Collings Crash And Safety Culture


The FAA wasted little time last week in denying the Collings Foundation’s request to renew its passenger-carrying authority under the Living History Flight Exemptions program. That decision came as a result of the Oct. 2, 2019, crash of the foundation’s B-17G at Windsor Locks, Connecticut, that killed five passengers and two crew members and destroyed the Nine-O-Nine Flying Fortress. I say little time because the agency interviewed the surviving crew chief on March 20 and made its decision just five days later.

The foundation had voluntarily stopped flying passengers following the crash, but its request to renew the LHFE had been pending. LHFE lifts the restriction against flying revenue passengers in experimental aircraft and it applies to so-called “fragile” historical aircraft as a means of preserving them and promoting their importance to the history of aviation. While dozens of aviation museums have restored examples of historic aircraft on static display, Collings flies its examples around the country giving rides, for which it’s allowed to charge.

Is this still a good idea? I think it is. And I’d like to see it continue. And so did an overwhelmingly large number of the 1626 people who commented on the FAA docket in Collings’ favor. However, as I mentioned in a previous blog, I favor a stronger application of informed consent and an explicit waiver so that passengers know what they’re getting into. That’s not the waiver that limits legal liability, but the one that tells the person signing up for a flight that this isn’t an airline trip. Neither of these relate to the FAA’s regulatory purview.

And by the way, it’s rubbish to say these airplanes were only designed to fly for 50 hours. In the case of the B-17, Boeing made it a strong, survivable aircraft that was legendary for bringing crews home. Predicted combat losses determined the production economics and volumes. But it is true that these legacy airplanes don’t get easier or less expensive to maintain. Eventually, they may not be.

I object to these flights being described—or implied—as the equivalent level of safety as a Part 135 or Part 121 operation. I think this misleads the potential passenger into underestimating the risk. Part 121 operations are based on some of the most reliable machines in the mechanical universe supported by a matrix of assistance from gate agents through dispatch through maintenance teams through monitored safety systems and on and on. They have considerable resources—money—to drive this and this results in that gauzy thing we call a culture of safety.

In its letter rescinding Collings’ LHFE, the FAA said the foundation lacked this. Although I don’t often quote myself, in the previous blog I said: “While the goal may be equivalent safety and while the mechanisms to achieve that may be in place, are these procedures actually being followed and were they in the Collings crash?” According to the FAA, the answer is no. So in this instance, Collings appears to have broken faith with its customers.

From the outside looking in, our impression of Collings was one of a stand-up organization that tried to do things right. What awaits further investigation and the NTSB probable cause is whether this was a one-of or part of a pattern of lax maintenance and oversight. I also suspect the worn mag, grounded lead and fouled plugs will be contributory to a primary cause. There has been no indication thus far that the aircraft didn’t have three operable engines after one was caged. In my view, the FAA was justified in pulling the plug on Collings’ LHFE temporarily, but perhaps not permanently. Why shouldn’t the foundation be given a chance to revise its procedures and training and resume operation under tighter FAA surveillance?

It occurs to me that there’s an immediate takeaway from the FAA findings on the Collings accident. If the operators of that aircraft knew there was a faulty or at least marginal mag and launched anyway, why? And if they didn’t know, why? The answer to those two questions taken together begin to define what a safety culture is.

It applies to anyone operating an aircraft at any level. All of us get sloppy with all aspects of flight from time to time, including maintenance. We all defer fixing stuff, not just because of the money but because of inertia. It worked the last time I used it and probably will this time, too. But ask yourself how you know that? I’m sure I don’t ask myself enough. Do you?

FAA-approved safety oversight is supposed to step this up a notch or two. That’s what required inspections and maintenance intervals are for. You know something is going to work or believe it a high probability that it will because you looked at it five hours ago, just as the approved maintenance program says you’re supposed to.

I doubt if there’s a fly-for-hire pilot alive who hasn’t complained about filling out some chicken^%$# form or complying with an inane procedure. I know I have. Doing those things doesn’t directly impact safety, but it at least forces you to think about the things that do.  

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  1. I didn’t read the FAA’s decision as one of permanence. It seems to me that if Collings’ puts together a program to fix the deficiencies and re-applies, they would then be granted the waiver (if it’s found to be acceptable by the FAA). My first reaction was that it was an overreach, but after reading what the findings were, I was a bit surprised that apparently so many things were allowed to get by.

