inspection on the airplane reported that

he had placed a piece of paper in the logbook indicating that the pitot-static system had recently been

inspected. No such piece of paper was found in the airplane’s records recovered at the crash site.
15

communications with the air traffic controllers at the Kansas City air route traffic control center

(ARTCC), who were responsible for aircraft in the Quincy area, did not indicate any difficulties

with radio communications. The ARTCC was in contact with the King Air from about 1443 to

1620.

One of the airplane’s passengers on the previous flight for the prospective buyers

of the airplane stated that he recalled the pilot and pilot/passenger had exchanged headsets at one

point because of difficulty hearing out of one of them. Another passenger recalled that the pilot

and pilot/passenger had exchanged microphones because the pilot/passenger’s microphone would

not transmit. This passenger also remembered the King Air pilot saying that the airplane was in

“great shape,” and that the only thing the airplane needed was “a small piece of avionics.”

1.10 Airport Information

Quincy Municipal Airport is an uncontrolled airport owned and operated by the

City of Quincy, Illinois, which is located about 10 miles away from the airport. The airport has

an elevation of 769 feet mean sea level, and it has three runways: 18/36, which is concrete, 5,397

feet long, and 150 feet wide; 13/31, which is asphalt, grooved, 5,398 feet long, and 150 feet

wide; and 04/22, which is asphalt, grooved, 7,097 feet long, and 150 feet wide. (See figure 3,

Airport Diagram.) Runway 18/36 is equipped with low intensity runway lights; runway 13/31

with medium intensity runway edge lights; and runway 04/22 with high intensity runway lights.

The airport holds an FAA-issued limited airport operating certificate.24 Although

a 500-gallon capacity airport aircraft rescue and fire fighting (ARFF) truck was located at the

airport, full-time ARFF services were not present or required at the time of the accident. (See

section 1.15.6, “Emergency Response,” for more information on ARFF services.)

1.11 Flight Recorders

The Beech 1900C was not equipped with a flight data recorder (FDR), nor was it

required to be. It was equipped with a Fairchild Model A100A CVR. The King Air was not

equipped with either an FDR or a CVR, nor was it required to be.

The Beech 1900C CVR included a “G switch,” which was designed to activate

and stop the CVR recording if the aircraft experienced forces of at least 2.5 G along its

longitudinal axis or lateral axis. The CVR recording stopped about the time of the impact.

 24Under 14 CFR Part 139, a limited airport operating certificate is issued to an airport

serving unscheduled (but not scheduled) operations of air carrier aircraft with a seating capacity of more

than 30 passengers.

17

The Beech 1900C’s CVR recording of the outgoing radio transmissions was faint

and of poor quality.25 As a result, the Board had difficulty determining the content of all

transmissions. The quality of the recorded voice communications between the flightcrew

members became noticeably poorer during radio transmissions; at other times, they were

generally adequate for readout.

The Safety Board addressed this issue in a May 22, 1997, recommendation letter

to the FAA. The letter noted that in the past 2 years, the Safety Board has investigated five other

accidents/incidents involving Beech 1900 airplanes in which the CVR poorly recorded the

incoming or outgoing radio transmissions.26 Four of these occurrences did not involve serious

injuries or fatalities, and the poor quality of the recordings was not a factor in the Board’s

determination of the circumstances surrounding the occurrences. The investigations revealed

that the problem originated in the isolation amplifiers installed in the airplanes rather than in the

actual CVR units.

The recommendation letter further noted that Raytheon had modified the audio

amplifier to correct the circuitry problem on later-model airplanes. However, more than 250

Beech 1900 airplanes are in service, and more than 170 of them may not have had the audio

amplifier modified. The company told Safety Board investigators that it plans to make a retrofit

kit available to the owners of these airplanes.

Accordingly, in its May 22, 1997, letter to the FAA, the Safety Board issued

Safety Recommendation A-97-36, which asked the FAA to do the following:

Promptly require the inspection of the CVR and associated equipment on

all Beech 1900 aircraft and ensure that operators take corrective action to

repair deficient CVR systems so that the intelligibility of recorded

communications, including radio transmissions to and from the airplane, is

as high as practicable.

The Safety Board has not yet received a response to this recommendation.

 25The Safety Board generally uses the following criteria to assess the quality of a CVR

recording: a “poor” recording is one in which a transcription is nearly impossible given that a large

portion of the recording is unintelligible; a “fair” recording is one in which a transcription is possible, but

the recording is difficult to understand; a “good” recording is one in which a few words are

unintelligible; and an “excellent” recording is very clear and easily understood.

26See Safety Board accident briefs FTW95FA004, Denver, Colorado, October 1, 1994;

FTW96FA198, Denver, Colorado, May 2, 1996 (preliminary report); NYC97FA045, Bangor, Maine,

January 10, 1997 (preliminary report); and incident briefs FTW97IA003, Pueblo, Colorado, October 3,

1996 (preliminary report): and CHI95IA066, Williston, North Dakota, January 12, 1995.
18

1.12 Wreckage and Impact Information

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.

1.12.1 Beech 1900C Wreckage Information

The Beech 1900C’s continuous tire skid marks were 475 feet long leading up to

the point where they converged with the scuff marks made by the King Air’s tires. The majority

of the airplane’s upper fuselage, including the cockpit area and both wings, was destroyed by fire.

The nose of the fuselage was intact, but it had separated at the forward cockpit

area and was resting on its right side with the nose gear extended. The right side of the nose

section was compressed inward about 10 inches, and blue paint transfer was found along the

right side of the nose assembly that matched the color of the paint trim on the King Air. The tail

assembly remained intact and was resting on the left horizontal stabilizer.

The engine and propeller assembly remained attached to the left wing. All four

right engine propeller blades had fractured at the blade root and had separated from the hub. One

of the propeller blades was found along the east edge of runway 04 at the intersection with

runway 13. The blade’s leading edge had blue paint transfer that matched the color of the paint

trim on the King Air. The leading edge of another torn propeller blade exhibited white paint

transfer that matched the color of paint on the King Air’s fuselage and wing surface.

Examination of the control cables to the fuel controls of both engines revealed positions

consistent with normal engine shutdown.

The forward air stair door was destroyed by fire. The door latches, latch mounts,

control cable, and control handle assemblies were recovered from the wreckage. Examination of

the latches revealed that they were all partially or fully latched.

1.12.2 King Air A90 Wreckage Information

The King Air’s tire scuff marks veered continually to the right on runway 04 for

about 260 feet before they converged with the skid marks from the Beech 1900C. A dark area

with an odor consistent with that of jet fuel was found on the runway near the converging skid

marks. The grass next to the airplane wreckage was burned and dark and also had an odor

consistent with jet fuel.

Except for the outboard sections of the right wing and the right horizontal

stabilizer, the King Air was consumed by the postcrash fire. No evidence of the main cabin door

or the emergency exit hatch could be found. The nose gear was folded forward in the down-andlocked position. The radome and a small section of the airplane’s left wing leading edge were

found on the runway next to the wreckage. The radome was torn and exhibited chipped paint
19

and abrasive marks on its exterior, and the section of the left wing’s leading edge showed black

paint transfer that matched the color of paint on the Beech 1900C’s propellers. Examination of

the control cables to the fuel controls of both engines revealed positions consistent with normal

engine shutdown. The cockpit-mounted radio controls were consumed by the postcrash fire. The

nose-mounted communication radio units were found crushed and partially burned. No

information about the radio’s functioning or its settings at the time of the accident could be

obtained from the wreckage.

1.13 Medical and Pathological Information

Autopsies were performed on the occupants of both airplanes. According to the

Coroner, Adams County, Illinois, the cause of death for 10 occupants was “carbon monoxide

intoxication from inhalation of smoke and soot.” The cause of death for four occupants was

“inhalation of products of combustion.”

Toxicological tests were conducted on fluid and tissue samples of all four pilots.

Tests conducted on urine samples for benzodiazepines, alcohol, and other drugs were negative

for all of them except the King Air pilot. Lorazepam (a benzodiazepine)27 was detected in the

King Air pilot’s urine sample, but it was not detected in his blood or liver fluid samples.

1.14 Fire

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.

1.15 Survival Aspects

The bodies of the King Air pilot and pilot/passenger were found behind the seats

in the cockpit.

The bodies of seven of the passengers on the Beech 1900C were found forward of

row 4, and the bodies of three passengers were found near rows 7 and 8. The captain’s body was

found in the cockpit area, and the first officer’s body was found between the air stair door and the

forward right overwing exit.28

 27As indicated in section 1.5.2.1, the King Air pilot had a waiver from the FAA allowing

him to use this tranquilizer/sedative.

28Great Lakes Aviation told Safety Board investigators that passengers aboard flight

5925 were given seat assignments but was unable to provide the Safety Board with a record of those seat

assignments. The company’s load manifest divided the cabin into forward and aft sections. The forward

section included seat rows 1 through 5, and the aft section included rows 6 through 9. According to the

load manifest, at least four passengers were seated in rows 6 through 9 and at least 5 passengers were

seated in rows 1 through 5. The 10th passenger was not listed on the load manifest.
20

1.15.1 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.29 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.

According to the manufacturer, to unlock the air stair door from the outside, a

release button above the door handle must be depressed while the handle is simultaneously

rotated downward. The following instructions for operating the air stair door were printed on a

small placard, with black letters 2/10-inch high on a white background, that was located aft and

slightly lower than the door handle on the exterior of the airplane: “PUSH BUTTON AND

TURN HANDLE TO OPEN.” No further instructions were posted on the exterior of the

airplane. The button above the handle was black, and it was located on a background color

scheme of medium-hued blue. The button was not outlined. The FBO pilot said that he did not

know that the proper procedure for opening the door involved depressing the button above the

handle while simultaneously turning the handle.

On January 3, 1997, the Safety Board issued urgent Safety Recommendation

A-97-1, which asked the FAA to do the following:

 29According to the manufacturer, when the handle is in the 6 o’clock position, the door is

unlocked, and when it is in the 3 o’clock position, it is locked.
21

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.

In February 1997, Raytheon Aircraft Company issued Service Bulletin (SB) No.

