2019 — Oct 2, Collings Fdn. B17 Flying Fortress landing/runway crash, Windsor Locks AP, CT– 7

–7 AP. “Historic B-17 Crashes, Killing Seven Aboard.” Daily Herald, Arlington Heights, IL, 10-3-2019.
–7 Aviation Safety Network. Collings Fdn. B-17 approach/runway crash, Windsor Locks IAP 10-2-2019.
–7 National Transportation Safety Board. Aviation Investigation Final Report ERA20MA001.

Narrative Information

Aviation Safety Network, Flight Safety Foundation, Database, 2019:
“Date: 2 October 2019 Time: 09:53
“Type: Boeing B-17F Flying Fortress
“Operator: The Collings Foundation
“Registration: N93012 MSN: 32216
“First flight: 1944 Total airframe hrs.: 11388
“Engines: 4 Wright R-1820-97
“Crew: Fatalities: 2 / Occupants: 3
“Passengers: Fatalities: 5 / Occupants: 10
“Total: Fatalities: 7 / Occupants: 13
….
“Location: Windsor Locks-Bradley International Airport, CT
“Phase: Landing (LDG)
“Nature: Domestic Non Scheduled Passenger
“Departure airport: Windsor Locks-Bradley International Airport, CT
“Destination airport: Windsor Locks-Bradley International Airport, CT.”

National Transportation Safety Board. Aviation Investigation Final Report ERA20MA001:

“The vintage, former US military bomber airplane was on a tour that allowed members of the public to purchase an excursion aboard the airplane for an LHFE [living flight history experience] flight. The accident flight was the airplane’s first flight of the day. During the initial climb, one of the pilots retracted the landing gear, and the crew chief/flight engineer (referred to as the loadmaster) left the cockpit to inform the passengers that they could leave their seats and walk around the airplane.

“One of the pilots reported to air traffic control that the airplane needed to return to the airport because of a rough magneto. At that time, the airplane was at an altitude of about 600 ft above ground level (agl) on the right crosswind leg of the airport traffic pattern for runway 6. The approach controller asked the pilot if he needed any assistance, to which the pilot replied, ‘negative.’

“When the loadmaster returned to the cockpit, he realized that the airplane was no longer climbing, and the pilot, realizing the same, instructed the copilot to extend the landing gear, which he did. The loadmaster left the cockpit to instruct the passengers to return to their seats and fasten their seat belts. When the loadmaster returned again to the cockpit, the pilot stated that the No. 4 engine was losing power; the pilot then shut down that engine and feathered the propeller without any further coordination or discussion.

“When the airplane was at an altitude of about 400 ft agl, it was on a midfield right downwind leg for runway 6. Witness video showed that the landing gear had already been extended by that time, even though the airplane still had about 2.7 nautical miles to fly in the traffic pattern before reaching the runway 6 threshold.

“During final approach, the airplane struck the runway 6 approach lights in a right-wind-down attitude about 1,000 ft before the runway and then contacted the ground about 500 ft before the runway. After landing short of the runway, the airplane traveled onto the right edge of the runway threshold and continued to veer to the right. The airplane collided with vehicles and a deicing fluid tank before coming to rest upright about 940 ft to the right of the runway. A postcrash fire ensued.

“….Teardown examination of the No. 4 engine revealed that the left magneto’s P-lead was partially
pulled out of the magneto housing and that a single strand of safety wire was around the retaining nut. Although the No. 4 engine’s left magneto produced a strong spark on the ignition leads for all nine cylinders, the grounding tab contacted the housing and caused the magneto to short and not function during a post-accident test. The No. 4 engine’s right magneto produced no spark on one of the nine ignition leads and a weak and intermittent spark on the other eight ignition leads because of wear to the compensator cam. The shorted-out left magneto would have caused rough engine operation and a partial loss of engine power that would have been exacerbated by the weak right magneto, which is likely what prompted the pilot to shut down the No. 4 engine and return to the airport.

“With the No. 4 engine shut down, the pilot would have had to use a higher power setting for the No. 3 engine to compensate for the loss of power from the No. 4 engine. Teardown examination of the No. 3 engine revealed evidence of detonation on four of the nine cylinders. In addition, the teardown examination revealed that the spark plugs were worn and had gaps between the electrodes that were beyond the manufacturer’s specifications. The condition of the spark plugs likely resulted in detonation and a partial loss of engine power that further reduced the total thrust available and exacerbated the thrust asymmetry. The pilot likely did not recognize, or recognized too late, the extent of the loss of engine power on the airplane’s right side.

“The pilot had performed a preflight run-up check of the magnetos at an engine speed of 1,700 rpm, which was higher than the 1,600-rpm speed in the Collings Foundation’s run-up checklist; after the check, the magnetos appeared to perform normally. However, a B-17 engine ground test checklist included instructions to check the magnetos at an engine speed between 1,900 and 2,000 rpm. If the pilots had been required to perform the magneto check at the higher rpm, they might have detected the detonation on the No. 3 engine and/or the magneto anomalies on the No. 4 engine (if either resulted in an rpm drop that exceeded 100 rpm, which would have been inconsistent with the B-17’s acceptable limits) and taken action before the flight to resolve the issues.

“During the return to the airport, the pilot flew the traffic pattern at an airspeed of 100 mph and below, and he allowed the airspeed to decay far below that required to minimize the loss of altitude over a given distance flown (about 120 mph). It is likely that the airplane was unable to maintain altitude at the lower airspeeds because the pilot could apply only a limited amount of power to the left-wing engines while simultaneously trimming the asymmetric thrust with the available rudder authority. Extending the landing gear created additional drag that exacerbated this situation; the landing gear should not have been extended until it became evident that the airplane could reach the runway. If the pilot had lowered the airplane’s nose to maintain the airspeed that was initially achieved during the climb and kept the landing gear retracted until landing on the runway was assured, the NTSB’s airplane performance study showed that the airplane could likely have overflown the approach lights and touched down beyond the runway threshold. Thus, the pilot did not appropriately manage the airplane’s configuration and airspeed after he shut down the No. 4 engine.