  2. We all remember how the safety management system concept (SMS) hit the turbine aircraft operations industry like gangbusters during the first decade of the 2000s. What followed was an overnight emergence of the SMS mill cottage industry. Flight departments and organizations did everything from purchasing SMS packages to writing their own with the goal of eventually attaining three levels of ISBAO certification. Some organizations nurtured SMS into a living, breathing organism which described standards, incentivized and measured the meeting of those standards as a culture. Other organizations simply purchased or wrote their own SMS to show perfunctory compliance and let their systems gather dust on shelves.

    I once asked a pilot of a level 3 ISBAO certified major OEM how frequently they used their flight risk assessment tool (FRAT). He responded that he couldn’t remember ever using a FRAT and was actually not conversant on the matter. So much for the value of SMS if not used.

    According to another account of the Collings accident inquiry, the crew chief, when asked, supposedly stated that he had no idea some sort of safety management initiative existed with the organization. Across the industry, items like healthy mags, leads and spark plugs have historically been maintained by good old fashioned 1945 era sense of duty sans fancy sounding safety management initiatives, and flights have likewise been dispatched. But a living, breathing organizational safety culture standardizes, incentivizes and measures the achievement of healthy mag, lead and spark plug maintenance as the way of life in an organization. It sounds like, in addition to informed consent and explicit waivers, the birth of this kind of culture will need to take place and breath within this organization for passenger flight operations of these aircraft to continue.

    • There is no FAA requirement for SMS in pt135 ops, or for pt91 either. SMS is only effective if management believes in it. Otherwise it is just an additional worthless paperwork exercise for flight crews. I flew for a company that did lots of international flights, which SMS is a foreign requirement. The owner used it as an advertisement for business but rarely would follow the program. Frat scores are a useful tool but again they can be manipulated if management doesn’t believe in them. I don’t think even the FAA likes the SMS idea or they would have made it mandatory for everyone long ago. The only reason pt121 is mandated is due to international ICAO requirements just like SIC type ratings are.

      • Who said anything about SMS being a requirement in pt135 or pt 91? Precisely not my point. Otherwise, Matt you’re making my point and don’t realize it. Of course SMS is only effective if management believes in it, and if your management doesn’t believe it in, you are working for the wrong company. We have a case in point in this story where management obviously did not believe in it. It doesn’t have to be some big paperwork fiasco to work. It shouldn’t be. It doesn’t need to be blessed by ICAO. It needs only to be emotionally owned by your management, practical, a pleasure to use, and you need to feel in your bones that it is there to protect your life. If that’s not the case, it’s not a true SMS and your company is playing with your life.

        • That company I was describing I no longer work for. The company I work for now and the first company I worked for has good trustworthy maintenance, and a management that never asked or expected me to operate their aircraft in any illegal or unsafe manner, and did so without an SMS. Unfortunately the third one had questionable maintenance that took several years before the FAA took any action. That company finally went under.

          Definitely some questionable things going on with Collings Foundation. If the maintenance logbook entries were in error then what else is? Since it took a fatal accident for the FAA to act it makes me wonder what good an SMS would have done.

  3. Ahh, the FAA’s denial of the Collings Foundation’s application to renew its Living History Flight Exemption status is just another case of a sinister assault on the Constitution. They should be allowed to take people up for hire because hey, it’s all about being free to do whatever we want, you know?

    And don’t start with me about governments ordering me to stay home — what about my rights and my liberty??

  4. Each aircraft is built with thousands of parts. The parts that wear out the most get used up. We (the industry), with little choice, keep pushing them back into service. Owners tell me all the time that “this part is ‘just-like-new’ “. That is just not the exact same thing as “NEW”. Many component maintenance shops will sign a component off as ‘repaired’. They don’t have the required parts to meet the ‘overhaul’ requirements.

    Sorry to be the bearer of bad news but, many parts are just not available anymore. They have all been used up over the past 80 years. We need those promised cheap 3D printers.

  5. The crash of the Collings Foundation B-17 was caused by trust. The Collings Foundation had the highest time B-17 pilot in history flying their airplane thousands of hours over at least two decades. He was trusted to use good judgement when preparing for and during flight. He was entrusted the mechanical care of this airplane as well. He was both the Director of Maintenance as well as chief pilot. As President Reagan said, “trust but verify”.

    Our FAA regulations are in place largely to be used in a trustworthy manner. But that trust is to be verified by documentation as well as verification procedures to ensure the documentation and corrective actions are one and the same.