2741 requiring, within the next 200 flight hours, new exterior operating instruction placards for

the air stair and cargo doors for the Beech 1900 and 1900C and new exterior operating

instruction placards for the air stair, cargo, and emergency exits for the 1900D.

On February 24, 1997, the FAA responded to Safety Recommendation A-97-1,

stating that it had issued Priority Letter AD 97-04-02, which refers to Raytheon’s SB No. 2741,

to require the installation of new exterior operating instructions, markings, and placards for the

air stair door, cargo door and emergency exits. Based on the FAA’s action, the Safety Board

classified Safety Recommendation A-97-1 “Closed—Acceptable Action” on April 25, 1997.

1.15.2 Passenger Briefing

At 1638:12, the CVR recorded a flightcrew-activated, prerecorded passenger

briefing as flight 5925 departed Burlington for Quincy. The prerecorded briefing stated the

following, in part:

Please remove the passenger briefing card located in the seat pocket in

front of you. We suggest that you follow along as we explain the location

and operation of the aircraft’s safety equipment.

Passengers seated in 4C, 6A, or 6C should review the information card

explaining exit row seating requirements. If you feel you would be unable

to carry out these instructions or wish to be re-seated, please notify a

crewmember.

There are four exits aboard this aircraft. There are three clearly marked

overwing exits, two over the right wing and one over the left wing. To

open, pull down on the handle and pull the exit inward. The main cabin

door through which you entered is also an emergency exit. To open, push

the button next to the handle then rotate the handle counter-clockwise and

push the door open.
22

1.15.3 Beech 1900C Exits

1.15.3.1 Air Stair Door

The Beechcraft 1900 maintenance manual describes the operation of the air stair

exit door as follows:

The air stair door has six cam locks positioned around the exterior of the

door, with three cams on each side. A continuous cable connects the

exterior and interior door handle assemblies and the six cams. During

operation of either door handle, the cable rotates each cam approximately

150o to lock or unlock the air stair door. The air stair door weighs 58

pounds, and the center of gravity for the door is 3 inches inside the hinge

line.

Whether unlocking the door from the outside or inside, the release button

adjacent to the door handle must be held depressed before the handle can

be rotated to unlock the door. The release button acts as a safety device to

help prevent accidental opening of the door.

See figure 4 for a diagram of the Beech 1900/1900C air stair door and latching

mechanism.

According to representatives of Raytheon, if there is more than 1⁄4 inch of slack in

the cable, the cam locks may not fully rotate when the handle is rotated.

The air stair door parts from the accident airplane were examined at the Safety

Board’s Materials Laboratory on January 30, 1997. The findings of the examination were as

follows:

1. All cams were either fully or partially latched;

2. The exterior door handle was frozen in the latched position with aluminum

melted around it;

3. The position of the interior door handle assembly could not be determined

because there was no frame of reference to compare it to surrounding

structure;

4. The door control cable was attached at both handle assemblies and was

fractured at both turnbuckles. The metallurgical examination of the

turnbuckle fracture surfaces revealed a topography typical of copper alloys

subject to static failure influenced by high temperatures and steady state

strain rates.

24

1.15.3.2 Overwing Exit Hatches

Two overwing exit hatches are located on the right side and one on the left side of

the Beech 1900C passenger cabin. From the inside, the doors are released with a pull-down

handle, placarded “EXIT - PULL.” From the outside, the doors are released with a flushmounted, pull-out handle. The exit hatches are nonhinged, plug-type doors that completely

remove from the fuselage frame into the cabin when the latches are released. (See figure 5.)

Windows at the overwing exits have a placard with instructions to “push seat backs to clear exit.”

During the investigation, Safety Board investigators opened a Beech 1900C

overwing exit while two persons were in the seats next to the hatch. An investigator was able to

pull the exit into the cabin even though the seats were occupied and the seat backs were not

pushed forward to clear the exit.

During wreckage recovery, the overwing exit hatch release latches and

turnbuckles were examined. No conclusion could be drawn regarding their positions before the

postcrash fire because the release latch secured to the airframe could have fallen from its latched

position when the surrounding structure burned away.

1.15.4 Pilot Evacuation Procedures and Training

Great Lakes Aviation’s General Operating Manual, Volume 3, Chapter 7, dated

August 25, 1994, includes a section for “Unplanned Immediate Action.” The instructions call for

immediate action when an obvious emergency has occurred. Crewmembers are instructed to

shout “Unfasten Seat Belts and Get Out” when the airplane has come to a complete stop. The

manual indicates that a “crewmember will then open a usable exit (main cabin door) and direct

opening of other exits.” The manual includes the following instructions for an unusable exit:

Do not waste time at an exit that will not open and is not going to get

anyone out. Assign an able-bodied person (ABP) to redirect everyone to

an appropriate alternate exit. With the ABP redirecting by saying “go that

way,” it is easier for you to direct passengers toward you by using the

verbal command, “come this way” to the alternate exit.

The manual instructs the first officer to leave the airplane as quickly as possible,

preferably through one of the forward exits. It also states that the first officer should be one of

the first out and should ensure that all usable exits have been opened.

The most recent emergency training of the captain of flight 5925 was completed

during her captain upgrade training on February 5, 1996. It included ground evacuation and

drills on emergency exits.

The first officer’s most recent emergency training and emergency drills were

completed on August 6, 1996.

26

1.15.5 Previous Safety Board Recommendations on Emergency Exits

The Safety Board has issued two previous safety recommendations related to the

external operation of emergency exits.

Safety Recommendation A-81-28 was issued to the FAA on March 20, 1981,

following a series of Piper PA-28 accidents in which repeated attempts to open cabin doors and

break windows to rescue surviving occupants were unsuccessful. The safety recommendation

urged the FAA to do the following:

Amend 14 CFR 23.783, 14 CFR 23.807(b)(3), and 14 CFR Part 91 to

require external doors and emergency exits of aircraft to be conspicuously

marked on the outside with directions for opening the door.

Based on the Safety Board’s later recommendation of A-82-94 (discussed below)

and on the FAA’s airworthiness review of 14 CFR 23, which included the issue of external

markings of exits openable from the outside, on June 12, 1984, the Safety Board classified Safety

Recommendation A-81-28 “Closed—Superseded.”

On March 27, 1980, a Beechcraft 200, Super King Air, crashed and burned in a

field near Parker, Colorado. The pilot and four of the eight passengers survived the crash, but

they died from smoke or fire-related injuries because they were unable to escape through the

emergency exits. On August 20, 1982, the Safety Board issued Safety Recommendation

A-82-94, which asked the FAA to do the following:

Issue an [AD] directing all operators of airplanes equipped with

emergency exits openable from the outside to mark the exits and their

means of operation on the airplane fuselage in the manner described by 14

CFR 25.811(f)(1), (2), and (3) irrespective of the rules under which the

aircraft are being operated.

In a letter to the FAA, dated May 22, 1984, the Safety Board classified Safety

Recommendation A-82-94 “Closed—Acceptable Alternate Action,” after the FAA issued AC

23.807-3, “Emergency Exits Openable from Outside for Small Airplanes,” on January 20, 1984.

AC 23.807-3 recommended that “all manufacturers, operators and owners of

small airplanes, with emergency exits openable from the outside of the airplane, add external

markings to these exits.” The AC gave guidance for methods to improve the visibility and

identity of exits; and recommended that a decal be installed on the outside of the emergency exit

or on the outside of the airplane next to the exit showing how to open the emergency exit,

including special instructions, if applicable. Four methods to visually identify the exit were

suggested: (1) outline the exit with a band of such color contrast as to be readily distinguishable

from the surrounding fuselage surface, (2) mark the corners of the emergency exit in a

conspicuous manner, (3) outline the emergency exit handle with a band of contrasting color, and

(4) mark the emergency exit with any other conspicuous visual identification scheme.
27

At the time of this accident, United Express Beech 1900 exits were not marked

using any of the methods suggested in AC 23.807-3.

On December 20, 1995, the FAA issued regulations requiring commuter operators

that conduct scheduled passenger-carrying operations in airplanes with 10 to 30 seats to comply

by March 20, 1997, with the requirements for exterior exit markings outlined in 14 CFR Part

121.310 (g), which states the following, in part:

Exterior exit markings. Each passenger emergency exit and the means of

opening that exit from the outside must be marked on the outside of the

airplane. There must be a 2-inch colored band outlining each passenger

emergency exit on the side of the fuselage. Each outside marking,

including the band, must be readily distinguishable from the surrounding

fuselage area by contrast in color....

United Express is now in compliance with the new requirement.

1.15.6 Emergency Response

The Quincy Fire Department’s (QFD) 911 dispatch records showed that the initial

notification of the airplane crash was received at 1701, and that units, consisting of two engines,

seven firefighters, and two other vehicles, were dispatched to the scene at 1702. At 1714,30 after

traveling a distance of about 10 miles, the first units arrived at the scene and observed that both

airplanes were engulfed in flames. The firefighters from the two engines used 13⁄4-inch hose lines

to extinguish the fire with water, and other firefighters activated the Quincy Airport 500-gallon

ARFF truck. Shortly after the QFD units arrived, units from the Central Adams County Fire

Department arrived and supplied additional water for the ARFF truck. The incident commander

reported that the fire was under control within 10 minutes after the QFD’s arrival and that only

spot fires remained.

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.31 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.

 30The time reference is according to the QFD incident commander’s report supplement.

3114 CFR Part 139.3 defines air carrier operations as “the takeoff or landing of an air

carrier aircraft [with a seating capacity of more than 30 passengers] and includes the period of time from

15 minutes before and until 15 minutes after the takeoff or landing.”
28

1.15.7 Commuter Airline Study

In November 1994, the Safety Board issued a safety study entitled Commuter

Airline Safety32 that states the following, in part:

The National Transportation Safety Board has had a longstanding interest

in commuter airline safety and has issued safety recommendations in the

past seeking various actions by government and industry to address

needed safety improvements. The recommendations followed the Board’s

1972 study of air taxi safety, its 1980 study of commuter airline safety,

and investigations of accidents involving commuter airline operations. In

response to the recommendations and through other initiatives taken by

government and industry, regulatory revisions and other actions have

resulted in a greatly improved safety record for scheduled Part 135

airlines: the accident rate per 100,000 departures in 1993 was one-fourth

the accident rate observed in 1980.

