The Monkey Guarding the Bananas?

What caused the crash of the Collings Foundation WWII Boeing B-17G Flying Fortress October 2nd, 2019 at the Bradley International Airport, Windsor Locks, CT during a Living History Flight Exemption passenger flight? The FAA has revealed some very damning information that has caused the FAA to remove the Living History Flight Exhemption with the result that the Colling Foundation cannot fly their warbirds with paying passengers aboard.

I am in total agreement with the FAA when I read the official document explaining their reason for rescinding the Collings Foundation Living History Flight Exemption (LHFE) number 6540P. I am surprised and deeply disappointed in how the Collings Foundation allowed the “Monkey to Guard the Bananas” allowing a first class warbird restoration and living history flight operation degrade, in the case of B-17G “Nine-O-Nine” specifically, resulting in an emergency landing attempt that ultimately destroyed the airplane, killing seven passengers and crew and injuring five others.

So what did actually degrade? First was normal, but critical maintenance of the engines ignition system. Two was record keeping of aircraft discrepancies and maintenance that was to correct them. Three was no prior training given to the crew chief regarding the Collings Foundation own Safety Management System to be performed by the crew chief specifically required by the Living History Flight Exemption regulations. Four, the pilot in command was also the Director of Maintenance hence, the title “The Monkey Guarding the Bananas”.

1. Maintenance issues.

The airplane lost power in both the number three and number four engines, both being on the right side of the airplane. Although, the NTSB has not determined an official final cause for the accident, the NTSB investigation thus far has revealed the number three engine had numerous ignition related issues. I quote… “An inspection of engine 3 showed all spark plugs electrode gaps were out of tolerance, fouled, and revealed various signs of detonation. Further inspection of this engine revealed problems with the cylinders.”

Number four engine was worse. “Regarding engine 4, to prevent the magneto “P” leads from separating from the magnetos, someone had attempted to rig the magneto leads in place with safety wire. Inspection and testing of engine 4 left magneto revealed the movement of the safety-wired lead caused grounding to the case, which rendered the magneto lead inoperative. In addition, the right magneto of engine 4 was found unserviceable. The cam follower was worn beyond limits and the point gap was less than half the measurement required by service documents. When tested, the magneto produced weak or no spark to four of the nine cylinders. All spark plugs were inspected and required cleaning and all electrode gaps were out of tolerance; therefore, further engine inspection indicated signs of detonation and associated damage.”

Number 2. Maintenance discrepancies record keeping.

“The discrepancies noted above indicate maintenance, or lack thereof, occurred in a manner contrary to maintaining aircraft in accordance with the General Maintenance Manual (GMM). Moreover, the records memorializing the inspections and maintenance performed on the B-17G lack key information and, in some cases, indicate maintenance was either not performed at all or was performed in a manner contrary to the applicable requirements.” Furthermore, the FAA looked back at previous flights flown in May of 2019 showing a record of two passenger flights flown after determining ignition wires burned and arcing but without any further maintenance or adjustments to determine the cause. “In addition, maintenance records indicate the removal of wires and no further repairs or adjustments, even though a wire was burned and arcing. See NL93012 B-17G Flying Fortress Flight Report (May 11, 2019). The same record, as well as a record from the following day, indicates flights with passengers occurred in the aircraft.”

Number 3. Lack of formal training for the crew chief.

“While Collings produced some training records for maintenance personnel and pilots, the evidence indicates that Collings did not train the crew chief who was onboard the B-17G that was involved in the accident on October 2, 2019. The applicable General Operations Manual states that crew chiefs are assigned to every passenger flight aboard the B-17, B-25, and B-24. Crew chiefs must assist the flight-crew with duties as assigned during each flight. Such duties include, but are not limited to, assisting flight-crew with checklists and handling emergencies, as well as assisting flight-crew and maintenance personnel in preparation for each flight and helping with ground operations and ramp safety. Crew chiefs are required to be familiar with all documents that must be on board the aircraft and must be “trained by the [pilot in command], [second in command], another Crew Chief or the [Director of Maintenance]. In an interview with the FAA on March 2, 2020, the crew chief verified that he received no initial training and was unaware of basic information concerning operations under the exemption. Instead, he only received on-the-job training.”

Number 4. The Monkey Guarding the Bananas.

“…notable maintenance discrepancies existed with the B-17G, yet the Collings Director of Maintenance signed inspection records—dated as recently as September 23, 2019—indicating no findings of discrepancies. No records or evidence of the completion of periodic audits exist with regard to this aircraft. In addition, the pilot in command of the B-17G was also the Director of Maintenance; as a result, Collings did not have a structure to ensure adequate oversight of his decisions to conduct passenger-carrying operations such as the October 2 flight. This indicates Collings lacked a safety culture when operating the B-17G.”

