On November 19, 1996, a Beechcraft 1900C (B1900) with ten passengers and two pilots was making a straight-in approach at dusk in visual meteorological conditions (VMC) to Runway 13 at Quincy (Illinois, U.S.) Municipal Airport, an uncontrolled airport. A King Air 90 (BE90) with a pilot and passenger-pilot was in takeoff position on Runway 04, which intersected Runway 13. Waiting in the run-up area, second in line for takeoff behind the BE90, was a Piper Cherokee (PA-28). Several seconds before the B1900 touched down on Runway 13, the BE90 began its takeoff run on Runway 04. Despite evasive action by the pilots of both aircraft (a/c), they collided at the intersection of the two runways, killing all aboard. The occupants did not sustain blunt-force injuries that would have impeded their ability to move about or evacuate the a/c, but died from inhaling smoke, soot or other combustion products from the post-accident fire.
The final report of the U.S. National Transportation Safety Board (NTSB) said that "the probable cause of this accident was the failure of the pilots in the [BE90] to effectively monitor the common traffic advisory frequency (CTAF) or to properly scan for traffic, resulting in their commencing a [take-off] roll when the [B1900] was landing on an intersecting runway. Contributing to the accident was the [PA-28] pilot’s interrupted radio transmission, which led to the [B1900] pilots’ misunderstanding of the transmission as an indication from the [BE90] that it would not take off until after the [B1900] had cleared the runway."
The sequence of events — The captain of the B1900 stated on the CTAF that they were about 30 mi. north of the airport and that they would be landing on Runway 13; she also asked that "any traffic in the area please advise." No replies were received to this request. CTAF is a radio frequency designated for use by pilots operating near uncontrolled airports, similar to mandatory frequencies (MF) in Canada. Pilots use this frequency to broadcast their positions or intended flight activities or ground operations.
The passenger-pilot of the BE90 announced that they were taxiing out for takeoff on Runway 04; this was followed by the pilot of the PA-28 announcing that he was "back-taxiing" to Runway 04. The B1900 captain commented to the first officer (F/O), "They’re both using 04. You’re planning on one three still, right?" The F/O replied, "Yeah, unless it doesn’t look good then we’ll just do a downwind for four but ... right now plan one three."
The B1900 captain announced "Quincy traffic, [call sign] is currently 10 mi. 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. Two minutes later, the BE90 crew announced that they were holding short of Runway 04, but would be taking the runway for departure. The report said, "The [B1900] captain...commented "she’s takin’ Runway four right now?" The F/O replied, "Yeah."
The B1900 captain reported on short final for Runway one three and asked "the a/c gonna hold in position on Runway four or you guys gonna take off?" The BE90 passenger-pilot did not respond, but the pilot of the PA-28 did, stating, "[PA-28 call sign] ... holding ... for departure on Runway four..." The B1900 CVR [cockpit voice recorder] then recorded an interruption in the transmission by a mechanical "two hundred" from their ground-proximity warning system. The CVR then recorded the last part of the transmission from the PA-28 as "...on the uh, King Air."
When the PA-28 responded to the question, the B1900 captain believed that she was hearing the King Air crew. The NTSB, however, reports that subtle cues indicated that the transmission did not come from the BE90. Specifically, the speaker gave a different registration number, and the voice was from a male, as opposed to previous transmissions from a female voice in the BE90. ... The PA-28 pilot stated that all the transmissions from both the B1900 and the BE90 were in female voices. "However, because the [B1900] pilots were most likely preoccupied with landing the a/c, and because the speaker said "King Air" and did not say "Cherokee," and the pilots had no reason to expect a response from any a/c other than the BE90, they probably did not notice or focus on those cues."
Although the BE90 had been sitting on Runway 04 for about one minute, the BE90 pilot began the takeoff without making a take-off announcement over the CTAF. Such an announcement would have afforded the B1900 flight crew the opportunity to take evasive action. The PA-28 pilot, who had only 80 hrs of flight time, saw the two airplanes converging, and had the opportunity to alert the B1900 to the situation, which would have been prudent. Despite the 90-degree angle between Runways 04 and 13, the PA-28 pilot stated he did not realize that the runways intersected.
