Rights of Way: The crash of United Express flight 5925 (The Quincy runway collision)
On the 19th of November 1996, a United Express commuter flight landing in Quincy, Illinois collided at an intersection with a private Beechcraft King Air, sending the two planes sliding off the runway in flames. As witnesses rushed to help, they found that the 12 passengers and crew of United Express flight 5925 had all survived the crash — but the door wouldn’t open, trapping them in the burning plane. After their frantic efforts to open the door failed, fire ripped through the cabin, killing everyone inside. The National Transportation Safety Board investigation had to answer two key questions: which crew was at fault, and why did no one survive the crash? The investigators’ conclusions contained sobering lessons about vigilance, right of way, and the value of listening to in-flight safety briefings.
For its services to small, regional airports, United Airlines has long employed smaller contract airlines which operate under United Express branding. One of these was Great Lakes Airlines, a large regional airline which operated small airplanes on behalf of several name-brand carriers, including United. With a fleet of 19-passenger Beechcraft 1900C twin turboprops, Great Lakes/United Express flew passengers into a wide variety of midsized towns across the central United States.
Among these destinations was Quincy, Illinois, a town of about 40,000 people on the banks of the Mississippi River. Quincy Regional Airport is the main air travel hub for the community. Historically, the airport was never served by more than two carriers at a time; in the 1990s, these were Trans World Express and United Express, both of which operated daily flights to and from Chicago using the Beech 1900C. Due to the low volume of commercial traffic (never more than two takeoffs and landings per day) Quincy Regional Airport did not and still does not have a control tower to coordinate traffic on its three intersecting runways and in the surrounding airspace.
The 19th of November 1996 was a day like any other for 30-year-old Captain Kate Gathje and 24-year-old First Officer Darren McCombs, the two Great Lakes pilots who would be flying the service to Quincy that day. After leaving Quincy early that morning, they had spent the day hopping between several Midwestern airports, before finally making their way back to Quincy after stops in Chicago and Burlington, Iowa. The Burlington-Quincy leg was to be their eighth and final flight of the day, and they were over two and a half hours behind schedule due to a mechanical problem — pushing their working day over into the hours of twilight.
Meanwhile at Quincy Airport, retired TWA pilot turned flight instructor Neil Reinwald was preparing to fly home with one of his students, Laura Brooks. Brooks was a commercial multi-engine rated pilot who was trying to build up enough hours to get a job at a regional airline; in order to help her accrue flying time, Reinwald brought her along on many flights on an informal basis. Today he and Brooks had been flying a twin-engine, seven-passenger Beechcraft King Air A90 back and forth between Quincy and Tulsa, Oklahoma to introduce the plane to potential buyers. This was Brooks’ first time in a King Air, and Reinwald was also taking the opportunity to teach her some of the basics of flying this type of airplane.
Shortly before 5:00 p.m., as dusk enveloped the region, United Express flight 5925 began its approach to Quincy Airport with ten passengers and two crew on board. First Officer Darren McCombs was flying the plane while Captain Kate Gathje handled the radio. Because Quincy Airport was an “uncontrolled airport” — an airport without a control tower — it was her responsibility to announce their every move over a common frequency, so that all airplanes operating in and around Quincy would know their intentions.
At 4:55, Laura Brooks, the student pilot on the private King Air, called on the common frequency and said, “Quincy traffic, King Air one one two seven delta’s taxiing out uh, takeoff on runway four, Quincy.” Brooks had a pronounced lisp which made her voice rather distinctive.
On board the United Express Beech 1900, the pilots joked about her voice. “Quincy twaffic,” Captain Gathje said with a chuckle.
“Sounds like a little kid,” agreed First Officer McCombs.
Moments later, a private single-engine Piper Cherokee also called on the common frequency. “Quincy traffic, Cherokee seven six four six Juliet back-taxi uh, taxing to runway four, Quincy,” said the pilot.