Included in this safety study were two airport-related safety recommendations

addressed to the FAA to enhance the level of safety at airports served by commuter airlines:

Seek[ ] legislative action within 6 months to include in the Airport

Certification Program all airports served by air carriers that provide

scheduled passenger service. (A-94-203)

Revis[e] and expand[ ] 14 CFR 135, following enactment of the legislative

action described in Safety Recommendation A-94-203, to permit

scheduled passenger operation only at airports certificated under the

standards contained in Part 139, “Certifications and Operations: Land

Airports Serving Certain Air Carriers.” (A-94-204)

In its February 23, 1995, response to the Safety Board, the FAA stated that it was

“undertaking a process which will lead to a legislative proposal to amend 14 CFR Part 139 to

include airports servicing scheduled aircraft with more than 10 passenger seats.”

In its April 7, 1995, reply to the FAA, the Safety Board stated that although it

was:

pleased that the FAA has initiated a request for legislative activity to

revise the airport certification standards, the Board is concerned that the

proposal is restricted to airports servicing aircraft with 10 or more

passenger seats. Recommendations A-94-203 and -204 did not specify a

minimum number of passenger seats for which Part 139 certification

should be required, and reflect the Board’s strong belief that Part 139

 32See NTSB/SS-94/02.
29

certification provides a safety standard that should be applied to all

scheduled passenger operations, regardless of aircraft size. However, the

Board also recognizes that eliminating the passenger seat restriction may

have the greatest economic impact on small airports located in remote

communities that rely heavily on small aircraft operations for basic

necessities. If the FAA has determined that the airport improvements

required under Part 139 represent an excessive economic hardship on

airports receiving scheduled service in aircraft with fewer than 10 seats,

the Board would like to review the analysis that supports this position.

Pending review of that information, the Board classifies Safety

Recommendations A-94-203 and -204 “Open—Acceptable Response.”

In its May 6, 1997, response to the Safety Board concerning Safety

Recommendations A-94-203 and -204, the FAA stated:

The Federal Aviation Reauthorization Act of 1996 provides requirements for

the Federal Aviation Administration (FAA) to issue airport operating

certificates for airports that (1) serve an air carrier operating aircraft designed

for at least 31 passenger seats, (2) are not located in the State of Alaska and

serve any scheduled passenger operation of an air carrier operating aircraft

designed for more than 9 passenger seats but less than 31 passenger seats, and

(3) the Administrator determines a certificate is required. The Aviation

Rulemaking Advisory Committee (ARAC) developed recommendations on

what requirements should be applicable to the certification of airports that

serve scheduled air carrier aircraft with 10 to 30 seats. The FAA is preparing

a notice of proposed rulemaking to revise 14 CFR Part 139. The FAA

proposal will include a revision to 14 CFR Part 121 to reflect the revisions to

14 CFR Part 139.

In February 1997, an Aviation Rulemaking Advisory Committee (ARAC)

addressed the issue of establishing standards for smaller, currently noncertificated airports that

receive commuter airline service in aircraft having 10 or more seats. It recommended the

following, in part, to the FAA:33

more emphasis on education directed at accident prevention rather than

accident mitigation and upon developing a comprehensive plan for

responding to an emergency and for ensuring airfield safety. The Working

Group majority clearly feels that the limited funds available to these small

airports would be better spent on accident prevention rather than on

accident mitigation.

 33ARAC Executive Summary, dated December 30, 1996.
30

A minority position was taken by the Air Line Pilots Association members

of the group, mostly with regard to [advocating] ARFF equipment and

personnel available on or adjacent [to] the airport in order to meet a 3-

minute response time.

The FAA is currently reviewing the ARAC recommendations, and the Safety

Board is currently reviewing the FAA’s letter of May 6, 1997. The Safety Board has not received

any communication from the FAA concerning its intentions with regard to certification of

airports serving smaller air carrier aircraft.

In December 1996, the FAA reported that at that time 70 airports in the

contiguous states, 150 airports in Alaska, 2 in American Samoa, and 2 in Hawaii were not

certificated under Title 14 CFR Part 139 but were served by commuter airlines.

1.16 Tests and Research

1.16.1 Takeoff Distance and Accelerate and Stop Distance for King Air A90

Based on the weather at the time of the accident and the estimated weight of the

King Air A90 (8,117 pounds), and manufacturer’s airplane performance data, the normal takeoff

distance34 for the airplane was calculated to be about 1,500 feet. The King Air’s main gear tires

left 260 feet of scuff marks (consistent with hard turning) immediately preceding the impact

point at the intersection. Assuming, as reported by the Cherokee pilot, that the King Air was

positioned on runway 04 so that enough clearance remained behind him for the Cherokee to have

access to runway 36, the distance from the King Air to the intersection of runway 04 and 13 was

approximately 1,900 feet.

1.16.2 Visibility Tests and Study

Safety Board investigators performed tests at the accident site to determine the

line of sight visibility and conspicuity of the Beech 1900C in sunset/dusk conditions. The Safety

Board also conducted a photographic visibility study to determine the locations of the airplanes

as they would have appeared in the pilots’ fields of vision.

1.16.2.1 Conspicuity/Visibility Tests

On November 22, 1996, between 1637 and 1708, at dusk in weather conditions

similar to those at the time of the accident, and with the sunset behind them, two investigators

positioned themselves in an airport service truck in the runup area at the approach end of runway

04 facing the direction of the King Air’s takeoff roll. At 1648, they observed an airplane (a King

 34A normal takeoff is defined as one using takeoff power, flaps up, and a level, dry

surface. The normal takeoff procedure is to accelerate with both engines at takeoff power to 101 knots

CAS, take off, retract the landing gear, and climb at 101 knots CAS. Takeoff distance is defined as that

necessary to clear a 50-foot obstacle.
31

Air C90) fly overhead, make a downwind entry, and land on runway 13. The strobe and landing

lights of the airplane were observed to be conspicuous during the sequence, and there were no

obstructions to visibility. At 1645, they observed another airplane (a Cessna Conquest) and, at

1653, another (a Dassault Falcon) taxi out and take off on runway 13. The strobe lights of both

these airplanes appeared to be conspicuous during taxi, and the strobe and landing lights

appeared to be conspicuous during takeoff. No obstructions to visibility were observed.

Additional visibility tests involving a Beech l900 were conducted on November

22, 1996, between 1800 and 1930. The Beech 1900, carrying two test pilots and an investigator

seated in the jumpseat, took off, performed a left pattern, and landed on runway 13, while another

investigator observed from the left seat of a King Air B90 positioned on runway 04 in the

approximate takeoff position of the accident airplane. During the Beech 1900’s landing

sequence on final approach and touchdown, the investigator in the King Air observed

obstructions to his direct view of the Beech 1900 caused by the rear side window post in the

King Air for most of the landing sequence on short final. In a second and third test, an

investigator observer sat in the right seat (second test) and then in the left seat (third test) of the

King Air B90, which was positioned about 100 feet forward of its previous position on the

runway, and a test pilot sat in the remaining seat. When the Beech 1900 was about 200 feet agl

on final approach, the test pilot began a fast taxi along the runway toward the accident site. In

both tests, the Beech 1900 appeared close to the King Air captain’s forward window post. No

surface obstructions to visibility were observed in either test.

1.16.2.2 Photographic Visibility Study

Photographs provided by the manufacturer representing the view from within the

cockpits of both aircraft are shown as figures 6 through 9. Two superimposed photographs

represent the visual image for each eye and show the aircraft windshield visibility angles. The

camera used for these photographs is located at the captain’s35 cockpit eye zero reference point,

and the photographs are a panorama of what the pilot would see as the head was rotated. The

photographs do not account for any movement of the torso, or head movement forward,

backward, up or down. Because the cockpit is symmetrical, the captain’s view of the first

officer’s side window is the same as the first officer’s side view of the captain’s side window, but

on opposite sides of their respective fields of view.

As shown in figure 6, the Safety Board’s study using its VIZPC computer

program indicated that the view of the King Air from the Beech 1900C captain’s position would

have been partially obstructed by the center post and windshield wipers during the airplane’s

final approach and would have been totally obscured by the center post for 6 seconds, starting

about 17:00:43. Approximately 10 seconds before touchdown,36 at 1700:49, until the time of the

 35For the purposes of this study, the captain’s eye position refers to the view from the left

seat position, and the first officer’s eye position refers to the view from the right seat position.

36Although a precise touchdown point and impact speed could not be determined, a

touchdown at 1,000 feet, with typical braking for 5.5 seconds and hard skidding braking for 4.5 seconds,
32

collision, the captain would have had a partially obscured view of the King Air through the first

officer’s front windshield.

As shown in figure 7, the view from the Beech 1900C first officer’s position

would have been partially obstructed by the first officer’s side posts for nearly 30 seconds before

touchdown until impact, including 6 seconds starting at 17:00:42 when the first officer’s view of

the King Air would have been totally obstructed by the front windshield side post.

The VIZPC study also indicates that while the King Air was stationary near the

end of runway 04, the left seat occupant’s37 view of the Beech 1900C would have been

unobstructed at nearly 72o

 to the left, as viewed through the side window of the King Air. (See

figure 8). About 17:00:40, 4 seconds before the King Air began its takeoff roll, the view of the

Beech 1900C from the left seat occupant’s position would have become partially obstructed at

nearly 68o to the left, and fully obstructed at 17:00:54, about 55o to the left, when the King Air

would have been accelerating during the roll; this time is immediately before the touchdown of

the Beech 1900C. The view of the Beech 1900C from the left seat occupant’s position would

have been fully obstructed from 17:00:54 until impact at 17:01:09, except for 2 seconds at

17:01:02 when the view would have been partially obstructed.

As shown in figure 9, the King Air right seat occupant’s view of the Beech 1900C

would have been partially obstructed by the left seat occupant’s side posts until just before the

start of the King Air’s takeoff roll. At 17:00:39, the Beech 1900C would have emerged into clear

view in the left front windshield. It was noted that when the right seat occupant’s view would

have been obstructed, the left seat occupant’s view would have been clear, and vice versa. At the

start of engine throttle back by the King Air pilot, the Beech 1900C would have been about 50o

to the left of the King Air. This position would have been fully obstructed from the King Air left

seat occupant’s position, but in clear view from the right seat occupant’s position.

