FAA report on Collings B-17 crash

[II/JG17_HerrMurf]

It seems the Collings Foundation lost it's B-17 today. No reports on injuries yet. Terrible terrible loss. Hoping it was only the aircraft as it is used for tour rides.

 

https://www.nytimes.com/2019/10/02/nyregion/plane-crash.html

 

Update: Landing accident, not take off or airborne. Six injured.

 

https://people.com/human-interest/vintage-wwii-plane-crash-bradley-airport-connecticut/

Edited October 2, 2019 by II/JG17_HerrMurf

[Sharpe43]

there's something in off topic on this as well.

[Jason_Williams]

Damn it. A great loss for sure! Looks like people got hurt unfortunately.

 

Jason

[Motherbrain]

I'm really sad to see this. I got to ride Aluminum Overcast for free when I volunteered for my EAA chapter a few years back.

 

Hopefully no fatalities. 

 

[II/JG17_HerrMurf]

Aboard a couple of years ago.

[VBF-12_Stick-95]

Sad.  Fatalities reported.

 

Quote

Windsor Locks first selectman Chris Kervick confirmed that 13 people in all were aboard the plane. Three were crew members and 10 were passengers.

 

Troopers reported that some of the victims were injured beyond recognition.

Six were transported to hospitals.

 

I caught the breaking news of the crash showing the burning plane but did not realize it was 909.

 

https://www.wfsb.com/news/b--wwii-plane-crash-at-bradley-airport-was-deadly/article_d514bd24-e51d-11e9-b6ac-47e02ec67428.html

 

I flew on her a while ago.

 

Edited October 2, 2019 by VBF-12_Stick-95

[EAF19_Marsh]

Crap ?

[Sokol1]

Looks that someone party...

 

https://forum.il2sturmovik.com/topic/54168-congratulations-your-flight-has-been-booked/

 

Edited October 2, 2019 by Sokol1

[Jade_Monkey]

This is so sad. I was about to go on a ride two years ago when they came not too far from my house, and i was waiting to see the next time they came over to give it a shot.

[EAF19_Marsh]

Looks like a total loss. Heart goes out to the injured and their families.

[69th_chuter]

It looks like it may have taken off of 33 and perhaps have immediately attempted a 270° left hand turn for 6.  Where it rests is about 100° to the right and in line from the end of 6 as if it couldn't complete the turn.  Could it have been miss-fueled?  I've spent decades maintaining aircraft (including at times a couple of B-17s) and these tragedies are hard on me ... they just shouldn't happen. 

[Deacon352nd]

There are 5 dead at the present time.  Took a ride on the plane 7 years ago and just two weeks ago I toured it along with 4 others from the Collins foundation when they were at a local airfield.  I spend time talking to the co-pilot and he informed me that the pilot had more than 7000 hours flying this plane.  With that amount of experience, I can't believe it's pilot error.  There was definitely mechanical problem that forced a return to the airfield.  The only thing left is the tail/rudder and the elevator sections of the plane.

[danielprates]

CNN mentions some tidbits of radio comms between them and the tower. It seems they had some engine issue soon after takeoff, tries to return but couldn't.

Edited October 2, 2019 by danielprates

[II./SG.1-MarkWilhelmsson]

This sags. Does anyone know if our fellow simmer who was allegedly onboard made it out ok?

[PatrickAWlson]

Latest is seven dead, three critical, three with lesser injuries.  Sucks.

[TheSNAFU]

So sorry this happened. Everyone and everything is irreplaceable. 

[von_Michelstamm]

Wow, no one left uninjured, half dead and “difficult to identify”... almost nothing left of the plane and lots of fire... this sounds nearly as bad as could be imagined, maybe worse for some...

Edited October 2, 2019 by von_Michelstamm

[Stoopy]

Absolute shame and my heart goes out to the families of those involved.

 

Strange coincidence, this was the desktop pic on my computer when I got home (set to change randomly every day out of over 300 images)....this is the plane, confirmed by looking at the news footage.

 

 

[Rjel]

I thought this was well written. 

 

https://www.planeandpilotmag.com/going-direct-how-people-are-talking-about-the-b-17-crash-at-bradley-airport/amp/

 

[CIA_Yankee_]

I had the privilege of walking (well, crawling) through Nine-O-Nine exactly a year ago, when the Collins Foundation set up a small fly-in exposition at BTV (Burlington Vermont). It was an amazing piece of history, and getting to just see it was quite impressive.

 

It's loss, not to mention those of the crew and passengers, is terrible indeed. 

[1./KG4_Blackwolf]

I got to crawl thought the 909 back in 94 with my 4 year old daughter at an airshow here in VA. I got to meet the pilots and crew. Such a sad loss.

 

[II/JG17_HerrMurf]

It is a tragedy on so many levels.

[-332FG-Gordon200]

Here is the preliminary National Transportation Safety Board investigation report.

Engine failure of #3 and 4.

https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20191002X11326&AKey=1&RType=Prelim&IType=MA

[II/JG17_HerrMurf]

Between the audio and the report it appears they had a partial or full failure of number 4. I think it's way too early to draw conclusions about number 3 yet.