"Because no pilot would take off knowing that another a/c was about to land on an intersecting runway, the occupants of the BE90 must have been unaware at the time they began their [take-off] roll that an a/c was about to land." This lack of awareness could have derived from three sources: failure of the BE90 pilots to monitor the CTAF, mechanical radio problems or the setting of the radio controls on the King Air so the flight crew could transmit but not receive.
"Had the occupants of the BE90 been monitoring the CTAF, they should have heard the four announcements from the B1900 indicating that the a/c was inbound and was planning to land on Runway 13. Because of the extensive fire damage, the settings on the radios at the time of the accident could not be determined."
A time and distance study conducted by the NTSB indicated that the BE90 began its take-off roll about 13 seconds before the B1900 touched down. The occupants of the PA-28 said that the BE90 had been in position on Runway 04 for about one minute before beginning its take-off roll. The PA-28 pilot did not hear a take-off announcement from the BE90 on the CTAF; no take-off announcement from the BE90 was recorded on the B1900 CVR.
The B1900 collided with the BE90 during the landing roll-out at the intersection of Runways 13 and 04. The first people to reach the scene reported that the right side of the B1900 and the BE90 were engulfed in fire. Despite efforts by these people to open the B1900 air-stair door, they were unable to do so. The investigation focussed extensively on the air-stair door, how and why it jammed, its use in an emergency, why nobody could open it from either inside or outside, and its maintenance. "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 following are significant excerpts from the NTSB conclusions:
As a result of the investigation, the NTSB made recommendations to the Federal Aviation Administration on scanning techniques during pilot training and biennial flight reviews, jamming of the B1900 door frame system when it sustains minimal permanent door deformation, methods to ensure compliance with the freedom-from-jamming certification requirements and maintenance oversight.
Editorial note: The many lessons to be drawn from this accident are of interest to all pilots, but, owing to space limitations, we had to focus on the communication and "see-and-avoid" aspects in an uncontrolled environment. Issues such as the jamming of the B1900 air-stair door and the crash response could not be discussed as comprehensively as in the Flight Safety Foundation’s newsletter Accident Prevention, Vol. 55 No. 1, January 1998, from which this article was adapted. Interested readers are encouraged to check it out on the Web at http://flightsafety.org/archives-and-resources/publications/accident-prevention/accident-prevention-1998, or obtain a copy of NTSB Report NTSB/AAR-97-04.
On reading the latest edition of Aviation Safety Letter (issue 3/98), I greatly appreciated the checklist on how to avoid runway incursions; we posted the checklist in a prominent place in our pilot briefing room. We would like to make one comment, however. At the beginning of the article, you forgot to mention that flight service specialists also should observe air traffic as part of their airport advisory service at uncontrolled aerodromes. We participate actively in a variety of programs designed specifically to avoid runway incursions.
As manager of the flight information station at Mont-Joli, I devote a great deal of time and effort to the problem of runway incursions. I also drafted a document to assist me with the annual refresher training that I give to machinery operators at the Mont-Joli, Rimouski and Baie-Comeau airports. I'm going to amend my course documentation to reflect the content of the article entitled I Thought That I Heard..., which I just read and consider very appropriate.
Reading your article on the dangers of casual radiotelephony (RT) in ASL 2/98 brought to mind the low standard of controller RT I encountered recently. At Toronto Pearson, I heard controllers issue clearances to airlines by using numbers only, with no airline call sign. This is unbelievable; there are over 50 airlines serving Toronto so you have flight number duplications. A flight could move on a clearance meant for someone else, with disastrous results.
Similarly, I heard general aviation (GA) pilots contact air traffic control (ATC) using call letters instead of phonetics and controllers issue clearances using letters only. Many letters sound the same over the air so again an aircraft could move on a clearance meant for someone else. The use of phonetics was indeed meant to avert mid-air collisions.
Recently ATC changed the wording on instrument landing system (ILS) vectoring to "join" the localizer, replacing the lengthy word "intercept". I heard a clearance to an airliner to "Fly 020 for the join." "For the join?" What kind of RT is that?