1.17 Organizational and Management Information

1.17.1 Great Lakes Aviation, Ltd.

Founded in 1977, Great Lakes Aviation is a regional airline that holds a commuter

air carrier operating certificate issued by the FAA under 14 CFR Part 135. It operates under the

following marketing identities: United Express, under a cooperative marketing agreement with

United Airlines, Inc.; Midway Connection, under a cooperative marketing agreement with

Midway Airlines, Inc.; Great Lakes Airlines; and Arizona Airways Express.

 

consistent with the CVR recording, could result in the collision occurring where it did, with residual

speed and sufficient momentum to carry the airplane to its final resting point.

37Traditionally, the flying pilot would be in the left seat and the passenger in the right

seat. However, because the bodies of the King Air pilot and pilot/passenger were found out of their

seats, the Safety Board was unable to determine which seats the pilot and pilot/passenger occupied.




37

At the time of the accident, the company employed more than 1,200 employees,

including 382 pilots. According to company documents, the airline operated a combined fleet of

44 Beechcraft 1900s and 12 Embraer EMB-120s and provided scheduled service to 87

destinations in 20 states and Mexico.

Crew resource management (CRM) training consisted of an initial 12 hours for

newly hired pilots and 2 hours for recurrent CRM training. The company reported that traffic

pattern procedures for uncontrolled airports are reviewed during both initial and recurrent

training.

The FAA principal operations inspector for Great Lakes stated that her

relationship with the company was good and that she was unaware of any complaints by pilots.

She stated that a National Aviation Safety Inspection Program review of the company was

conducted in June 1995 and that there were no major findings. She noted that when she had

conduced type rating check rides en route to Quincy, company pilots had used appropriate calls

and procedures for landing, and that the carrier served a high number of uncontrolled airports.

She stated that she had personally observed a recurrent training class that addressed the issues of

uncontrolled airports and procedures.

Great Lakes Aviation voluntarily suspended flight operations on May 16, 1997,

after the FAA identified discrepancies in the airline’s maintenance operations. According to the

FAA, the suspension was unrelated to this accident. On June 23, 1997, the company resumed

limited service; and, according to the FAA, as of July 1, 1997, it was operating 18 of its airplanes

on 18 routes into 26 cities.

1.18 Additional Information

1.18.1 Operating Procedures at Uncontrolled Airports

Guidance Regarding Radio Communications

Paragraph 4-1-9, a. 1., of the Aeronautical Information Manual (AIM) states the

following:

There is no substitute for alertness while in the vicinity of an

[uncontrolled] airport. It is essential that pilots be alert and look for other

traffic and exchange traffic information when approaching or departing an

airport without an operating control tower. This is of particular

importance since other aircraft may not have communication capability or,

in some cases, pilots may not communicate their presence or intentions

when operating into or out of such airports. To achieve the greatest degree

of safety, it is essential that all radio-equipped aircraft transmit/receive on

a common frequency identified for the purpose of airport advisories.

Paragraph 4-1-9, c. 1., of the AIM, also states that at uncontrolled airports:
38

[p]ilots of inbound traffic should monitor and communicate as appropriate

on the designated CTAF from 10 miles to landing. Pilots of departing

aircraft should monitor/communicate on the appropriate frequency from

start-up, during taxi, and until 10 miles from the airport unless the FARs

or local procedures require otherwise.

Table 4-1-1 of the AIM, “Summary of Recommended Communication

Procedures,” specifies the following recommended broadcasts:

for outbound aircraft - before taxiing, and before taxiing on the runway for

departure;

for inbound aircraft - 10 miles out, entering downwind, base, final, and

leaving the runway.

In addition, the AIM provides general guidance regarding proper radio

communication phraseology and techniques. Paragraph 4-2-4, “Aircraft Call Signs,” states,

“[c]ivil aircraft pilots should state the aircraft type, model or manufacturer’s name followed by

the digits/letters of the registration number. When the aircraft manufacturer’s name or model is

stated, the prefix “N” is dropped; e.g., Aztec Two Four Six Four Alpha.”

Guidance Regarding Traffic Patterns

AC 90-66A, “Recommended Standard Traffic Patterns and Practices for

Aeronautical Operations at Airports Without Operating Control Towers,” describes regulatory

requirements and recommended operating procedures at airports without control towers.

AC 90-66A states the following, in part:

7. General Operating Practices.

b. The use of any traffic pattern procedure does not alter the responsibility

of each pilot to see and avoid other aircraft. Pilots are encouraged to

participate in “Operation Lights On,” which is a voluntary pilot safety

program described in the AIM designed to enhance the “see and avoid”

requirement.

e. The FAA encourages pilots to use the standard traffic pattern.

However, for those pilots who choose to execute a straight-in approach,

maneuvering for and execution of the approach should be completed so as

not to disrupt the flow of arriving and departing traffic. Therefore, pilots

operating in the traffic pattern should be alert at all times to aircraft

executing straight-in approaches.
39

In addition, Title 14, CFR Part 91, Subpart B - Flight Rules, section 91.113, states

the following, in part:

91.113 Right-of-way rules: Except water operations.

(b) General. When weather conditions permit, regardless of whether an

operation is conducted under instrument flight rules or visual flight rules,

vigilance shall be maintained by each person operating an aircraft so as to

see and avoid other aircraft....

(g) Landing. Aircraft, while on final approach to land or while landing,

have the right-of-way over other aircraft in flight or operating on the

surface....

Guidance Regarding Scanning for Other Traffic

AC 90-48C, “Pilots’ Role in Collision Avoidance,” describes how to scan for

traffic and states the following, in part:

Pilots are reminded of the requirement to move one’s head in order to

search around the physical obstructions, such as door and window posts.

The doorpost can cover a considerable amount of sky, but a small head

movement may uncover an area which might be concealing a threat....

Prior to taxiing onto a runway or landing area for takeoff, scan the

approach areas for possible landing traffic by maneuvering the

aircraft to provide a clear view of such areas....

AC 90-42F, “Traffic Advisory Practices at Airports Without Operating Control

Towers,” contains the same guidance provided in the AIM and states, in part, “Departing aircraft

should always be alert for arrival aircraft that are [coming from the] opposite direction.”

As a result of this accident and at the request of the FAA, which asked for help in

reinforcing pilot education, the Air Safety Foundation of the Aircraft Owners and Pilots

Association distributed a poster to more than 5,000 FBOs and flight schools about uncontrolled

airport operations. The poster includes the message, “Don’t let a collision ruin your day—

REACT.” REACT is an acronym for Radio, Eyes, Announce, Courtesy, and Traffic pattern. The

poster also includes this list:

• Radio - Listen for traffic and form a mental picture of the position and

movement of all aircraft;

• Eyes - Look for all traffic—including no-radio aircraft—and turn on

landing lights when within 10 miles of the airport to make it easier to

be seen;
40

• Announce - Broadcast position on taking the active runway and on

pattern entry, crosswind, downwind, base, and final;

• Courtesy - Be courteous in the pattern. Discuss conflicts on the

ground, not on the radio;

• Traffic Pattern - Fly a standard traffic pattern at the recommended

altitude.

In addition, the Foundation published a “Safety Advisor” booklet on uncontrolled

airport operations, is providing more information at Flight Instructor Refresher Clinics, and has

published the pamphlet “Pilot Operations at Nontowered Airports” and other safety articles on

the Internet (http://www.aopa.org).38

1.18.2 Previous Safety Board Recommendation on Scanning Techniques

In its report adopted on September 13, 1993, concerning the midair collision of a

Mitsubishi MU-2B-60 and a Piper PA-32-301 in Greenwood, Indiana, on September 11, 1992,39

the Safety Board issued Safety Recommendation A-93-130, which asked the FAA to do the

following:

Inform flight instructors about the necessity for emphasizing scanning

techniques during training and biennial flight reviews.

On January 24, 1994, the FAA responded to the Safety Board stating that

scanning techniques would be emphasized in the FAA’s flight instructor refresher clinics and

designated pilot examiner standardization courses. On April 1, 1994, the Safety Board classified

Safety Recommendation A-93-130 “Closed—Acceptable Action.”

1.18.3 Postaccident Actions by the FAA

As a result of this accident, the FAA prepared a report, dated January 3, 1997,

entitled “Comparison of Accidents and Incidents Between Towered and Nontowered Airports.”

The report, which evaluated accidents involving at least one Part 121 or scheduled Part 135

operation at airports receiving commercial airline service, found that for the years between 1983

and 1996, the number of airport accidents (occurring within a 5 mile radius of the airport)

declined for both types of airports. Also, using the same timeframe, the accident rate per 100,000

operations for towered airports indicated a downward trend. The report stated that an accident

 38For more detailed information on AOPA’s actions since the accident, see the February

1997 issue of AOPA Pilot. 39See Aircraft Accident Report, “Midair Collision, Mitsubishi MU-2B-60, N74FB, and

Piper PA-32-301, N82419, Greenwood Municipal Airport, Greenwood, Indiana, September 11, 1992”

(NTSB/AAR-93/05)
41

rate for nontowered airports was not calculated because “activity data for nontowered airports are

unreliable.”

According to the report:

Accidents involving high-speed runway collisions in which at least one of

the aircraft were engaged in commercial service are extremely rare events.

Only two such accidents occurred during the last five full year period, and

those accidents occurred at airports with an operating tower. The data

does not indicate that the recommended practices, procedures and services

currently being used to prevent aircraft collisions in the airport

environment are systematically inadequate.

In addition, on December 2, 1996, the FAA issued a letter to all pilots referring to

this accident. The letter encouraged pilots to review the AIM relating to operations at

uncontrolled airports and cited the three ACs discussed in section 1.18.1. The letter also stated

the following, in part:

As pilots you have been trained to “see and avoid,” and there is no need to

remind you of that duty. We need to take stock of our traffic scanning and

radio communications techniques, particularly when operating at

nontowered airports. Transmitting on UNICOM or on the Common

Traffic Advisory Frequency while operating at nontowered airports—

particularly during busy periods of operation or during early morning or

dusk—can mean the difference between a safe operation and an accident

or incident. For aircraft without radios, of course, a pilot’s scanning

technique at nontowered airports is a necessity and his or her best

insurance against involvement in a collision on the ground or in the air.
42

2. ANALYSIS

2.1 General

The pilots of flight 5925 were properly certificated, trained, and qualified for their

duties in accordance with 14 CFR Parts 61 and 135 and company requirements.