    What really bothers me is the mechanical issues found in the wreckage are not something that could be regarded as a minor oops. Jury rigged P-leads, worn beyond limits cam followers, magneto points beyond service limits, weak spark to 4 cylinders and no spark to five. Fouled plugs, gap tolerances out of limits, total magneto failure, un-described cylinder issues on both engines, with evidence of detonation signatures. This shows intentional disregard for clear maintenance issues combined with lying about both the discrepancies and the expected repairs with the logbook entries. These problems are not something simply missed. It shows there was intentional disregard for proper procedures to the extent both time and energy were spent in jury rigging alternative measures to get another flight out of these clearly abused engines. To make matters worse, prior to the fatal flight the engine ignition was so degraded that one of them would not start after repeated attempts forcing shut down of the remaining three. At the direction of the DOM, compressed air was aimed at the magneto to dry it out the pilot/DOM claimed was simply damp. A passenger who subsequently died in the crash expressed concerns about engine’s failure to start. A mechanic’s answer was once it starts it will keep running.

    The trust the Collings Foundation had placed with the DOM/pilot was misplaced. This cycle of willful disregard for proper maintenance was something that according to what the FAA has revealed, had been happening since May of 2019. The logbook entries read as if there was nothing ever wrong with those engines. This is clearly a serious integrity problem with the DOM/Pilot. We also don’t know what kind of power these now damaged engines were making during the runup and take-off. But the DOM/pilot clearly knew these engines had multiple issues.

    I believe he fully expected to be able to handle whatever emergency this airplane could throw at him. The tone in the ATC tapes show no surprise. They identified it as a magneto problem. With what he knew of the issues, I am sure he was not surprised until after feathering the one, the other right engine was giving up too. Its blades were in partial feather when colliding with the approach lights. The passengers trusted the DOM/Pilot, the Collings Foundation, and the FAA that maintenance was performed correctly, regularly, with intentionality of doing their best. Those passengers expected an airworthy airplane. The FAA trusted that the Collings Foundation had checks and balances in place to ensure LHFE compliance. The FAA simply verified that expected trust.

    Too bad seven people had to be killed, family’s lives torn up, a WWII bomber destroyed, and general aviation with the warbird community having to bear the consequences of trust without verification. I am in full agreement with the FAA that the LHFE should be rescinded from the Collings Foundation at this time. At this time, the Collings Foundation cannot be trusted.

    Freedom assumes and demands responsibility. We can use our freedom to scoff at laws, ignore regulations, and live recklessly. Freedom gives us opportunity to act both responsibly and irresponsibly. Freedom gives us opportunity to act, behave, with expectation we conduct ourselves in a manner that would not be harmful to others. This DOM/chief pilot chose to ignore his responsibility to do what was right. He used his freedom to intentionally fly an airplane that he knew had multiple engine discrepancies. Likewise, we can choose to ignore our responsibility to do what would be in the best interests of us, our families, our neighbors, and all of the folks we don’t know the names of… but have contact with.

    Freedom gives us a “right” to think only of ourselves in whatever we do. I can use my freedom to use my airplane as either a weapon or a safe flying machine. Freedom gives me that “right” to choose how I fly my airplane. My passengers trust I will fly with responsibility for their best interests. Those on the ground beneath me and other pilots in the air trust I will do the same. Isn’t that the way we are supposed to live life where we have such precious freedom?

    Surviving freedom exercised without responsibility is difficult at best for the individual, and impossible for a country in a very short time.

    • >>At the direction of the DOM, compressed air was aimed at the magneto to dry it out the pilot/DOM claimed was simply damp. A passenger who subsequently died in the crash expressed concerns about engine’s failure to start. A mechanic’s answer was once it starts it will keep running. <<
      This has all the appearances of assuming the same cause of a problem (engine won't start) and addressing it with a solution which had worked in the past, then deciding the problem was solved when the engine eventually started and "ran", however poorly. This is shadetree mechanic stuff. Collings Foundation may get their LHFE waiver back someday but they'll have to do a really good job of convincing the FAA they are completely on top of Best Practices – which are based on plain old common sense.

    • I fully agree with that assessment, and am aghast at the unforgivable maintenance practices of Collings. Also, I was set to fly in this plane out of Concord, California, summer 2018. I was already on board when they had everyone get off because they were having trouble starting an engine. I didn’t get back on.

  6. I’ve never flown on a warbird, but it seems to me that simply signing an informed consent or waiver isn’t enough. The intended inhabitants of these aircraft were trained military warfighters. I assume most went through extensive training for safety and egress in case of emergency. Does anyone know if passengers are given orientations and safety training, or is it just “sign the paper, fork over the money, and hop in”?
    I don’t think signing a waiver is enough for passengers on these flights. The enthusiasm that goes along with rides on these aircraft will completely overwhelm common sense and rational weighing of risk. This places a lot of trust in the operator to make sure that nothing bad will happen.
    I think that part of the safety culture should include the passengers, not just the aircraft itself.
    If anyone has ridden on these types of aircraft, it would be interesting to hear what kind of briefings and orientation you receive in case of emergency.

