Nine-O-Nine Final Report Cites Inadequate SMS Oversight

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The NTSB has released its final report on the fatal crash of the Collings Foundation’s B-17 Nine-O-Nine and the board’s takeaway is no surprise to anyone who has been following the story. While the primary cause of the accident is reported as “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,” the rest of the report tells the deeper story.

“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.” So, the pilot, who also served as Collings’s maintenance director while on tour, was landing with two good engines on one side, and on the other side, one shut down and one with partial power.

The Flying Fortress was on a “living history flight experience” flight from Bradley International Airport in Hartford, Connecticut, with 10 paying passengers and four crew members. Shortly after takeoff, the pilot told the tower he was returning due to engine problems with the No. 4 engine, which the crew shut down and feathered. The landing went wrong when the bomber hit the ground before reaching the runway and veered to the right, hitting parked vehicles and a deicing tank. The airplane caught fire and seven onboard died, including the pilot and copilot.

The board attributed the loss of power in two engines to inadequate maintenance and inattention to the voluntary safety management system the foundation implemented two years before the accident, saying “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 [contributed to the accident].”

The board concluded in its summary of the report, “We have seen instances where operators may have voluntarily implemented an SMS, but its components are not actively functioning as an integrated system.”

The NTSB recently released recommendations that revenue-generating flights flown under Part 91, including living history flight experience sorties, face greater scrutiny and oversight, criticizing the FAA for inadequate supervision.

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27 COMMENTS

  1. Why fly a war relic with people onboard when you know issues with the engines were present because you were responsible for them? They risked life and limb of trusting people knowing they were doing wrong. I don’t trust the FAA because of my dealing with them on airport Grant Assurance issues, I sure don’t trust them to keep me safe.

  2. I agree with Cameron. The Root Cause of the problem was the faulty maintenance on the engines, not pilot error. If the engines had been maintained as required, this accident would not have happened. Yes, pilot error did occur as well. He lowered the landing gear too soon and lost airspeed and altitude and that contributed to the accident. I did not hear that there was problems with 3 of the 4 engines as this article states. I read the NTSB accident report and it only indicated engine 3 and 4. Either way, this shows the lack of confidence in aviation when you have someone operating an aircraft but not maintaining it and it cost peoples lives. Such a shame.

  3. I think the main blame should be the Collings Foundation. It was their airplane and their pilot who they hired to fly and perform the maintenance duties on it. Hopefully they had a big insurance policy covering any deficiencies. I wonder if the FAA is going after them to see if all their other aircraft are performing properly.

    • Yes. The FAA is only so big with resources. When the FAA gives approval to any of us, whether it’s a pilot’s license, an approval for 121 or 135 operation, approving a maintenance program, and on the list could go, there is then an expectation by the FAA that we will operate as approved, with accepting personal responsibility. The FAA then has scheduled follow up for whatever it might be. But it will be assumed you are operating responsibly basically until it is proven other wise, and unfortunately that sometimes occurs with a tragic accident. The FAA just does not have the personnel to do otherwise. All I can suggest is you alert the FAA to anything you see that is suspect. They will then try to follow up. But as implied, they cannot be all things to the big world of US aviation. It a “damned if you do, and damned if you don’t”.

  4. This is what I don’t understand.
    How could the “faulty” engines have passed the pre takeoff runup & then fail a couple minutes after?
    Would not lousy maintenance (whatever that means) show up when FULL take off
    power was applied? (as an A&P, I would like to know)
    Sure wish someone were alive for this answer.

  5. I agree with the trend of these comments. The line between too much and too little FAA oversight is fuzzy at best. In the case of the loopholes regarding revenue-generating flights carried out under Part 91 (ride-shares, parachute drops, living history flights, “doors off” helicopter sightseeing, hot air balloon rides, and other vintage aircraft rides, for a few examples), there have been eight recent accidents that have killed 45 people. This got the NTSB’s undivided attention, and in a recent hearing, the board has made it clear the status quo needs to change. A voluntary SMS is only as good as the level of compliance, and where the FAA’s responsibility begins and ends is probably going to become a lot more clear. Further, what constitutes a “paying passenger” vs a willing risk-sharing participant is not a simple question. News reports on the B-17 crash talked about passengers who had “bought tickets” as if they lined up at a booth outside the fence. You could argue that the passengers were obviously aware they were strapping in to an antique airplane and the risk is clearly higher than riding on an airliner. But at the same time, they probably also assumed a certain level of assurance that if the airplane was flying legally in the eyes of the FAA, it must meet some reasonable level of safety. The fuzzy line in between is likely to get a lot more distinct going forward.