The pilot of the King Air was properly certificated under 14 CFR Part 61.

The Beech 1900C was equipped and maintained in accordance with applicable

rules and directives.

No records were found to indicate that the King Air had undergone the required

transponder and pitot static inspections within the past 2 years. Other than this possible

maintenance deficiency, which was not a factor in the accident, the King Air was maintained in

accordance with applicable rules and directives.

Weather was not a factor in the accident.

2.2 United Express Flightcrew Performance

The Safety Board analyzed the flightcrew’s use of a straight-in approach to

runway 13, radio communications, and post-touchdown actions, to determine whether they were

factors in the accident.

The flightcrew of flight 5925 made a straight-in approach, rather than using the

standard traffic pattern as recommended in AC 90-66A and the AIM for uncontrolled airports.

Although the FAA encourages pilots to use the standard traffic pattern, it recognizes in AC 90-

66A that some pilots may choose to execute a straight-in approach, and therefore urges all pilots

operating in the pattern to be alert to such approaches.

Although the wind direction and speed did not favor the use of either runway in

this case, the flightcrew of 5925 probably chose the straight-in approach to runway 13 rather than

a downwind or base leg entry to runway 04 to save time because they had been delayed

previously and because it was easier to accomplish than maneuvering in a pattern.

The Beech 1900C was visible to other airport traffic during its approach.

Witnesses, including the occupants of the Cherokee taxiing behind the King Air, said that they

could see the airplane and that it had its landing lights on. Further, the Beech 1900C flightcrew

discussed the fact that two airplanes were planning to take off on runway 04, and they had an

alternate plan to use runway 04 if necessary. The captain’s request at 10 miles out for other

traffic to “please advise” gave them sufficient time to revert to this alternate plan if needed. The

pilots observed when the King Air entered runway 04, and later attempted to ensure that runway

13 would remain clear for their landing by asking whether the airplane on the runway (i.e., the

King Air) intended to hold or take off.
43

The Safety Board concludes that given the Beech 1900 flightcrew’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 flightcrew’s decision to fly a straight-in

approach to runway 13 was not inappropriate.

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.40 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.

Subtle cues indicated that the transmission did not come from the King Air.

Specifically, the speaker gave a different “N” number, and the voice and gender of the speaker

were different than heard in previous transmissions from the King Air. However, because the

pilots were most likely preoccupied with landing the airplane, and because the speaker said

“King Air” but did not say “Cherokee” and the pilots had no reason to expect a response from

any aircraft other than the King Air, they probably did not notice or focus on those cues. Having

received what they believed was an assurance from the airplane on the runway that it was going

to hold, the pilots may have become less concerned about continuing to watch the King Air

during their landing.

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

 40Recommended broadcasts in AIM and AC (10 miles out; entering downwind; base; and

final) assume the inbound plane is flying a pattern approach. Because flight 5925 was flying a straight-in

approach, it did not enter a downwind leg and, therefore, such a call would have been inappropriate.
44

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.

2.3 King Air Pilot and Pilot/Passenger Performance

There were several indications suggesting that the pilot may have been giving

instruction to the pilot/passenger on the accident flight. The pilot/passenger’s former husband

indicated that she was building hours towards obtaining her ATP certificate and that she wanted

eventually to fly for an air carrier. The pilot had instructed her in the past, and this was the first

time the pilot/passenger had flown a King Air. Observations made by the passengers on the King

Air’s earlier flight to Tulsa and back were consistent with the pilot instructing the

pilot/passenger.

After the passengers had departed, the King Air pilot would have had a good

opportunity to demonstrate the systems of the King Air to the pilot/passenger. The King Air’s 1-

minute delay after taxiing onto the runway before power was applied for takeoff is consistent

with instruction. The presence of scuff marks associated with hard turning farther down the

runway indicates that the occupants of the King Air may not have seen the Beech 1900C until

just before the collision,41 suggesting that they may have been preoccupied with instructional

activities inside the cockpit.

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.42 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

 41Witnesses said they heard the King Air throttle back just before the collision.

42A pilot inside the FBO stated that shortly before the accident, he thought he heard a

male pilot transmitting at the same time as a female pilot, timed so that the female pilot would not have

known her transmission had been “stepped on.” The Safety Board considered whether this could indicate

that the King Air pilot made a takeoff announcement simultaneously with the Beech 1900C captain’s

request (at 1700:16) for the intentions of the airplane holding on runway 04, and that the announcement

was therefore not recorded on the Beech 1900C’s CVR. However, this potential scenario was

contradicted by the recollections of an employee of the FBO who also heard the CTAF transmissions.

The employee remembered the entire content of the Beech 1900C captain’s transmission, which indicates

it was not overridden by another transmission. Further, the Cherokee pilot stated that all the

transmissions from both the Beech 1900C and the King Air were in female voices. Therefore, it is likely

that the pilot was mistaken in his belief that he heard a “stepped on” transmission.
45

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.

The Safety Board considered whether their failure to hear the transmissions made

over the CTAF could have been a result of mechanical radio problems. On the previous flight,

Tulsa ground control indicated a problem receiving outgoing transmissions from the airplane.

Although a passenger recalled the pilots exchanging headsets, indicating that one of the headsets

might have had some trouble receiving incoming transmissions, subsequent communications

with the Kansas City ARTCC did not indicate that the pilot of the King Air, who was then

handling the radios, had any trouble receiving incoming transmissions. The Safety Board could

not determine from the wreckage whether the radio equipment was working properly. However,

problems with outgoing transmissions would not have affected the occupants’ ability to hear

incoming transmissions over the CTAF. And if there had been previous problems with incoming

transmissions, they apparently affected only one of the headsets and would not have prevented

both occupants from hearing incoming transmissions on the CTAF.

The Safety Board also considered whether the occupants might have

unintentionally set the radio controls so they could transmit but not receive over the CTAF; or

that they might have tuned the receiver to a different frequency (such as the first anticipated air

traffic control frequency), or turned the volume down. However, because of the extensive fire

damage, the settings on the radios at the time of the accident could not be determined.

The Safety Board concludes that it is likely that either the King Air occupants did

not properly configure the radio receiver switches to the CTAF, or that they were preoccupied,

distracted, or inattentive.

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,
46

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.

It is conceivable that the King Air pilot assumed that the absence of CTAF

transmissions from incoming aircraft indicated that there was no traffic in the area and therefore

no need to scan for traffic. However, even if the pilot thought that they were properly tuned to

the CTAF, it would not have been reasonable or prudent for him to assume that the absence of

any transmissions would mean that no traffic was in the area because that absence would not

preclude the presence of non-radio-equipped aircraft in the area.

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 accident occurred at 1701, a time often associated with fatigue. According to

the pilot’s wife, he slept normally in the days before the accident but awoke earlier than his usual

time of 0800 on the day of the accident. The detection of lorazepam in the pilot’s urine indicates

that he ingested the medication in the previous days or weeks. However, the absence of the

medication in his blood indicates that he was not impaired by the medication at the time of the

accident. Nevertheless, his potentially recent use of the medication suggests that he may have

had some difficulty sleeping. Based on his early wake-up time, the time of day that the accident

occurred, and the possibility that he had difficulty sleeping recently, he was most likely not at his

peak alertness at the time of the accident. However, the Safety Board could not determine the

extent to which this may have affected his performance.

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.

The pilot/passenger was a ground instructor with Flight Safety International and

had instructed commuter pilots on proper procedures at uncontrolled airports. She would have

known the importance of scanning for traffic before taking off. The fact that she did not do so in

this case suggests that she may have been preoccupied with the instruction, focusing solely on the

cockpit instruments, and she may have assumed that the pilot had already scanned for traffic

before taking off.
47

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.

2.4 Cherokee Pilot Performance

The Cherokee pilot had accumulated only 80 hours of flight time, and his radio

communications reflected his inexperience. In his first communication, a taxi announcement at

1655:40, “Quincy traffic, Cherokee seven six four six Juliet back-taxi uh, taxiing to runway four,

Quincy,” he used the term “back-taxi” inappropriately. The term refers to taxiing on a runway

opposite the traffic flow. Further, at 1700:16, he responded to the transmission from the captain

of flight 5925, which was clearly not directed at his airplane. He then failed to correct the

resulting misunderstanding.

The Cherokee pilot’s response to flight 5925’s question (directed to the airplane

“in position on runway four”) was unnecessary and inappropriate because he was not the first in

line for takeoff. If he did not understand the transmission and thought a pilot from the King Air

was talking to him,43 which they would have had no apparent reason to do, he should have asked

for clarification before answering. In any event, even if the Cherokee pilot did not know he was

responding to the Beech 1900C flightcrew’s request, he should have realized that his

transmission could be misinterpreted or could create confusion.

In addition, the Cherokee pilot’s transmission created the potential for confusion

and misunderstanding because he failed to precede his N number with his airplane model

(“Cherokee”), as recommended in the AIM. He should have been alerted by flight 5925’s

response that such a misunderstanding had occurred. But he then reinforced the

misunderstanding by not correcting it.

The Safety Board concludes that 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 flightcrew’s misunderstanding, misled the flightcrew into believing that it had

been communicating with the King Air, and that the King Air would continue holding.

 43After the accident, the Cherokee pilot claimed that he responded to a transmission

because he thought the King Air pilot was talking to him. However, because the Cherokee pilot’s

recollection was not consistent with the sequence of events as recorded on the Beech 1900’s CVR, it was

not clear whether this explanation related to his transmission following flight 5925’s question, or his

earlier broadcast at 1655:40 (“Quincy traffic, Cherokee seven six four six Juliet back-taxi uh, taxiing to

runway four, Quincy”), which followed the King Air’s broadcast that he was taxiing to runway four.
48

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.

2.5 Survival Aspects

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.

