# NTSB CHI91FA211: Piper PA-28-180, N8498W, Quincy, IL, July 7, 1991 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 7, 1991, 08:20 local (13:20 UTC) - Place: Quincy, IL - Coordinates: 39.930183, -91.38063 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.9302&lon=-91.3806&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal, 1 minor - Status: Completed, report July 13, 1993 - Report: Approved by Office Director - NTSB case key (mKey): 14906 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI91FA211 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/14906/pdf - Page: https://openairdocs.org/ntsb/CHI91FA211 ## Probable cause (aircraft 2) THE FAILURE BY THE PILOT OF THE OTHER AIRPLANE TO MAINTAIN CLEARANCE. FACTORS IN THE ACCIDENT WERE THE PILOT'S ATTEMPT TO FLY FORMATION, HIS INADEQUATE GROUP BRIEFING, AND THE LACK OF EXPERIENCE ON THE PART OF THE PILOT OF THE OTHER AIRPLANE. ## Probable cause (aircraft 1) THE PILOT'S FAILURE TO MAINTAIN CLEARANCE AND FAILURE TO MAINTAIN AIRCRAFT CONTROL AFTER COLLISION. FACTORS IN THE ACCIDENT WERE THE PILOT'S ATTEMPT TO FLY FORMATION, AND INADEQUATE GROUP BRIEFING BY THE PILOT OF THE OTHER AIRPLANE, AND THE PILOT'S LACK OF EXPERIENCE. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Midair collision, cruise - formation flying - attempted, pilot in command (contributing factor) - overconfidence in personal ability, pilot in command - crew/group briefing - inadequate, pilot of other aircraft (contributing factor) - clearance - not maintained, pilot in command (cause) - lack of total experience, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - aircraft control - not maintained, pilot in command (cause) - Midair collision, cruise - formation flying - attempted, pilot in command (contributing factor) - crew/group briefing - inadequate, pilot in command (contributing factor) - clearance - not maintained, pilot of other aircraft (cause) - Altitude deviation,uncontrolled, descent - uncontrolled - flight control,aileron - separation - flight controls - restricted, above - remedial action - performed, pilot in command ## Analysis (aircraft 2) THE PILOTS OF FOUR AIRPLANES TOOK OFF IN CLOSE INTERVAL FOR A FORMATION CROSS-COUNTRY FLIGHT. THE LEAD AND SECOND AIRPLANES STEADIED AT CRUISE HEADING, ALTITUDE AND SPEED, WHILE THE THIRD AIRPLANE JOINED FROM BEHIND AND BELOW. AS IT CLOSED DISTANCE ON THE LEADER, THE THIRD AIRPLANE ARRIVED UNDER AND ROSE INTO LEAD'S RIGHT WING AND FUSELAGE. ## Analysis (aircraft 1) THE PILOTS OF FOUR AIRPLANES TOOK OFF IN CLOSE INTERVAL FOR A FORMATION CROSS-COUNTRY FLIGHT. THE LEAD AND SECOND AIRPLANES STEADIED AT CRUISE HEADING, ALTITUDE AND SPEED, WHILE THE THIRD AIRPLANE JOINED FROM BEHIND AND BELOW. AS IT CLOSED DISTANCE ON THE LEADER, THE THIRD AIRPLANE ARRIVED UNDER AND ROSE INTO LEAD'S RIGHT WING AND FUSELAGE. ## Aircraft 1 - Registration: [N8498W](https://openairdocs.org/deregistered/N8498W-1991-08-02), registration cancelled 1991-08-02, S/N 282746 (OpenAirDocs) - Reported make and model: PIPER PA-28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Category: Airplane - Serial number: 28-2746 - Airframe hours: 1177 - Engines: LYCOMING O-360-A3A 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Raymond D. Buehrle - Registered owner: Raymond D. Buehrle - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 7, 1991, 19 hours before - Destination: 3SZ, ST. CHARLES, MO - Airport: UIN, Muni. Baldwin Field, runway 22, 7,097 × 150 ft, asphalt ## Aircraft 2 - Registration: [N4349J](https://openairdocs.org/aircraft/N4349J), registered now, S/N 28-2749 (OpenAirDocs) - Reported make and model: PIPER PA-28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Category: Airplane - Serial number: 28-2749 - Airframe hours: 2200 - Engines: LYCOMING O-360-A3A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Ernest L. Sturgeon - Registered owner: Ernest L. Sturgeon - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 18, 1990, 174 hours before - Destination: 1HO, ST. CHARLES, MO - Airport: UIN, Muni. Baldwin Field, runway 22, 7,097 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N8498W; age 51; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; toxicology performed; flight hours: 73 total, 21 in this make and model, 39 as pilot in command, 19 in the last 90 days, 9 in the last 30 days, 1 in the last 24 hours - Pilot, aircraft N4349J; age 70; airplane ratings: single-engine land, single-engine sea; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 3,935 total, 3,000 in this make and model, 3,900 as pilot in command, 70 in the last 90 days, 30 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 13 knots, gusting 18 - Visibility: 8 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 66 °F - Altimeter: 29.00 inHg - Observed at: UIN, 1 nm away ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19910707026291A](https://openairdocs.org/incident/19910707026291A), Jul 7, 1991: Piper PA28180, Quincy, IL, Destroyed, 4 fatal. Formation flight of 5,NR3 on crossunder climbed and struck underside of lead plane N4349J. NR3 spiraled and crashed - [Accident 19910707026292A](https://openairdocs.org/incident/19910707026292A), Jul 7, 1991: Piper PA28180, Quincy, IL, Substantial damage. Formation flight of 5 lead plane N4349J was struck on underside by NR3 N8498W on a cross-under. Lead landed safe. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.