This gets to the real heart of why None-O-Nine ended up destroyed including the deaths of paying passengers, the pilot, and co-pilot. The crew chief was supposed to be on board as a member of the flight crew to assist in operation of the airplane plus be trained and ready to assist the flight crew in the event of an emergency. He was there , behind the cockpit,with no seat nor seat belt available, in addition to no knowledge of the Safety Management System. ”On October 2, 2019, Collings operated a Boeing B-17G (registration number N93012, serial number 32264) under Exemption 6540P in Windsor Locks, Connecticut, during which it undertook an emergency landing and crashed, causing a fire and resulting in fatal injuries to five passengers and two crewmembers onboard the aircraft.2 Findings from the accident investigation establish that 13 persons were onboard the aircraft at the time of the accident. No seat with a seatbelt on the aircraft existed for the Collings Foundation Crew Chief.“

The Director of Maintenance for the Collings Foundation was the None-O-Nine’s chief pilot. He was the highest time B-17 pilot ever. He had flown this airplane thousands of hours. He directed all the maintenance. However, over time, he began to fly this airplane with known problems. He began to falsify the maintenance documents lying by omission. These magneto, ignition, cylinder and plug problems had grown to a point that on the morning of the accident flight, they had considerable difficulty in getting one of the engines to start. The Director of Maintenance attributed that to wet magnetos and shut down the running engines, using external compressed air pointed at the wet or damp magneto in an attempt to dry it out for an eventual successful engine start. These magnetos are designed to run in the worst of rains. More evidence that the performance of the ignition system was so compromised, starting the engines in high humidity was problematic. One of the now deceased passengers had concerns about safety with the first failed attempt to start the engine but was assured by a mechanic that once the engine starts, it will be fine. Even with that amount of difficulty getting the engine to start, which was another warning sign of a faulty ignition system, after they managed to get it started, they still decided to fly with a multitude of known and documented issues. We don’t know if nor how much power these engines were making at take-off. Enough for the take off but shortly after take off they requested a return to the airport. Up to this time, the pilot/DOM had overcome and handled every previous in flight maintenance related problem.

Since he was not only the chief pilot and the Director of Maintenance, with a decades long record of accident free, successful flying with paying passengers, no one questioned his integrity nor his decision-making skills. His record up to this time was virtually unblemished. The Collings Foundation has had a reputation for rebuilding, restoring, and maintaining warbirds winning many awards for their efforts. And their Director of Maintenance was the highest time, most experienced B-17 pilot in the world. They have been audited in accordance with all FAA guidelines regularly meeting or exceeding all of the standards. All of that confidence proved to be ill-placed. There are reasons for checks and balances specifically for this kind of deteriorating judgement.

I was extremely shocked at these new revelations uncovered by the FAA since Collings last review. I was one of the 1500 comments made by individuals requesting the FAA to allow the Collings Foundation to keep their LHFE adding another aircraft ( B-25) to be flown carrying paying passengers as they finished a restoration on a replacement B-17.

“As noted in the previous section regarding rescission of Exemption No. 6540P, the FAA has determined through ongoing investigation that Collings has not been operating in compliance with the conditions and limitations of the 6540P exemption issued to Collings. In addition, the FAA continues to gather facts that indicate Collings lacked a commitment to safety, insofar as Collings did not take seriously its safety management system program. Based on the totality of facts the FAA has gathered, granting an extension to Collings’s current authority to operate and permitting Collings to add an aircraft to its exemption would adversely affect safety.”

At this point, we don’t know if the FAA found other shortcomings in the remaining Collings Foundation fleet of restored warbirds. I want to think no. I am hoping this lack of integrity regarding falsification of maintenance records, lack of maintenance, and shoddy maintenance when performed was isolated to the B-17 Nine-O-Nine and it’s Director of Maintenance/chief pilot. Hopefully, if any and all shortcomings can be corrected, the FAA can consider returning the LHFE to Collings. .

We will never know what was going through the DOM’s mind nor his motives to do what he did. Unfortunately, this behavior continued because a lack of checks and balances in place to question the DOM’s position, authority, responsibilities, and evaluate his decision-making skills. This behavior was long term and methodical indicating that he was confident he could deal with any issue that might arise, giving him an increasing false sense of confidence. Sadly, it appears to this writer that he was also confident he would not be caught further increasing the bravado.

Time will tell. The NTSB ‘s final cause report will reveal more information as well. But sadly, this was a case of “The Monkey Guarding the Bananas” with no internal interest questioning or evaluation of the DOM’s overall performance. Most likely due because of the long term safety record of Nine-O-Nine, his high time in the airplane, his position as DOM, with ultimately Collings Foundation’s placing what appears to be blind trust in his abilities and integrity.

However, the Collings Foundation, the families of the victims, the Living History Flight Exemption program, and general aviation as whole is paying an enormous price for those failures and misplaced trust. As with most accidents, there is a long chain of small events, that when linked together, makes what was for a time, problems but with manageable outcomes. Unfortunately, there is a saturation point where adding one more variable turns the formerly manageable into lethal. The culture that allowed this behavior to continue unchecked, is what the FAA has determined to be dangerous to public safety. That is where the beginning of the accident chain started.

So far, no comments or response from the Collings Foundation. In addition, the NTSB is still several months, if not for another year, away from issuing a final cause for this crash. This writer sadly agrees with the FAA. The Collings Foundation internal maintenance culture has got to change to include strict adherence to establish rules and procedures very clearly delineated in the Living History Flight Exemption program before being allowed flying warbirds with paying passengers again.