Because Great Lakes Aviation was unable to provide the Safety Board with a

record of passenger seat assignments, the Safety Board was unable to determine the distance or

direction that the passengers on the Beech 1900C moved from their seats toward an exit. The

Safety Board could not determine the time that was available for the occupants of that airplane to

have escaped in the presence of the smoke and soot of the fire.

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.
49

2.5.1 Air Stair Door

The FBO pilot found the exterior air stair door handle in the 6 o’clock (unlocked)

position. He stated that he tried to pull on the door and move the handle in all directions in an

attempt to open the door. Although he recollected that he was unable to rotate the handle any

farther than the 5 o’clock position, he probably rotated the handle to the 3 o’clock (locked)

position, where the United Express pilot subsequently found it. Because he did not understand

how the door handle worked, and he had initially been unable to open the door with the handle in

the 6 o’clock (unlocked) position, it is understandable why the FBO pilot would have attempted

to open the door by rotating the handle to a different position. The United Express pilot pushed

the button and rotated the handle back to the unlocked position but was also unable to open the

door. The FBO pilot then made another unsucessful attempt to open the door and probably

rotated the handle back to the locked position.

All six of the air stair’s cam locks were recovered from the wreckage and were

determined to be in locked positions. The exterior door handle lock plate was also found in the

locked position.

If the impact caused deformation of the door and/or the fuselage that prevented

one or more of the cam locks from moving, it would not have been possible for the exterior door

control handle to be moved from the closed position to the open position as easily as it was

described to have been done by the United Express pilot who tried to open the air stair door from

the outside.

However, if the impact caused deformation of the door/frame system that

introduced slack into the cable system, the exterior handle could have been moved from the

closed to the open position, but the cable would not necessarily simultaneously rotate all the cam

locks to the completely open position. This would explain why the FBO pilot found the door

handle in the unlocked position when he first arrived but could not open the door. According to

Raytheon, the introduction of as little as 1⁄4 inch of slack in the cable could prevent the cams from

fully rotating.

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.

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
50

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.

Although the requirement that doors be reasonably free from jamming as a result

of fuselage deformation is stated in at least three applicable regulations relevant to certification

under 14 CFR Part 23,44 two of which existed at the time the Beech 1900C was certificated, there

is apparently no clear guidance indicating how a manufacturer should demonstrate compliance

with these requirements. Specifically, there appears to be no clear written guidance from the

FAA specifying the degree of fuselage deformation contemplated by those regulations, or

explaining what is meant by “reasonably free” from jamming. Although Beech requested and

received FAA approval of the specific tests it used to show compliance and conducted additional

“unofficial” tests to demonstrate freedom from jamming in a particular accident configuration

over which the FAA had expressed concern (both main gears collapsed), there is apparently no

specific written FAA standard against which a manufacturer’s compliance is to be measured.

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.

Further, because the air stair door on the accident airplane jammed as a result of

an impact that caused little or no injury to the occupants of the airplane, the Safety Board

concludes that the FAA’s freedom from jamming certification process may be inadequate.

Therefore, the Safety Board believes that the FAA should consider the circumstances of this

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.

In addition, in light of Great Lakes Aviation’s maintenance practices for the air

stair door, the Safety Board considered the possibility that a mechanic improperly routed the

door’s cable, a situation that might not have been evident immediately after installation, which

could have led to a binding or loosening of the cable over long periods of use. Such a condition

might have prevented the door from operating properly after the collision. However, the Safety

Board was unable to find any evidence that the cable was misrouted.

The Safety Board concludes that formal training for maintenance personnel in

specific tasks they are assigned to accomplish is critical for the proper, sustained operation of

aircraft. Therefore, the Safety Board believes that the FAA 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.

 44Similar requirements also appear several times in Part 25.
51

2.5.2 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.

Further, in an effort to inform commuter airline passengers about airports that do

not have ARFF capabilities, the Safety Board believes that the FAA 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.
52

3. CONCLUSIONS

3.1 Findings

1. The pilots of flight 5925 were properly certificated, trained, and

qualified for their duties in accordance with 14 Code of Federal

Regulations Parts 61 and 135 and company requirements.

2. The pilot of the King Air was properly certificated under 14 Code of

Federal Regulations Part 61.

3. The Beech 1900C was equipped and maintained in accordance with

applicable rules and directives.

4. No records were found to indicate that the King Air had undergone

the required transponder and pitot static inspections within the past 2

years. Other than this possible maintenance deficiency, which was

not a factor in the accident, the King Air was maintained in

accordance with applicable rules and directives.

5. Weather was not a factor in the accident.

6. Given the Beech 1900C flightcrew’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

flightcrew’s decision to fly a straight-in approach to runway 13 was

not inappropriate.

7. 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.

8. 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.

9. 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.
53

10. The occupants of the King Air were inattentive to or distracted from

their duty to “see and avoid” other traffic.

11. 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 flightcrew’s misunderstanding, misled the flightcrew

into believing that it had been communicating with the King Air, and

that the King Air would continue holding.

12. 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.

13. The impact forces were at a survivable level for the occupants of both

airplanes.

14. 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.

15. 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.

16. 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.

17. 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.

18. The FAA’s freedom from jamming certification standards may be

inadequate.

19. Formal training for maintenance personnel in specific tasks they are

assigned to accomplish is critical for the proper, sustained operation

of aircraft.

20. If on-airport aircraft rescue and fire fighting equipment protection had

been required for this operation at Quincy Airport, lives might have

been saved.

21. Although some communities may lack adequate funds to provide

aircraft rescue and fire fighting protection for small airports served by
54

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.

3.2 Probable Cause

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.
55

4. RECOMMENDATIONS

As a result of the investigation of this accident, the National Transportation Safety

Board makes the following recommendations:

--to the Federal Aviation Administration:

Reiterate to flight instructors the importance of emphasizing careful

scanning techniques during pilot training and biennial flight reviews.

(A-97-102)

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)

Establish clear and specific methods for showing compliance with the

freedom from jamming certification requirements. (A-97-104)

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)

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)

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)

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, the Safety Board reiterates Safety Recommendation A-94-204 to the

FAA:

Permit scheduled passenger operation only at airports certificated under

the standards contained in Part 139, “Certification and Operations: Land

Airports Serving Certain Air Carriers.”
56

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

James E. Hall

Chairman

Robert T. Francis II

Vice Chairman

John Hammerschmidt

Member

John J. Goglia

Member

George W. Black, Jr.

Member

July 1, 1997
57

5. APPENDIXES

APPENDIX A—INVESTIGATION AND HEARING

1. Investigation

The National Transportation Safety Board was notified of the accident about 1830

on November 19, 1996. An investigative team was dispatched shortly thereafter, arriving at

Quincy early the next morning. Investigative specialists for meteorology, air traffic control,

operations, airplane performance, structures, systems, human performance, survival factors,

airports and powerplants gathered evidence at the scene for about 1 week. An investigative

group for the cockpit voice recorder was also formed in Washington, D. C. Member Black was

the Safety Board Member on scene.

Parties to the investigation included the Federal Aviation Administration,

Raytheon Aircraft Company, Great Lakes Aviation, Ltd., United Technologies Pratt and

Whitney, and the National Air Traffic Controllers Association.

2. Public Hearing

There was no public hearing conducted in conjunction with this investigation.
58

APPENDIX B—COCKPIT VOICE RECORDER TRANSCRIPT

LEGEND

HOT Crewmember hot microphone voice or sound source

HOT-M Aircraft mechanical voice heard on all channels

RDO Radio transmission from accident aircraft

CAM Cockpit area microphone voice or sound source

PA Voice heard over aircraft public address system

PA4 Recorded passenger announcement over aircraft public address system

CTR1 Radio transmission from Chicago center controller

CTR2 Radio transmission from Kansas City center controller

1127D3 Radio transmission from King Air N1127D, male voice

1127D4 Radio transmission from King Air N1127D, female voice

7646J Radio transmission from Cherokee N7646J

BRLOP Radio transmission from Burlington operations

QCYOP5 Radio transmission from Quincy operations, female voice

QCYOP6 Radio transmission from Quincy operations, male voice

AWOS Radio transmission from Quincy Automated Weather Observation System

-B Sounds heard through both pilot’s hot microphone systems

-1 Voice identified as Pilot-in-Command (PIC)

-2 Voice identified as Co-Pilot.

-? Voice unidentified

* Unintelligible word

@ Non pertinent word

# Expletive

- - - Break in continuity

( ) Questionable insertion

[ ] Editorial insertion

..... Pause

Note 1: Times are expressed in central standard time (CST).

Note 2: Words shown with excess vowels, letters, or drawn out syllables are a phonetic representation of the words as spoken.
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SOURCE CONTENT SOURCE CONTENT

DCA97MA009A/B

START of RECORDING

START of TRANSCRIPT

1620:21

CTR-1 Lakes Air two fifty one, right now you are three miles

south of BURNS. maintain three thousand till

established on the localizer. cleared ILS approach to

Burlington airport.

1620:26

CAM [sound similar to aircraft altitude alert signal]

1620:31

RDO-2 * two fifty one uh, three thousand till established, cleared

ILS three six into Burlington.

1620:41

HOT-2 flaps?

1620:42

HOT-1 flaps * indicated takeoff.

1620:45

HOT-2 approach briefing?

1620:46

HOT-1 gonna be, that's complete.

1620:49

HOT-2 performance is one ten twenty five?

1620:51

HOT-1 reviewed.

1620:51

HOT-2 nav radios?

59
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1620:52HOT-1 they're set.1620:53HOT-2 ** identified, interior lights?1620:57HOT-1 aaare, comin' up.1620:59HOT-2 flaps?1621:01HOT-1 they're, ... takeoff.1621:02CAM [sound similar to aircraft altitude alert signal]1621:03HOT-2 approach check list?1621:04HOT-1 power back six hundred please.1621:05HOT-1 it's complete.1621:12HOT-1 call 'em established.