  7. After watching videos of Collings’ operations while giving LHFE rides in their B-25, my conclusion is that making money and holding schedule are their priority, not safety. I reached this conclusion after watching someone (I assume a crew member) hurriedly enter the aircraft while the engines were running. The hatch shut as soon as that person was onboard, and the plane was rolling less than four seconds later.

  8. One of the problems with keeping the legacy aircraft flying is as they age, more and better maintenance is required. Unfortunately the business model for these planes requires a cadre of enthusiastic volunteers with a dodgy budget. These volunteers are great but to a high degree not A&Ps or IAs and do not have the training and oversight needed to maintain a complex ageing aircraft. Too much maintenance gets done improperly or not at all. Nobody seems willing to stop and say”Whoa guys, this just ain’t right!” Actually given the condition and lack of disciplined maintenance involved, it is a real tribute to these great old airplanes that they don’t crash more often.

  9. Having flown warbirds for different operations and observed Collings Foundations ops many times, I found them in the comfort zone. To have so many casual, unengaged observers make claims to their ops, maintenance and budget based on nothing but the FAA’s regurgitation of the NTSB’s reports and one interview is not particularly enlightening to the operation as a whole .

    The Fed response is typical of them especially in regard to Collings politically, ie they have a lot of fans and a lot of detractors within the Fed. Because of their desire to restore and operate jets like the F-4 and Me-262 as well the high number of aircraft operated in the rides waiver by this one entity compared to others brings them under special scrutiny.

    As for operating maintenance and budget, their Mustangs lease engines from Roush whom is the holder of the only FAA repair station authorization for the Packard/Rolls Royce V-1650 Merlin. I don’t know where the 1820s on the B-17 are overhauled. Just an indication to me that Collings had and has a very good attitude towards safety, high quality maintenance and commitment to doing the right thing. I know they bought another B-17 before this accident with the intention of restoring it to airworthiness so 909 could be inspected and restored again which does not indicate a budget lacking but a long range plan of strategic maintenance.

    The Fed is being overly cautious here and no doubt why, it is a safety issue no signer of a waiver wants to bet his FAA bureaucratic pension over…

    The posters here seem to damn an organization they know little to nothing about not realizing their words are spread over all of the operators in this casual spew because there are others more casual still that think of all waiver ride givers as the same…

    As for the poster that saw wheels rolling seconds after the hatch closed… the job of the flight engineer or crew chief is to observe for oil leakage after engine start and clearing of the area before motion, also after run up an oil leak observation is conducted, also at clean up or soon after take off a visual engine observation is taken… because if a leak is detected early a take off will not be attempted if said leak is detected at start or run up, or immediately after take off an engine shut down can be conducted in the planned emergency procedure before failure and destruction contribute to a worse emergency like a fire or propeller control failure.

    This “wheels rolling seconds after hatch closing” poster’s conclusion is based on a premise more that of a subway train rider than a pilot with mechanical knowledge and is a peek at the ignorance of many commenting on the subject of the Collings Foundations B-17 accident in general.

    • If the condition of the ignition system on the number four engine is accurate, it speaks for itself. Is there another interpretation about the factual account that suggests it was really in airworthy condition? It begs a question about that high quality of maintenance and commitment to doing the right thing.

  10. July 20, 2007. The Collings Foundation was giving rides out of DuPage County Airport (DPA) west of Chicago. I was returning to the DeKalb, Il airport (DKB) 18 miles west of DPA after a training flight with a student. I made all the appropriate calls as we approached the airport and I heard three other pilots in the pattern announcing their positions. DKB is surrounded by lush green corn and bean fields in July. As we descended to pattern altitude I suddenly saw a flash of red in front of and just below us. I immediately recognized the red triangle on the tail and hauled back on the yoke. The Collings B-17 passed approximately100″ below us, its olive drab paint a perfect camouflage against the green crops below. My student was alarmed when I suddenly hauled back on the yoke and never saw the B-17. I announced what had just happened and asked the other pilots in the pattern if I had missed a call or something. One of those pilots told me no, I hadn’t missed anything; that the B-17 had flown directly through the DKB traffic pattern at pattern altitude and never said a thing.