And all day I heard clearances to "the" VOR, "the" beacon, or "the" approach. What is "the"? Again, the risk is an aircraft heading for the wrong facility, in clouds, and hitting someone on the way. "Oh, sorry, I assumed he was going to the right beacon." He was going to "the" beacon all right.
Can we stop this sloppy, unprofessional, potentially deadly talk BEFORE we have a mid-air collision? — It would surely stop right after.
In defense of controllers and GA pilots, commercial and airline pilots also have poor RT discipline on occasions. Nevertheless, you raise a good point. It is up to all of us to shape-up or shut-up. — Ed.
I would like to comment on question 3 of the self-paced study that was part of ASL 4/98. The question reads: "For airborne weather service, radio contact should be established with any in-range FSS on frequency ______ MHz." This question suggests that 126.7 MHz is the frequency that would always be used for obtaining en route weather information. The A.I.P. MET 1.1.4 is more correct in that it refers to en route services "normally" available on 126.7 MHz.
Frequency congestion on 126.7 MHz has been raised by pilots as a concern in a number of areas, particularly within uncontrolled airspace. In response to these concerns, alternate frequencies have been established at many flight service stations, remote communications outlets, and dial-up remote communications outlets. Pilots should be aware that, although 126.7 MHz is a common frequency and may be available, another frequency may be more appropriate. The current Canada Flight Supplement or NOTAM contains the current information regarding frequency availability and usage.
I expect that alternate frequencies will become even more common in the future. This may be necessary in order to ensure that pilots have suitable access to the en route frequency in order to broadcast their intentions and to co-ordinate their own separation from conflicting aircraft while operating in areas or conditions that require this. An additional statement in MET 1.1.4 may help to encourage pilots to check for an alternate frequency and, whenever one is available, use it for en route service.
Safety and Service Design, NAV CANADA
Chuck, the whole subject of en route services and frequencies will be revisited concurrent with the implementation of NAV CANADA flight information centre (FIC) concept. In the interim, existing equipment and procedures are quite acceptable. The Transport Canada office responsible for A.I.P. Canada will consider your suggestion to add a statement in MET 1.1.4 that would encourage pilots to check for an alternate frequency and, whenever one is available, use it for en route services.
Air Traffic Services Standards Inspector
I was reading about the ground collision between a Cessna 172 and a Diamond DA20 in ASL 4/98 and it reminded me of the dangers of flying incommunicado. Last year, while flying with an instructor, we faced a communication failure right after takeoff from Ottawa.
The vibration of the take-off roll jarred something loose and it knocked out the radios and the intercom. After we completed the communication failure procedure, I asked my instructor to take control as I reached into my flight bag and pulled out my cellular phone. Neither of us knew the tower’s phone number, so I called the flying club to get it from dispatch. I then called the tower and let them know our situation. We were cleared to land over the phone and given our taxi clearance back to the club.
Since this incident I make it a point never to fly without a fully charged cell phone. I also make sure I have the tower phone numbers of both my home base and other frequent destinations programmed into the phone. I noticed that the Canada Flight Supplement(CFS) does not have tower phone numbers listed for many fields. May I suggest that in the OPR, FLT PLN or directly in the COMM sections of the CFS, a TWR entry be made with the phone numbers of every controlled field’s tower.
Many pilots carry cell phones and I'm sure, if a rare communication failure were to occur, being able to call the tower while in flight to advise ATC of the situation would greatly improve the safety in the controlled zone.
The availability of a cell phone in such a case would certainly be advantageous. We have forwarded your suggestion to the CFS folks, and perhaps your letter will sell others to the idea of carrying a cell phone. — Ed.
On Sunday, December 7, 1997, two small aircraft collided on short final to Runway 29 at the Mascouche airport near Montreal, killing all four people aboard the aircraft. The weather was visual flight rules and there were only three aircraft in the circuit at the time. The Transportation Safety Board is investigating and a final report (TSB A97Q0250) should be available in a few months.
This unfortunate event could have happened at any uncontrolled aerodrome, but the fact that it happened in Mascouche caused some knee-jerk reactions and raised some old questions about the level of service there. For many years now, Mascouche has been known as a very busy aerodrome, but mostly in the summer months. In 1993, an internal Transport Canada working group recommended the operation of a mobile control tower for the summer of 1994 to analyze the traffic. The town of Mascouche requested the mobile tower once again for 1995, but Transport Canada refused, stating that the traffic did not meet the minimum criteria for the establishment of a control tower. In the end, Transport Canada decided to operate the mobile tower for one more season, combined with increased promotional activities, after an internal review concluded that one more season would be beneficial from a training perspective.