  6. AvWeb, when you do stories on a report or video which has a URL, could you please include the link, for those of us who want to investigate further? Links are a marvellous capability of the medium you write in. You would serve your readers well by making even better use of them. So, for this story: what is the URL and the docket number of this NTSB report?

    • For those who want the link, the NTSB says, “The full accident report, Impact with Terrain Short of the Runway, Boeing B-17G, Bradley International Airport, Windsor Locks, Connecticut, Oct. 2, 2019, is available online at https://go.usa.gov/xHbMw.” When I followed this link, the browser gave me a PDF file “Report_ERA20MA001_100356_4_16_2021 2 27 08 PM.pdf”, 5.35 MB, 24pp, internal title “National Transportation Safety Board Aviation Accident Final Report”, Accident Number: “ERA20MA001”.

      NTSB news release: “Pilot’s Actions, Maintenance Issues, Ineffective Safety Management System and Oversight, all Contributed to Fatal Crash of Historic B-17 Airplane”, 2021-04-13, https://www.ntsb.gov/news/press-releases/Pages/mr20210413a.aspx .

      The NTSB investigation docket appears to be ERA20MA001, https://data.ntsb.gov/Docket?ProjectID=100356 . I don’t see the Final Report in that docket (as of 2021-04-16 18:47Z).

    • Jim:
      There was a link embedded in the “Advocacy Update” email we got from the board, but unfortunately it did not work so I didn’t include it. I just now checked the NTSB site for a link for you, but I did not see this final report listed yet. I apologize.

      • Thank you, Mark. I appreciate the reply. I see the problem with getting working URLs from the NTSB. It looks like they don’t post the report to their website first, then use that link when sending out their updates. In the absence of a working URL, search fodder is also helpful, for example an NTSB accident number.

  7. These warbirds were designed to do one thing, provide a pilot or aircrew a fighter or bomber a means to deliver ground or air support during war times. A separate ground crew maintained these aircraft if they returned from combat. The men and women making up each aircraft’s ground crew were tied intimately to their assigned aircraft. Their valuable service isn’t overlooked. During war times, ground crews did whatever it took to present an airworthy a/c the next day to continue the war effort. Anyone can imagine the all nighters as each a/c was repaired and restored for the next day’s flight. As retired a/c with limitations and exemptions to allow living flights to promote and prolong them as living legends, I wonder how maintenance developed to ensure safety of flight. War times presents the best efforts for a specific cause, to bring war to an end. Tax payers paid the bills. In peace time, these warbirds are most likely very expensive maintenance nightmares requiring the same skills from WWII. The same for the aircrew, especially pilots flying them. Apparently, maintenance was lacking as well as pilot awareness perhaps not seeing the greater perspective of the same warbird requiring an experienced pilot to deal with single or multiple engine out conditions after take off, preflight checks to expose discrepancies before take off, etc. It’s sad and disappointing to read news of this avoidable accident as I too think of witnessing flight of this warbird, inside.

    • While maintenance of an aircraft like a B-17 is without doubt a big job, the small individual tasks like changing spark plugs and oil and compression testing of cylinders, those things are not terribly different from the same maintenance tasks on a general aviation airplane. They just take larger tools. Similarly, the electrical systems (while more complex) are still electrical systems with circuit breakers and lights and such. Hydraulics are hydraulics.
      It takes a LOT of mechanics to get the job done, but the individual tasks are mostly not unique or unknown to the maintenance population today. It doesn’t take mechanics from WWII to keep the thing going. It just takes an operator with the budget for the maintenance.

  8. The article says, “The board attributed the loss of power in three engines to…”, but this looks to me like a mistake. The Aviation Accident Final Report says, “…the partial loss of power to the Nos. 3 and 4 engines”. I don’t see that the report says anywhere, “in three engines”.

    Source: NTSB Aviation Accident Final Report, #ERA20MA001, section “Probable Cause and Findings”, page 5, which reads in part: “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.” (URL elided so that this reply does not get held for moderation.)

    • Jim:
      You are correct. The pilot shut down No. 4, and then the No. 3 engine experienced partial power loss, so he had two good engines on one side of the airplane, one delivering partial power, and one shut down on the other side. I will edit the story. Thank you for flagging that.