    After wrapping up the lesson I drove to DPA to talk to the Collings pilots but was told by a ground crewmember that they had left for the day.

    Pilots unfamiliar with the area? On the wrong Unicom frequency? They came within a second or two of a mid-air collision. Was this near mid-air the result of a lack of preparation? Did they fly out of so many airports that the areas just blur together? “Let’s give the rides then hurry on to the next airport?”.

  11. Scott,
    In my air racing experience these big bore engines fail and are damaged quickly. When it failed, vibration, structural elasticity, and general catastrophic violence could have made everything from the points adjustment, spark plug clearances, detonation damage and the P-Lead stabilizing fix worn to ground happen in a very short period, like in seconds. I advise awaiting the final on this accident.

  12. Chris M…”“In my air racing experience these big bore engines fail and are damaged quickly. When it failed, vibration, structural elasticity, and general catastrophic violence could have made everything from the points adjustment, spark plug clearances, detonation damage and the P-Lead stabilizing fix worn to ground happen in a very short period, like in seconds.”

    In my experience fixing airplane engines and racing engines, when low compression radials, opposed 4/6 cylinder piston engines fail to develop rated power or even suffer catastrophic failure of a rod, crank, crankcase, piston, or cylinder, even at full throttle, I have never seen point adjustment changes, plug gaps change, or contribute to magnetos being out of service limits. I have helped perform NTSB investigative tear downs on a variety of aircraft engines that have been augured in or came apart due to something internally breaking and have never seen your description attributing the condition of the ignition system, plugs, or magnetos the NTSB found on the Collings B-17. I have seen weak and out of service limits magnetos, performing less then optimum ignition timing, and lack of accurate timing contribute to detonation damage over long periods of time.
    The FAA description of the condition of the ignition system and the cylinders came from poor maintenance. Not only was it poor maintenance, someone went to the extent of doing a Rube Goldberg repair to the loose P-leads. Both engines three and four had similar issues. One engine was mid-time the other low time. Then, logbook entries lied about both the discrepancies and the repair of both engines. None of that happened as a result of “big bore engines fail and are damaged quickly”.

    I have seen detonation damage, magneto failures, plug/valve/piston/cylinder destruction to racing engines who are being pushed so hard, developing two to three times their rated original power running manifold pressures that are mind boggling, turning RPM’s 30-40% past stock, with the addition of ADI operating on 130+ octane fuel with timing advanced well past any stock parameters. To suggest those two radial on the Collings B-17 was pushed to anywhere near those limits, had any ability to develop those kind of manifold pressures, and that catastrophic failure occurred to contribute to a worn out, purposefully jury rigged ignition system followed with pencil whipped log entries does not line up with any of the evidence. Have you read the FAA report?

    Collings Foundation lost their LHFE because they lost control of the day to day maintenance of that particular airplane. They trusted a long-term DOM/chief pilot was being truthful handling all maintenance aspects of that airplane including accurate and complete documentation of the discrepancies and what should have been their subsequent repair.. They trusted the flying credentials and the judgement of the DOM/Chief pilot that every flight would be safe and flown under LHFE compliance. Their LHFE was rescinded because they failed to verify.

    Investigation of their overall operation will reveal if this was standard operating procedures for the remaining Collings Foundation LHFE warbirds. Award winning, high dollar restorations being poorly maintained and managed through a show season cannot be tolerated. I would like to think that what has previously appeared to be first class operation simply let this one airplane get away from LHFE procedures and their own Safety Manual Systems. We all wanted to “say it ain’t so”. The evidence is overwhelming regarding this particular airplane. There is nothing to defend.

  13. After a skim of the NTSB Preliminary Reports and the comments, I have no doubt engine maintenance was the primary cause of this accident. And that cause lies squarely with the owner / operator of ‘909,’ the Collings Foundation.

    The role of the pilot, who was also the maintenance officer (DOM), needs to be more thoroughly examined.

    Let’s examine, for a moment, the final cause of the accident events chain: failure to maintain flying speed and altitude, sometimes described as energy management.

    Let’s face it … hitting the ALS structures resulted in a loss of control, and a significant departure from the runway center-line. Why so slow, too slow? Why so low? Presumably the pilots knew the correct airspeed to maintain under those circumstances. Were the flaps positioned properly? They may have been… or not. Did the pilot in command (PIC) simply neglect to maintain airspeed in a no-flap configuration?

    Sadly, it does appear that the accident was completely within the purview of the PIC / DOM, one way or another…

    Was this tragic ending essentially unavoidable, given the loss of two engines on one side? Dunno. Perhaps…