“They’re both using four,” said Gathje. Runway four intersected runway 13, their planned landing runway, so they would need to coordinate their takeoffs and landings. As the landing plane, flight 5925 had the right of way, but Gathje would need to make sure the other pilots were aware of that. At 4:57, she announced, “Quincy area traffic, Lakes Air 251 is a Beech airliner currently 10 miles to the north of the field. We’ll be inbound to enter on a left base for runway one three at Quincy. Any other traffic, please advise.” There was no reply. (Note that while the flight was marketed as United Express 5925, it was using the callsign Lakes Air 251.)
At 4:59, Laura Brooks came on the radio again. “Quincy traffic, King Air one one two seven delta holding short runway four. Be, uh, takin’ the runway for departure and heading, uh, southeast, Quincy.”
Coming in hot toward runway 13, Gathje was paying attention to Brooks’ comments. “She’s taking runway four right now?” she asked to First Officer McCombs.
“Yeah,” said McCombs.
Keying her mic again, Gathje said, “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 one three, more like a five mile final for runway one three at Quincy.”
At that moment, the King Air was holding at the threshold of runway four with the Piper Cherokee in line behind it. Having received no response to any of her transmissions, Captain Gathje again asked, “The aircraft gonna hold in position on runway four, or you guys gonna take off?”
After several seconds with no reply from the King Air, the pilot of the Cherokee piped up instead. “Seven six four six Juliet, holding for departure on runway four, (behind) on the uh, King Air.”
At that exact moment, the ground proximity warning system on the Beech 1900 called out “TWO HUNDRED” to inform the pilots that they were 200 feet above the ground. As a result, Gathje and McCombs heard, “Seven six four six Juliet, holding for departure on runway four, TWO HUNDRED on the uh, King Air.” Although voice of the Cherokee pilot was male and the voice of the King Air pilot was female, Gathje apparently missed this difference. Because the Cherokee pilot replied to her question, which was aimed at the first plane in line to take off, and because he used the word “King Air,” she made a snap assumption that the transmission came from the King Air.
“Okay, we’ll get through your intersection in just a second sir, we appreciate that,” she said.
But in fact, there was no indication that the King Air pilots ever heard that the Beech 1900 was about to land. Nine seconds after Gathje’s last transmission, instructor pilot Neil Reinwald pushed the throttles forward for takeoff, and the King Air began to rumble off down the runway.
Each plane should have been at least partially visible to the pilots of the other, but with the United Express pilots occupied with their final preparations for landing and the King Air pilots apparently unaware of the Beech 1900, neither managed to spot the other converging on the twilit intersection.
At 5:00 and 59 seconds, flight 5925 touched down on runway 13, and Captain Gathje called for max reverse thrust. But a split second later, she caught sight of the King Air hurtling toward them on the intersecting runway. “Oh shit!” she exclaimed, slamming on the brakes.
“What? Ooooh shit!” said McCombs.
“Oh fuck me!”
On the King Air, Reinwald and Brooks apparently spotted the Beech 1900 just seconds away, prompting them to slam on the brakes as well. They steered to the right to try to avoid the airliner, while United Express pilots Gathje and McCombs steered hard to the left, but it was too late. The King Air plowed directly into the side of the Beech 1900, severing both planes’ fuel tanks and triggering a raging fire. Tangled together by their wings and engines, the two planes skidded to a halt on the edge of the intersection, surrounded by flames.
The impact forces involved were not much more than a moderate car crash, and everyone survived the collision with minimal injuries — but their ordeal was only just beginning. The King Air came to rest in the pool of spilled fuel and was overrun by flames within seconds. Reinwald and Brooks managed to get up out of their seats in an attempt to reach the rear exit, but they were quickly overcome by noxious fumes and collapsed from smoke inhalation. On board the Beech 1900, flames had not yet penetrated the cabin, and the passengers rushed toward the main exit door, on the forward left part of the aircraft. While Captain Gathje shut down the engines, First Officer McCombs went back to open the door, but to his horror, it refused to budge. The crash had deformed the doorframe, causing the door to jam!