“The accident pilot was also the Collings Foundation’s director of maintenance and was responsible for performing the airplane’s maintenance while it was on tour. However, the teardown examinations of the Nos. 3 and 4 engines revealed maintenance issues that were not addressed during the airplane’s current tour. For example, the No. 3 engine’s 25-hour inspection occurred less than 1 month before the accident. As part of that inspection, the spark plugs should either have been cleaned, inspected, and tested or replaced with new plugs, and the gap between the electrodes should have been checked. The teardown examination found worn spark plugs with gaps between the electrodes that were beyond the manufacturer’s specifications, which should have been identified and corrected during the inspection of the No. 3 engine. As previously stated, the worn spark plugs would have contributed to the partial loss of power on the No. 3 engine and the asymmetric thrust.

“The 25-hour inspection also includes a check of the point gap for each magneto. The No. 4 engine had its 25-hour inspection 9 days before the accident, but the teardown examination found that the gap between the points on the right magneto was less than the minimum gap that the manufacturer required, indicating that this check was either not performed or was improperly performed. As a result of the point gap, most of the ignition leads produced sparks that were weak or intermittent, adding to the loss of engine power caused by the short in the left magneto….

“At the time of the accident, the Collings Foundation was operating with an LHFE exemption that provided the operator with relief from specific FAA regulations. The FAA’s most recent letter granting the Collings Foundation’s exemption stated that the foundation “must maintain and apply on a continuous basis its safety and risk management program that meets or exceeds the criteria specified in the FAA [LHFE] Policy.” The FAA’s policy stated that LHFE operators, including the Collings Foundation, were required to have a plan to mitigate risks that followed safety risk management principles.

“The Collings Foundation implemented an SMS about 2 1/2 years before the accident, which could have met the requirements of the FAA’s LHFE policy and the FAA’s letter that granted the foundation’s LHFE exemption. However, the SMS was not an effective safety risk management program. The SMS safety officer, who was responsible for managing the SMS, was a part-time, volunteer pilot and, as such, interacted with the foundation’s management and personnel on a sporadic basis only. Further, the SMS did not detect and appropriately manage the risks associated with safety issues related to the pilot’s inadequate maintenance of the airplane while it was on tour.

“The SMS also did not detect that the Collings Foundation’s engine run-up checklist was inconsistent with the B-17 engine ground test checklist or that the pilot and copilot did not wear their shoulder harnesses during flights (as reported by the loadmaster). In addition, the SMS did not detect that the loadmaster’s passenger briefings might have been insufficient (as indicated by statements from multiple surviving passengers that the briefing did not include information about seat belts, exits, or emergency equipment) or that he would stand unrestrained between the pilot and copilot during takeoff and landing, even though the foundation indicated that the seat to the left of the ball turret was available for him. The pilots’ failure to use their shoulder harnesses and the loadmaster’s failure to be restrained during takeoff and landing were inconsistent with federal regulations addressing the use of safety belts and shoulder harnesses….

“Probable Cause and Findings

“The National Transportation Safety Board determines the probable cause(s) of this accident to be:

“The pilot’s failure to properly manage the airplane’s configuration and airspeed after he shut down the No. 4 engine following its partial loss of power during the initial climb. Contributing to the accident was the pilot/maintenance director’s inadequate maintenance while the airplane was on tour, which resulted in the partial loss of power to the Nos. 3 and 4 engines; the Collings Foundation’s ineffective safety management system (SMS), which failed to identify and mitigate safety risks; and the Federal Aviation Administration’s inadequate oversight of the Collings Foundation’s SMS.”

Newspaper

Oct 3, AP: “A World War-II era B-17 bomber that has toured the U.S. crashed and burned after an aborted takeoff Wednesday in Connecticut, killing seven of the 13 people aboard.

“The historic plane frequently had been at Chicago Executive Airport in Wheeling, most recently at the end of July, as part of the annual Wings of Freedom tour run by the Collings Foundation.

“The passengers and three crew members were on board Wednesday as the four-engine, propeller-driven plane struggled to get into the air and slammed into a maintenance shed at Bradley International Airport in Windsor Locks, Connecticut, when the pilots circled back for a landing, officials and witnesses said.

“Connecticut Public Safety Commissioner James Rovella said hours after the crash that some of those on board were burned, and ‘the victims are very difficult to identify.’….No children were on the plane….” (AP. “Historic B-17 Crashes, Killing Seven Aboard.” Lake County Daily Herald, Arlington Heights, IL, 10-3-2019.)

Sources

Associated Press (Chris Ehrmann and Dave Collins). “Historic B-17 Crashes, Killing Seven Aboard.” Daily Herald, Arlington Heights, IL, 10-3-2019. Accessed 8-2-2023 at:
https://newspaperarchive.com/arlington-heights-daily-herald-suburban-chicago-oct-03-2019-p-44/

Aviation Safety Network, Flight Safety Foundation, Database, 2019. Collings Foundation B-17G Flying Fortress approach/runway crash, Windsor Locks-Bradley International Airport, CT. 10-2-2019. Accessed 8-2-2023 at: https://aviation-safety.net/database/record.php?id=20191002-0

National Transportation Safety Board. Aviation Investigation Final Report ERA20MA001. Washington, DC: NTSB, 24 pages. Accessed 8-2-2023 at: file:///C:/Users/Wayne/Downloads/Report_ERA20MA001_100356_8_2_2023%204%2032%2029%20PM.pdf