July 21, 1997 What Really Happened at Quincy?

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by	Dan Corich

NTSB Identification: DCA97MA009.
Aircraft #1: Beech A90, registration: N112D
Aircraft #2: Beech 1900C, registration: N87GL
Scheduled 14 CFR 135 operation of GREAT LAKES AVIATION, LTD.
(D.B.A. United Express AIRLINES)
Accident occurred NOV-19-96 at QUINCY, IL
Injuries: 14 Fatal.

On November 19, 1996, at 1703 CST, a United Express Beechcraft 1900c, Flight 5925 collided with a Beechcraft King Air A90, N1127D, at Quincy Municipal Airport, near Quincy, Illinois. The United Express flight was completing its landing roll on runway 13 and the King Air was departing on runway 24. Both pilots and 10 passengers on the 1900C and both pilots on the A90D were killed. Both aircraft were destroyed. The 1900C was on an IFR flight plan and operating under FAR part 135. The A90 had not filed a flight plan and was operating under FAR part 91.
[NTSB Preliminary Report]

UNSEEN AND UNAVOIDED IN ILLINOIS: QUINCY COLLISION KILLS 14
There were 12 souls on the Beech 1900 and two others on the Beech King Air 90 when the planes skidded into one another at the intersection of Runways 4 and 13 Tuesday evening in an accident no one can easily explain. With overcast skies, visibility of 10 or more and at best the dusk light of 5:02 p.m. CST, it's conceivable that the 1900 crew thought the King Air pilot saw their approach to Runway 13 before the 90 started rolling on take off from Runway 4. If both crews were using the 123.0 MHz CTAF, they apparently weren't both hearing.
[AVflash 2.47 11/25/96]

NOTE: The opinions expressed below are solely those of the author, and not those of AVweb or its staffmembers.

Dear AVweb,

I read your article about the NTSB conclusions regarding the Nov. 19, 1996 accident at the Quincy airport. Once again the NTSB has shown us it is incapable of conducting a thorough, complete and independent investigation of a transportation accident. From witnessing the NTSB Board meeting and reading the NTSB factual reports, it was clear they were not interested in finding the root cause of this accident.

Let me state right up front that I am not a pilot and was an aviation novice before this accident, but have tried my best to become knowledgeable since. Neal Reinwald, one of the King Air 90 pilots, was my stepfather. I am a concerned family member, pursuing the truth about the causes of this tragedy...hoping to prevent anything like it from ever happening again. I am also a U.S. citizen who is shocked and disillusioned by what I've learned about civil aviation and the NTSB's and FAA's unbelievable incompetence and negligence.

Since the accident, I've done a lot of investigating into the accident. I've corresponded and talked to many people in the aviation community including former FAA and NTSB employees, military aviation investigators, and private aviation investigators. I discussed with them general aviation guidelines, FAA & NTSB processes and their reputations, as well as the facts surrounding this accident.

I was surprised to find the NTSB and the FAA are held in such low regard by most of the people I talked to. I quickly became disillusioned with the NTSB after requesting information about the accident, and cooperating with their investigation. All I could think to myself was that these are not very bright people, and they don't seem to know what they're doing.

Didn't they listen to the CVR?

If you read through the NTSB conclusions and probable causes, you will see that they are self-contradictory.

The Board concluded that the King Air pilots failed to monitor communications and announce their intention to take off, but they also fault the Cherokee pilot for "stepping on" communications and the United Express pilot for confusing the Cherokee pilot (a male) for the King Air pilot (a female). But if there wasn't any radio communication between the three planes, how could the United Express pilots "mistake" the Cherokee pilot for the King Air pilot?

The Board also discussed the "stepping on" of radio transmissions by the Cherokee pilot, and probably the ground proximity warning on the Beech 1900, that interrupted radio communications. But if you go back to the transcript of the CVR, you will see that the King Air pilot did announce her take off from Runway 4 just over one minute before the crash. It is perfectly normal for a plane to spend 30 or 45 or 60 seconds on a runway to complete a checklist, particularly in the case of a training flight (which is what the King Air flight was).

Based on the position report that the United Express pilots transmitted on CTAF, the King Air pilots undoubtedly believed they had plenty of time to complete their checklist and take off before the United Express plane landed. If the United Express plane was where it said it was, at the altitude and speed it announced, there would have been more than enough time for the King Air to take off before the United Express plane was even close to the Quincy airport.

Based on the CVR transcript, the United Express pilot and co-pilot had to be fully aware that there were two other planes operating at Quincy, and that the pilot of the King Air was a female with an unusual sounding voice. With all this radio communication between the three airplanes involved just minutes and seconds before the crash and the "probable" stepping on of radio transmissions by the Cherokee pilot, I fail to see how the NTSB could reach the conclusion that there was a failure to communicate by the King Air pilot.

Further investigation of the runways at the Quincy airport will show that Runways 4 and 13 have a 15-foot difference in altitude which causes a "blind spot" on the horizon when looking towards Runway 13 from Runway 4. Why weren't Runway 13's lights turned on at dusk (expecially given the low overcast ceiling)? The CVR transcripts show that a microphone was "clicked" to key-up the pilot-controlled runway lights a few minutes before the accident.