The ASL will report fully on this accident once the final report has been released, but, as mentioned above, it is important for all of us to realize that this could have happened at any other uncontrolled aerodrome and not to jump to conclusions about the specific site where it happened. I doubt that new lessons will be learned as a result of this accident, but, in the meantime, let’s keep that one in mind and pay particular attention to basic airmanship issues such as proper communications, circuit procedures and spacing and, of course, look out for all other traffic.
Originally Published: Aviation Safety Letter 02/1998
Original Article: Mid-air Collision at Mascouche
Following a recent conversation with and suggestion by Mr. Moe Baile, System Safety, Prairie and Northern Region, we wish to make you aware of an aviation safety issue that has arisen from some near misses that have happened to our company and its contractors in the past two summers. We also wish to have you consider whether these incidents might be appropriate for publication to make the aviation community aware of the safety issue.
Throughout western Alberta and eastern British Columbia, especially during the summer season, a petroleum industry activity known as helicopter-assisted seismic activity, or heli-seismic activity for short, is conducted. Generally, this activity involves one or several light to medium helicopters that conduct multiple low-level missions (below 500 ft. above ground level (AGL)) from dawn until dusk within a defined geographical area.
The helicopter missions involve a variety of tasks, including the transport of crews and equipment, reconnaissance and scouting, and the slinging of portable drills and other equipment. Helicopters have proven to be an indispensable tool for this activity. Risk management is a vital part of engaging in this activity safely. Rugged terrain, mountain weather conditions, and operations at high density altitudes provide a variety of safety challenges for the crews.
Recent Near Misses
Almost all of the activity described above is conducted under visual flight rules within Class G (uncontrolled) airspace. In the past two summer seasons of operation, there have been near mid-air collisions between one of the helicopters working for us and other aircraft transiting our areas of operation.
In August 1996, a Douglas DC-6B conducting a simulated forest-fire-suppression mission passed uncomfortably close to an AStar B-2 helicopter working within one of our heli-seismic jobsites. Our internal near-miss investigation made the following findings:
In August 1997, two British Armed Forces helicopters flew at a low level (below 500 ft. AGL) through our area of heli-seismic activity and caused the AStar B-2 seismic pilot to take evasive action to avoid an anticipated mid-air collision. Within a couple of days of this incident, the Canadian Forces Snowbirds demo team had flown through one of our seismic jobsites at a low level (altitude unknown) while "warming up" just prior to commencing an air show at an airport about 40 NM from our jobsite. Crews on the ground warned the helicopter pilots of their presence and no conflict occurred. There might have been the potential for a conflict had the ground crews not warned the nearby pilots. Our internal near-miss investigation made the following findings:
Safety Awareness Issues
If our experiences of near mid-air collisions during low-level heli-seismic missions are typical, then many of the similar mission-specific activities, such as heli-logging, aerial surveying, remote sensing, pipeline patrol and air ambulance, must be experiencing similar incidents.
It seems that, because of the number of aircraft, the variety of missions and the resultant demands upon the flight crews, and the fluid nature of the geographical areas involved, there is no simple panacea for reducing the risk of mid-air collisions in Class G airspace.
The potential for mid-air collisions during low-level missions will probably increase in the future as new applications from new technology are found for aircraft.
We strongly urge Transport Canada to use all means available to raise the awareness of the Canadian aviation community (civil and military) about the increasing potential for mid-air collisions during low-level missions conducted in uncontrolled airspace.
We intend to make other aviation-industry agencies and associations aware of these issues to generate discussion and explore possible ways to mitigate some of the risks of mid-air collisions in uncontrolled airspace.
Thank you for your attention. I would be happy to communicate with you at any time regarding this letter.
W.K. (Bill) Gillespie
Shell Canada Limited
Originally Published: Aviation Safety Letter 02/1998
Original Article: To the letter - Watch for Heli-seismic Activity