1621:14RDO-2 two fifty one's established.1621:16CTR-1 Lakes Air two fifty one roger. rep

frequency. if unable through Ft. advisory is approved.
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1621:23RDO-2 two fifty one's change to advisory1621:26RDO-? [sound similar to someone keying 

times]

1621:31HOT-1 [sound similar to outer maker beacon signal]

1621:361127D-3 and Quincy traffic uh, King Air on

on a left base for runway four, Qu

1621:43CAM [sound similar to aircraft altitude alert signal]1621:48HOT-2 I didn't get any marker beacons.1621:51HOT-1 I got a low one. I think the volume might be way down.1621:57HOT-1 [sound similar to engine ignition]1621:58HOT-2 anyway, we're over the marker.1621:59CAM [sound similar to aircraft altitude alert signal]

1622:03RDO-2 Burlington area traffic Lakes Air t

inbound three six ILS.
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1622:11HOT-2 landing gear?1622:12HOT-1 down, three green.1622:13HOT-2 verified.1622:18HOT-2 three thousand is the missed approach altitude.

1622:331127D-5 Quincy traffic, Baron, I mean King 

Delta 'bout ready to turn final for 

1623:36HOT-1 approach flaps please.1623:37HOT-2 OK, check selected approach.1623:43HOT-2 indicated approach, approach lights in sight, continue.1623:52HOT-2 runway's in sight.1624:10HOT-1 landing flaps.1624:11HOT-2 speed checks, * to land.
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1624:15HOT-2 flaps are landing, yaw damps off. three in the green. final

checks are complete. runway's clear. ref's, one ten.

1624:22RDO-2 Burlington area traffic, Lakes two 

three six, Burlington.

1624:36CAM-3 two hundred.1624:42HOT-2 plus five.1624:53HOT-2 V ref.1625:00CAM [sound similar to aircraft touching down on runway]1625:02HOT-2 reverse available.1625:09CAM [sound of increase in engine noise similar to engine reverse

power being applied]

1625:53RDO-2 Burlington area (traffic Lakes) two 

clear all runways, Burlington.

1626:02RDO-2 Chicago center Lakes two fifty on

Burlington, cancel.

1626:07CTR-1 Lakes Air two fifty one, cancellati
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1626:10RDO-2 two fifty one uh, we broke out abo1626:13CTR-1 nine hundred AGL, thanks.

1626:21HOT-1 afters please.1626:22HOT-2 * lights are off, flaps up, trim's reset, radar, TCAS transponder standby auto feather's off anti-skid is not installed ice

protection boards pressurization is depressurized afterlanding checklist complete.

1626:33HOT-1 OK, thank you.

[several non pertinent comments between captain and co-pilot]

1627:13PA-2 ladies and gentlemen I'd like to welcome you to the Burlington airport for those of you getting off here in Burlington I'll

have the door for you in just a minute call for your departureas you exit please check around your seat make sure youcollect all your personal belongings you may have broughton board with you. please watch your head as you exit theexit is a little bit lower on the inside of the cabin. all yourbaggage will be inside the terminal. once again do apologize for the delay getting you into Burlington this afternoon,but uh, we do hope you have a real nice evening here inBurlington for those of you continuing on to Quincy we doask that you remain on the aircraft with your seatbelts fastened thanks.

1627:39CAM [sound similar to engines being shut off]
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1627:45CAM-1 mine looks clear I think, what about yours?1627:48CAM-2 turn around and look at it I guess.1627:49CAM-1 **.1627:49CAM [break in CVR recording similar to power being shut off]-----------------------------------------------------------------------------------------------------------------------------------------------------------------1636:21CAM-1 avionics off inverters off, mode controllers off blowers are

auto condition levers fuel cutoff prop area's been clearedbattery voltage checks engine start.

1636:29HOT-1 [sound similar to engine ignition]1636:52CAM [sound similar to engine being started]1636:53CAM [sound similar to altitude alert signal]
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1637:15HOT-1 doors and windows are closed and locked. loads checked.

panel lights are as required cabin lights are as required,cabin sign oops, wrong one isn't it. battery's on avionics areoff inverters are off mode controllers off blowers are auto Iknew which one I knew what I was doing. [sound ofchuckle]

1637:29HOT-2 oh. [sound of chuckle]1637:30HOT-1 I knew that the engine wasn't started. I just was saying the

wrong checklist. [sound of chuckle]

1637:35HOT-2 *.1637:36HOT-1 Kate your engine's not going..... oh thank you..... battery's

on avionics are off inverters are off mode controllers offblowers are auto, condition levers fuel cutoff prop area'sbeen cleared battery voltage checks engine start.

1637:51CAM [twin chime similar to no smoking/seatbelt sign being activated]1637:55HOT-1 [sound similar to engine ignition]1637:56CAM [sound similar to altitude alert signal]1638:12PA-4 Welcome aboard. Before we begin our flight, we would like

to review some important safety features of our Beechcraft1900 airliner. Please remove the passenger briefing card
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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located in the seat pocket in front of you. We suggest thatyou follow along as we explain the location and operation ofthe aircraft's safety equipment.Passengers seated in 4C, 6A or 6C should review the information card explaining exit row seating requirements. Ifyou feel you would be unable to carry out these instructionsor wish to be reseated, please notify a crew member.There are four exits aboard this aircraft. There are threeclearly marked overwing exits, two over the right wing andone over the left wing. To open, pull down on the handleand pull the exit inward. The main cabin door throughwhich you entered is also an emergency exit. To open,push the button next to the handle then rotate the handlecounter-clockwise and push the door open.This aircraft has two portable fire extinguishers. One located forward of the right front seat and the other locatedunder the right seat in the cockpit. To operate the extinguisher, unlatch it from its bracket, pull the pin in the handle, point the nozzle at the base of the flames, and thensqueeze the handle.In the unlikely event of a water landing, each seat cushioncan be used as a flotation device. Pull the seat cushionout, wrap your arms around the cushion and hold on to thestraps.Federal Aviation regulations require passenger compliancewith the lighted passenger information signs and postedplacards. Please observe the seat belt and no smokingsigns on the overhead panels. To fasten your seatbelt,push the metal tab into the end of the metal buckle, thenpull on the belt end to tighten. Release the seatbelt bylighting the buckle tab. For your safety keep seatbelts fastened for the takeoff and landing portions of the flight. Also,set backs and tray tables must be in the upright and
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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locked position during takeoff and landing. For your safetyand comfort we require you to keep your seatbelt fastenedfor the entire flight.Smoking is prohibited on this flight.This aircraft is pressurized for your comfort. If the need foroxygen should arise, pull on the mask and pull over yournose and mouth and breathe normally. If you are travelingwith small children, see to your needs first then assist thechild. The crew will advise you when it is safe to discontinueuse.For takeoff and landing the Federal Regulations require theproper stowage of carry on baggage. Stow carry-on itemsunder the seat in front of you or in the closet across fromthe main entrance door. The aisle must remain clear at alltimes.Portable radios and electronic devices may interfere withcommunication and navigation equipment. Please refrain fromusing such devices during flight.If anyone is having trouble with their seatbelt, please advisea crew member now. Thank you for your attention. Now weinvite you to sit back, relax, and enjoy the flight.

1638:28HOT-2 ..... loads checked panel lights are off cabin lights cabin sign

inverters on avionics on mode controllers on auto CVRGPWS checked, pressurization....

1638:36HOT-B [sound of tone]1638:41HOT-7 glide slope, pull up, pull up.
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1638:47HOT-2 ...fuel quantity flight and engine instruments checked, that checklist is complete.1638:48HOT-1 brakes are set, airplane's yours.1638:52HOT-2 umm, taxi checks.1638:53HOT-1 brakes?1638:54HOT-2 released checked.1638:55HOT-1 area.1638:55HOT-2 clear right and behind.1638:57HOT-1 clear left.1638:58HOT-1 passenger brief?1638:59HOT-2 complete.1639:00HOT-1 check list.1639:04HOT-2 complete.
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1639:10RDO-1 Burlington area traffic, Lakes Air 

airliner taxiing out to runway threBurlington.

1639:23HOT-1 ...nunciators?1639:25HOT-2 considered.1639:26HOT-1 engine instruments and loads.1639:30HOT-2 * green and parallel.1639:33HOT-1 flight instruments?1639:35HOT-2 eleven four, thirteen six uh try to get the direct course of a

hundred and eighty degrees off three six. three zero zerothree for the meter.

1639:47HOT-1 and the flaps? oops, sorry auto-feather?1639:50HOT-2 armed.1639:51HOT-1 trim controls?1639:52HOT-2 two zero zero set.
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1639:54HOT-1 flaps?1639:55HOT-2 set checked takeoff.1639:56HOT-1 flight controls.1639:58HOT-2 free and correct.1640:00HOT-1 and uh, performance is... seven and fourteen thirty three

hundred pounds no other restrictions.

1640:07HOT-2 reviewed.1640:08HOT-1 clearance?1640:11HOT-2 we have to get.1640:12HOT-1 and the takeoff departure briefing?1640:14HOT-2 normal standard Great Lakes off three six. problems after V

one, we'll try to keep it VFR and bring it back to Burlingtonif we can't we'll uh, ILS approach back to uh, three six.

1640:37HOT-1 ooh. risky.
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1641:15HOT-1 don't go missed.1641:33HOT-2 they gotta be training.1641:37HOT-2 they were up in Quincy yesterday training.... I thought he

said that's BS. but he said that'd be us.

1641:44HOT-B [sound of several chuckles]1641:48HOT-2 risky.1641:50HOT-1 oooh.

1641:53RDO-1 good afternoon Chicago center, L

on the ground at Burlington lookiChic.. to uh, Quincy I'm sorry, athree six.

1642:03CTR-1 Lakes Air two fifty one roger, you

Burlington airport to Quincy airpoand maintain three thousand, squcontact Chicago center upon depclearance void if not off by, two.. now two two four three and a hal
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1642:30RDO-1 Lakes Air two fifty one we're clea

three thousand, six five zero six otime two two five five. we'll call othree six in just about thirty secon

1642:41CTR-1 roger.

1642:43HOT-1 do you smell smoke?1642:50HOT-1 I have the clearance.1642:52HOT-2 * maintain three thousand.1642:55HOT-1 uh.1642:59HOT-2 ***.1643:05HOT-1 before takeoff checklist.1643:07HOT-2 that's complete.1643:13HOT-2 kinda smoke ya smell?1643:18HOT-1 I don't know. maybe the lights or something. I don't see

anything. ya got all your circuit breakers in?
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1643:26HOT-2 yeah.