Meanwhile, a pilot who was in a nearby hangar rushed to the crash site after hearing an explosion. He arrived to find smoke already filling the cabin of the Beech 1900, but he could see and hear people moving about inside. As he approached, Captain Gathje stuck her head out the cockpit window and pleaded with him to “get that door open.” He rushed to the door and pulled on the handle, but no matter what he did, it would not open. He could feel someone wiggling the handle from the inside; people were alive behind that door, and he needed to save them. Moments later, the United Express pilot who was scheduled to fly the Beech 1900 on its next leg also arrived at the scene. Desperate to save his coworker and her passengers, he tried to open the door, but he too was unsuccessful. Beaten back by the heat of the flames, they were forced to abandon their efforts. Less than a minute later, an explosion tore through the night, and they looked back to see the plane totally consumed in flames. There was no more sign of Kate Gathje at the window — it was obvious that she and all her passengers were already dead.
In those last moments aboard the plane, First Officer McCombs apparently abandoned his attempts to open the forward door and began moving back to try the left overwing exit instead. Unfortunately, he never made it. As black smoke filled the cabin, he and Captain Gathje, along with all ten of their passengers, perished from the toxic fumes.
Quincy Airport didn’t have a dedicated firefighting service. Although there was a fully equipped fire truck in a hangar just 300 meters from the scene of the collision, it was only staffed when an airplane with 30 or more seats was scheduled to land. Instead, firefighters had to come all the way from the city of Quincy, which took fourteen minutes. By the time they arrived, all 14 people aboard the two planes were long dead, and the fire had totally consumed both aircraft. Within ten minutes the firefighters extinguished the blaze, but all that remained of the planes was a pile of charred debris.
Investigators with the National Transportation Safety Board faced a difficult task. The pilots of both planes were dead, and the King Air had no black boxes that could reveal what they were talking about. The sequence of events would have to be determined based off the Beech 1900’s flight recorders, witness testimony, and physical clues left by the collision. Based on marks left on the two runways, it was apparent that both crews had seen each other a few seconds before the crash and made unsuccessful attempts to avoid colliding. But why were they on a collision course in the first place?
The first thing investigators noted was that no takeoff announcement from the King Air could be heard on the Beech 1900’s cockpit voice recording. Failing to issue a takeoff announcement would have been a violation of one of the most basic rules of uncontrolled airfield operations: always announce your intentions. So why was this crucial transmission not heard on the CVR?
A pilot at the airport who was listening to the conversations said he thought he heard a male voice “stepping on” a female voice just before the crash — that is, that one pilot had transmitted at the same time as another, blocking out the less powerful transmission. The only male pilot on the frequency that night was the Cherokee pilot, so if he had audibly stepped on Laura Brooks’ takeoff announcement, this should have showed up on the Beech 1900’s CVR, but it didn’t. Furthermore, two other witnesses stated that they heard no stepped-on transmission. Therefore, it could only be concluded that no takeoff announcement was ever made.
While the absence of evidence precluded a definitive determination of why this announcement was omitted, investigators did put forward several speculative reasons. Based on the fact that Brooks was handling the radio calls, universal principles of cockpit workload distribution held that Reinwald was almost certainly the pilot flying the airplane during the takeoff (not to mention the fact that Laura Brooks could scarcely be considered qualified on the King Air). And even if he wasn’t flying, as an instructor, it was his duty to make sure his student adhered to basic flight rules.
One reason why he might have taken off without having Brooks transmit his intentions was because he was badly distracted. On their previous flight, Reinwald was observed to be giving Brooks some informal training, and the fact that they stopped on the runway for a full minute before taking off suggested he might have been doing so again. Secondly, people who spoke to Reinwald before the flight suggested that he was in a rush to get home, which could have caused him to subconsciously skip steps in the takeoff procedure. And third, there were some aspects of his history which suggested that Reinwald had difficulty sticking to proper procedures. He was by all accounts an incredibly experienced pilot — he had more than 25,000 flight hours, flew with TWA for 27 years, had been a colonel in the Air Force reserves, was type-rated on no less than eight different full-sized airliners, and had several years’ experience flying for air taxi services and as an instructor pilot.