How did the United Express pilots lose track of the two planes on the ground at Quincy when the CVR transcripts clearly show they saw there were two planes on the ground? How could they have confused the Cherokee pilot for the King Air pilot on the radio when they had just commented about the King Air pilot's voice?

Where was United Express, and when?

I couldn't believe the NTSB investigation didn't include a timeline of events leading up to the accident, charting the actual locations of the three planes involved with their complete radio transmissions. The Board should should have investigated the altitude, speed and location of the United Express plane as reported by ATC radar, independent of the plane's radio transmissions. I'm convinced such an investigation would have shown that the United Express plane couldn't have possibly been where it said it was, and that the United Express pilots were fully aware they were "fudging" their speed and location so they could make a fast straight-in approach to Quincy because they were two hours behind schedule.

How did the United Express airplane approach the Quincy airport? What was their speed and altitude and location, compared to where they said they were on the radio transmissions? If they were six or five miles out from the airport when they reported those positions, and if they were traveling at normal approach speed, how did they get to the airport in such a short amount of time?

Why didn't United Express follow ATC instructions for altitude? They twice disregarded ATC instructions between Burlington and Quincy.

Why hasn't it been mentioned that the United Express flight was almost two hours behind schedule? Where and when did the United Express plane make its left hand turn for final approach into Quincy, as they announced doing on CTAF, when in fact they made a fast straight-in approach? Why did the United Express pilot radio their company ground station at Quincy that they would be landing at 5:07 pm, yet the accident occurred at 5:01 pm?

What did the last CVR comment from the United Express pilot, "We fudged in there a little bit..." mean? I believe they were in a big hurry to get into Quincy because they were behind schedule and very tired. They chose Runway 13, even though it was contra-indicated by the wind direction and speed. They had been warned about making straight-in approaches to Quincy. Please reference FAA Advisory Circular AC 90-66A: Recommended Standard Traffic Patterns and Practices for Aeronautical Operation at Airports without Operating Control Towers. They exceeded normal approach speed, did not fly a normal approach profile, and transmitted inaccurate locations during the approach.

Other factors the NTSB ignored

How could the NTSB conclude that United Express pilot fatigue was not a contributing factor, when the factual reports show that the United Express pilot did not go to bed before 11 pm on November 18, and then reported to work at 4:15 am on November 19th, with approx. five hours of sleep or less, and was completing over 13 hours on-duty time, flying eight legs in and out of O'Hare and other cities, changing airplanes because of equipment problems, and was running over two hours behind schedule? Why did the United Express ground crew want to know if she "was in another bad mood" when landing at Quincy.

How does the NTSB know who the Pilot-In-Command of the King Air was? The bodies of both pilots were discovered trying to escape the King Air; they were not in their seats. All radio communication was conducted by Laura Brooks. And, its documented in the NTSB factual reports that the instructor-pilot (Neal Reinwald) normally allowed the trainee-pilot (Laura Brooks) to fly PIC on the last leg of the trip. Given the radio transmissions, and the regular training procedures, it is logical to assume that Laura Brooks was the Pilot-In-Command. (She was also a fully certificated pilot.)

Why didn't the NTSB have a serious discussion about the lack of control towers at airports with scheduled airline service, whereas the Board did discuss fire equipment and staffing at great length? An operating control tower at this busy airport with regularly scheduled airline service would have prevented this accident from ever happening.

I invite you to keep probing. We still don't have the answers, and the NTSB is obviously not interested in a full investigation. A thorough investigation would show the NTSB's and the FAA's hidden agenda to promote the airlines at any cost, and to shield local and Federal governments from culpability.

Isn't it amazing that when an accident involves a private aircraft and an airliner, it's always the private aircraft's fault?

Family assistance? Yeah, right!

I continue to be very frustrated with the NTSB's self-congratulation for their performance with their newly mandated "family liaison responsibilities." I can tell you that our family has never been contacted by the NTSB offering any kind of assistance. We had to contact the NTSB to beg for information about the accident from day one, and still have to constantly ask them for reports.

A few days after the accident, I questioned the NTSB about their lack of communication with our family. They apologized, said we "slipped through the cracks," and reminded us that this accident was the first since the new directive went into effect. Last January when I again questioned their lack of communication with our family, they responded that since our family members (Neal Reinwald and Laura Brooks) were not on a commercial aircraft, we were not covered under their new family assistance directive.

Baloney! Nowhere in the new family assistance law are passenger families from non-commercial aircraft excluded.

The NTSB also congratulated United Airlines for their active role in working with the victims families, when they "really didn't have to," a comment I found particularly disturbing coming from the NTSB, a supposedly independent government agency. We have never been contacted by United Airlines or Great Lakes Aviation (the United Express carrier). Basically, our family has been treated like lepers by the NTSB, FAA and United Airlines.

I cringe whenever I see or hear media reports about what a great job the NTSB was doing with their new responsibilities. What a farce!