1643:37RDO-1 Burlington area traffic, Lakes Air 

airliner departing, runway three sfrom the area to the south. any oBurlington area, please advise.

1643:54HOT-2 line ups.1643:55HOT-1 ice protection?1643:57HOT-2 standard three boards.1644:01HOT-1 and the external lights?1644:03HOT-2 they're on.1644:05HOT-1 anti-skid?1644:07HOT-2 not installed.1644:09HOT-1 check list, I'm sorry. environmental mode and bleeds environmental off and off , and your radar's on standby, TCAS

is on, transponder's on alt, HSI/DG we're lookin' at aboutum, three fifty eight, that checks both sides. check listcomplete.
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1644:24CAM [sound of increase in propeller RPM similar to engine takeoff power being applied]1644:35HOT-1 feathers lit.1644:38HOT-2 that's affirm.1644:39HOT-1 power's set.1644:44HOT-1 eighty knots cross checks.1644:48HOT-1 V one.1644:50HOT-1 V two.1644:54HOT-1 positive rate.1644:56HOT-2 gear up.1645:01HOT-1 gear's in transit, gear's up, lights are out.1645:05HOT-1 four hundred.1645:06HOT-2 flaps up. climb power climb check.
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

TIME & TIME &SOURCE CONTENT SOURCE CONTEN

1645:18CAM [sound similar to decrease in propeller RPM]1645:23HOT-1 gear is up, flaps are up, environmental mode and bleeds

are on as required, your yaw damp's on,...

1645:28CAM [sound similar to altitude alert signal]1645:29HOT-1 ..... climb power set, check complete, one to go.

1646:01RDO-1 Burlington area traffic, Lakes Air, 

Beech airliner just off runway, thrturn out, departing the area to the 

1646:25HOT-1 wanna stay at four? we can stay below that high stuff. *

 sure, I s'pose six would probably do it too.... *** warm temperatures.

1646:38HOT-2 doesn't matter to me **.1646:44CAM [sound similar to altitude alert signal]1646:46HOT-1 be nice if they didn't have to de-ice.

1647:05RDO-1 Chicago center Lakes Air two fifty 

thousand off Burlington.
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1647:31RDO-1 Chicago, Lakes Air two fifty one l1647:51AWOS-1 ... zero at eight , visibility one two

thousand broken, two zero thoustemperature three, dew point minzero zero zero.

1648:08RDO-1 Chicago center, good afternoon. 

level three thousand.

1648:13CTR-1 Lakes Air two fifty one, ident.

1648:18HOT-1 oops. ident. you just love to sit over there and laugh at me.

1648:20CTR-1 Lakes Air two fifty one, squawk th1648:28RDO-1 three one one zero for Lakes Air 

1648:33HOT-1 three one one zero. ** where they came up with that one?

1648:48CTR-1 Lakes Air two fifty one radar cont

south of the Burlington airport. cthousand.

1648:56RDO-1 Lakes Air two fifty one, wonderin

a final today.
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMM

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1648:59CTR-1 sure Lakes Air two fifty one, ame

maintain six thousand. that'll be 

1649:04HOT-1 up to...

1649:05RDO-1 up to six thousand for Lakes Air t1649:11AWOS-2 Quincy Muni Baldwin field, two on

zero six zero at eight , visibility othousand broken, two zero thoustemperature three..

1650:02RDO-1 Burlington operations, fifty nine tw1650:06BRLOP this is Burlington, go ahead.1650:07RDO-1 we had two five, two seven, three 

our Hobbs two three zero one ponext time.

1650:19BRLOP OK, see you later, thank you.1650:30RDO-1 Quincy operations, Lakes Air fifty 

range.
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1650:40QCYOP this is Quincy, go ahead.

1650:43RDO-1 we'll see you at seven past. the 

fifteen hundred on board.

1650:50CTR-1 Lakes Air two fifty one have a go

Kansas City center one three five 

1650:51QCYOP see you at seven past.1650:57RDO-1 one thirty five fifty two for Lakes A

good night.

1651:02CTR-1 good night.1651:11QCYOP-8 Kate, are you in another bad moo1651:14RDO-1 Kansas City center , Lakes Air tw

climbing out of four thousand six thousand. we've got the Quincy 

1651:22CTR-2 Lakes Air two fifty one roger, than

1651:33HOT-2 what's the winds down there?
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1651:36HOT-1 um, they are, zero six zero at eight. twelve miles visibility,

thirteen thousand broken, twenty thousand overcast, threedegrees, negative three on the dew point. three zero zerozero, all balls baby.

1651:52HOT-2 that's the way you like it.1651:54HOT-1 oh yeah I like it.1651:56HOT-2 one three.1651:58HOT-1 OK.1652:04CAM [sound similar to altitude alert signal]

1652:07RDO-1 *** two fifty one is a Beech airline

to the north of the field will be inbone three at Quincy. any traffic iadvise.

1652:19HOT-2 [sound of deep breath] OK, cruise if you want.1652:26HOT-1 all right.... power is set.1652:30HOT-1 engine instruments are checked... fuel quantity is checked.

and the auto-feather is going to stay on for the * duration.
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1653:45RDO-? [sound similar to someone keying 

times]

1654:11CAM [sound similar to altitude alert signal]

1654:46CTR-2 Lakes air two fifty one descend a

thousand, that's pilot discretion.

1654:50RDO-1 Lakes Air two fifty one, pilots disc

thousand.

1654:54CTR-2 *.

1654:56HOT-1 look at that sunset man, that's gorgeous.

1655:191127D-6 Quincy traffic, King Air one one tw

out uh, takeoff on runway four, Q

1655:22HOT-1 Quincy twaffic.1655:26HOT-2 sounds like a little kid.1655:29HOT-1 Qwincy twaffic. [sound of chuckle]....... he's a little baby,

Elmer Fudd girl.
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1655:407646J Quincy traffic, Cherokee seven s

taxi uh, taxing to runway four, Qu

1655:48HOT-1 they're both using four.1656:13HOT-2 in sight.1656:16HOT-1 Okeydoky.

1656:21RDO-1 Lakes Air two fifty one, Quincy in 1656:26CTR-2 Lakes Air two fifty one cleared vis1656:29RDO-1 cleared for the visual Quincy for L

1656:42HOT-1 landing on one three, right?1656:43HOT-2 what's that?1656:44HOT-1 you're planning on one three still, right?1656:46HOT-2 yeah, unless it doesn't look good then we'll just do a downwind for four but uh, right now plan one three.
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1656:56RDO-1 Quincy area traffic, Lakes Air two 

airliner currently ten miles to the be inbound to enter on a left base at Quincy any other traffic please 

1657:20HOT-2 decent checklist.1657:21HOT-1 ice protection?1657:22HOT-2 standard three, boards any time.1657:27HOT-1 and the uh.... pressurization?1657:33HOT-2 that's set checked.1657:35HOT-1 antiiiii, altimeter, three zero zero zero zero.1657:38HOT-2 set right.1657:40HOT-1 passenger brief?1657:42HOT-2 they're, taken care of.1657:45HOT-1 and the landing and logo lights?
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1657:47HOT-2 they're on.1657:49HOT-1 fuel balance?1657:50HOT-2 checked.1657:51HOT-1 oops.... I'd better balance..... and the um, auto-feather?1657:58HOT-2 armed.1657:59HOT-1 anti-skid?1658:01HOT-2 not installed.1658:03HOT-1 and the checklist?1658:04HOT-2 complete.1658:05HOT-1 approach briefing?1658:08HOT-2 complete.1658:11HOT-1 and performance is gonna be one zero... uh one ten VYSE

blue line.
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1658:17HOT-2 reviewed.1658:19HOT-1 nav radios?1658:20HOT-2 set right.1658:21HOT-1 set left interior lights?1658:27HOT-2 on.1658:28HOT-1 and theee, * flaps?1658:32HOT-2 holding up for right now.

1658:41CTR-2 * two fifty one, cleared visual app

leaving three thousand.

1658:45RDO-1 Lakes Air two fifty one we're alrea

visual at Quincy um , before you currently out of two thousand thre

1658:54CTR-2 Lakes Air two fifty one roger. rada

change to advisory frequency is acancellation or down time on this 
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DCA97MA009A/B

1659:02

RDO-1 over to advisory....

1659:03

1127D [this transmission heard on both pilot's radio channels]

Quincy traffic, King Air one one two seven Delta holding

short of runway four. be uh, takin' the runway for

departure and heading uh, southeast, Quincy.

1659:04

RDO-1 ..... we'll uh, cancel on the ground with you and

cleared for the visual for Lakes two fifty one, good night.

1659:14

HOT-1 does sound little doesn't she.

1659:15

HOT-2 takeoff flaps.

1659:19

HOT-1 she's takin' runway four right now?

1659:22

HOT-2 yeah.

1659:29

RDO-1 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, one three, more like a five mile final

for runway one three at Quincy.

1659:42

HOT-2 gear down.

1659:50

HOT-2 landing checks.

86
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DCA97MA009A/B

1659:52

HOT-1 landing gear?

1659:52

HOT-2 down three green.

1659:54

HOT-1 * is.

1659:57

HOT-2 flaps approach.

1659:59

HOT-1 full indicated.

1700:12

CAM-3 five hundred.

1700:16

RDO-1 and Quincy traffic Lakes Air two fifty one's, on short final

for runway one three um, the aircraft gonna hold in

position on runway four or you guys gonna take off?

1700:28

7646J seven six four six Juliet uh, holding uh, for departure on

runway four ....

1700:34

CAM-3 two hundred.

1700:35

7646J .... * on the uh, King Air.

1700:37

RDO-1 OK, we'll, we'll get through your intersection in just a

second sir * we appreciate that.

87
 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

DCA97MA009A/B

1700:42

HOT-1 landing gear's down three green, flaps are at landing.

your yaw damp is off. finals are complete.

1700:48

HOT-1 we kinda .....

1700:49

HOT-2 kinda what?

1700:50

HOT-1 we kinda fudged, in there a little.

1700:59

CAM [sound similar to aircraft touching down on runway]

1701:01

HOT-1 max reverse.

1701:01

HOT-1 oh #.

1701:03

HOT-2 what, ooooh #.

1701:07

HOT-2 oh # me.

1701:08

END of RECORDING

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