But near the end of his airline career, things started to go downhill: in 1991, after failing a proficiency check and a follow-up line check, he was demoted from Captain to Flight Engineer. And earlier in 1996, he was conducting a training flight with a student in a Cessna when he landed with the landing gear retracted. As a result of the incident, the Federal Aviation Administration ordered him to undergo retraining, a decision to which he reacted with hostility. In a letter to the Safety Board, the FAA inspector assigned to his case said, “[Reinwald] 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.” Failing to follow proper procedures at an uncontrolled airport was therefore not entirely out of character.
The second key event that led to the crash occurred when the pilot of the Piper Cherokee answered Gathje’s question about whether the King Air was planning to take off. This transmission led Gathje to falsely assume that the King Air was holding on the runway; had she not received this misleading answer, she might have asked again and/or carefully observed to see whether the King Air was actually holding its position.
The Cherokee pilot only had 80 flight hours and was not experienced with radio etiquette. He told investigators that he thought the transmission had come from the King Air, which didn’t make much sense — why would the King Air pilot ask the plane behind her in line whether they were going to take off or hold? His inexperience led him not to ask this critical question. He also failed to adhere to the correct phraseology, as he didn’t specify that his plane was a Cherokee. Thus, when the “TWO HUNDRED” callout obscured the words he used to describe his position relative to the King Air, the pilots of the Beech 1900 assumed “on the King Air” meant that he was the pilot of the King Air, and that he was assuring them he would hold on the runway. Confirmation bias led Gathje and McCombs to this wrong conclusion. Although clues existed which suggested that the response did not come from the King Air, including the gender of the speaker and his airplane’s registration number, the existence of clues which did suggest that the response came from the King Air cancelled these out. The human brain tends to filter out information which contradicts a pre-conceived expectation and instead latches on to information which supports that expectation. In this case, Gathje’s expectation was that the King Air would reply to her message. In a high-workload environment during final approach, she didn’t take the time to question her own assumption. This unconscious bias can be even more pronounced if the pilot is experiencing fatigue. Since the United Express pilots had clocked in at 4:15 a.m. and had been on duty for nearly 13 hours, it was possible (but not certain) that fatigue affected their susceptibility to confirmation bias.
Investigators noted that the collision could have been prevented if either set of pilots had seen the other plane. Although both crews were legally obligated to look for nearby traffic at all times, the burden of responsibility in this case fell on the King Air pilots, because they did not have the right of way. They also had a clearer view of the Beech 1900 than the Beech 1900 pilots had of the King Air. The Beech 1900 was clearly visible out Reinwald’s left window for more than a minute during its final approach, and when it moved behind Reinwald’s window post, it should have become plainly visible to Brooks through the windscreen. The only plausible explanation for why they didn’t see it was that they didn’t look. Once again, this was probably because they were distracted with instructional activities.
Investigators also noted that Reinwald surely wouldn’t have taken off if he knew that the Beech 1900 was about to land. Although they had experienced a problem with their radios on the flight to Quincy from Tulsa, this problem only affected one headset’s ability to make outgoing transmissions; both headsets were perfectly capable of receiving inbound transmissions. The most plausible explanation was that the pilots simply set their receivers to the wrong frequency, thus allowing them to make transmissions on the common frequency without receiving anything in return. This would explain why Laura Brooks never directly replied to anyone else’s transmissions — she probably just never heard them. However, the total destruction of the King Air’s radio equipment in the post-crash fire precluded any conclusive determination. Internally, investigators noted that when Captain Gathje said they were 5 nautical miles from the airport, they were actually more like 2.7 nautical miles away — a fairly significant difference. While it was possible that Reinwald thought he could get out ahead of the Beech 1900, only for the airliner to turn up sooner than he was expecting, there was no direct evidence for this line of thinking, and it had to be consigned to the realm of speculation.
All of that having been said, a total disaster was not inevitable even after the planes collided. Although there was no chance for the King Air pilots to escape, some or all of the occupants of the Beech 1900 could have survived if they had managed to open the forward air stair door. Witness testimony showed that even after correctly following the unlocking procedures, the door did not open, and the cam locks were found in the locked position. Although the area around the door was destroyed in the fire, investigators theorized that the collision deformed the fuselage around the door, causing it to jam, possibly due to the sudden introduction of slack in the cable connecting the handle to the cam locks. However, during certification, Raytheon — the manufacturer of the Beech 1900 — had demonstrated to the FAA that the door would not jam in the event of a minor accident. By all accounts, the impact forces involved in the Quincy runway collision were light — no passengers or crew suffered any serious injuries, and both planes stayed upright resting on their landing gear. Therefore, it was unclear why the door should have jammed. The FAA rule requiring doors to be “reasonably free from jamming” in the event of a minor accident did not specify any standards against which a door’s resistance to jamming should be tested, and NTSB investigators felt that this could allow a door to be certified without conclusively proving that it would not jam.
Tragically, the jammed door wasn’t the only way for the passengers to escape the plane. Although the two exits on the right side were blocked by fire, the left overwing exit was safe to use and could have provided an escape route — if anyone had remembered that it was there. Naturally, passengers on small planes tend to try to leave the same way they came in; that is, through the main entry door. A pre-recorded safety briefing shown to the passengers before the flight discussed the locations of the other exits, but it was easy to tune out this presentation. In the actual emergency, the left overwing exit ended up out of sight and out of mind. Only after spending more than a minute (perhaps two) attempting to open the air stair door did First Officer McCombs start heading back to try to the overwing exit. By then, it was much too late. He and the rest of the passengers were overcome by the toxic smoke. Their deaths underscore the importance of a ubiquitous safety briefing refrain: the nearest exit may be behind you.
When the NTSB released its final report on the crash in July 1997, not everyone was satisfied with the findings. In particular, Raytheon lodged a formal complaint about the NTSB’s findings related to the jamming of the air stair door. Raytheon argued that the force of the collision was much higher than the NTSB believed, and that the door jammed because it was subjected to forces beyond its design limits. They also argued that this played no role in the outcome because the passengers, except for the captain, all died of smoke inhalation before they could reach any exit. This argument was rather blatantly contradicted by the known facts, such as the testimony of the witnesses who responded to the crash, and by the locations of the victims’ bodies — most of the passengers were found clustered in the front of the plane, and the First Officer was found near the middle, indicating that they had some time to move about the cabin before they died. The NTSB became bogged down in a month-long debate with Raytheon over these points which ultimately concluded with the agency rejecting six of Raytheon’s eight proposed amendments.
As a result of the accident, the NTSB issued several recommendations, including that the FAA reiterate to flight instructors the importance of scanning for traffic; that the FAA reevaluate the jamming characteristics of the Beech 1900 air stair door; that the freedom from jamming requirements be clarified; and that small airports that receive commercial flights have firefighters on duty for landings and takeoffs of airplanes with as few as 10 passenger seats, rather than 30. Indeed, had firefighters been present, some or all of the United Express passengers and crew could have been saved. The crash was a sobering reminder that operating into small uncontrolled airports carries an elevated level of risk, and that until or unless it becomes financially possible to have control towers and firefighting services at every airport in the country, passengers and crew flying into such airports should maintain extra vigilance.
In the end, the lack of evidence about the actions of the King Air pilots caused the report to come across to some people as overly legalistic. Family members of Neil Reinwald raised objections about the lack of attention to various scenarios which could have influenced his decision-making process, but without hard evidence, the NTSB could only say that the pilots took off without announcing their intentions, at a moment when they did not have the right of way. While a myriad of mitigating factors may or may not have led to those errors, why exactly they chose to take off will never be known for sure. Every human error is a chain of reactions to stimuli, assumptions, and split-second decisions that can be impossible to explain after the fact. And indeed, there were ways for Kate Gathje and Darren McCombs to have avoided the crash as well. They perhaps took it for granted that they had priority, and could have exercised a higher level of vigilance. After all, as they say, graveyards are full of people who had the right of way.
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