[LukeFF]

Not good news at all regarding Collings and the maintenance of the B-17: https://www.courant.com/news/connecticut/hc-news-faa-says-collings-foundation-cannot-carry-passengers-20200325-twq2alj7i5gztllf6h4p22mjyi-story.html?outputType=amp

[Art-J]

^ Site cannot be opened in Europe. Anything interesting in the article apart from what we can see in the link header? Did they get ban on any passenger carrying no matter what aircraft they use?

[ZachariasX]

This is terrible news indeed. Actually the worst imaginable. Today, there are hardly any folks left experienced with certifying those vintage aircraft. This means all the youngsters that fill the ranks at the FAA (or the BAZL over here) can only do one thing: check whether the plane matches vintage specification exactly or if there are discrepancies. This means, if you replace an item with a better version, that item is a deviation that could void the formal airworthiness of the aircraft. As one is required to replace most parts over the decades, it becomes increasingly hard to maintain an aircraft both exactly to original specification as well as for safe operation.

 

The only "experts" that we are left with are the ones operating the respective aircraft. FAA has to believe their word. If those are caught cheating, you're left with nothing. As I mentioned before in the Ju-52 thread, the main problem in getting those up again is finding someone signing off on the restored aircraft. Why should any youngster risk his career cutting a reastored aircraft some slack and signing it off? If there is a crash, the buck stops with that chairbone. Engine mods to ensure safe operation (like in Bücker, Fiesler Storch etc., you don't want an Argus or Hirth engines if you actually plan to fly those birds) will render an aircraft not safer, but grounded.

 

Back then, those aircraft were really throw away items. If something felt fishy, just generously replace everything of that. Nobody had to pay for those items, they just used what they were given. Not a problem of how much a mag costs, just a problem of "do I have a spare mag in my shelf?". Today, we have to preserve even the cheapest then makeshift products that in effect ensure a terrible maintenance ration. Fixing things to get decent maintenance and thus getting a somewhat decent uptime (that would allow for some sporadic operation) just turned into a risk for grounding the aircraft. In cars, you can replace a cheap 1960's Holley carb (just stamp pressed tin or whatever, over the years things bend and there's nothng you can do anymore) with a new build of that with high quality parts. A Holley made right.

 

Vintage aircraft have terrible operating costs. The idea that you can make a living with passenger flights has to go. If you require $5'000 for an hour with an oridinary Mustang, then $20'000 would be below the minimum for a B-17. If they have 5 passengers paying $500 each, you get $2'500 per flight. This pays the oil and gasoline for that flight. But no more. The less spares you have and the less people there are, capable of properly servicing that aircraft, the more this cost is to rise. Until today, those vintage aviators could operate like normal airlines. But I guess time has come that there will be change.

 

2 minutes ago, Art-J said:

^ Site cannot be opened in Europe. Anything interesting in the article apart from what we can see in the link header? Did they get ban on any passenger carrying no matter what aircraft they use?

 

Spoiler

 

Connecticut

FAA says owner of World War II bomber involved in deadly Bradley crash did not take safety seriously and can no longer carry passengers

By David Owens

Hartford Courant |

Mar 25, 2020 | 7:46 PM

 

 

 

In this Oct. 3, 2019, image taken from video released by National Transportation Safety Board, the wreckage of a World War II B-17 bomber plane that crashed remains on the tarmac at Bradley International Airport in Windsor Locks. The plane crashed and burned after experiencing mechanical trouble on takeoff. (NTSB via AP)(AP)

 

The Federal Aviation Administration, citing safety concerns, has revoked the Collings Foundation’s permission to carry passengers aboard its historic aircraft, one of which crashed and burned at Bradley International Airport in October, killing seven.

The World War II B-17G bomber Nine O Nine developed engine trouble shortly after takeoff from Bradley on Oct. 2 and crashed as the pilot tried to nurse the crippled aircraft back to the airport. Five passengers who paid $450 each to fly aboard the historic aircraft, the pilot and the co-pilot were killed in the resulting crash and fire.

Four passengers and the flight’s crew chief survived, although some suffered serious burns.

NTSB releases preliminary report about crash of B-17 at Bradley International Airport »

In a decision released Wednesday, Robert C. Carty, the FAA’s deputy executive director of flight service standards, found that there were problems with two of the aircraft’s four engines and that the Collings Foundation did not follow the requirements of its permission to operate the aircraft and carry passengers and “lacked a safety culture when operating the B-17G.”

Collings spokesman Hunter Chaney did not respond to an email request for comment Wednesday evening.

Collings, of Stow, Massachusetts, has operated a variety of historic aircraft for three decades and toured the country with what it called its “Wings of Freedom" tour. It has made dozens of stops in Connecticut over the years, including the stop at Bradley in the fall. The organization brought five World War II aircraft, including the B-17, a B-24J Liberator bomber, a P-51 Mustang fighter, a P-40 Warhawk fighter and a B-25 Mitchell bomber on Sept. 30 for several days of ground tours and morning and evening flights aboard the B-17 and B-24. Collings charged $450 for “living history flight experiences” on its bombers.

 

Historic plane flights grounded while investigation continues into deadly B-17 bomber crash at Bradley International Airport »

The FAA decision revokes the permission Collings had obtained to offer flights for pay, and denies the organization’s request to extend that permission for the 10 aircraft it owns, including a B-17 it obtained to replace the one that crashed at Bradley.

Less than two weeks after the crash at Bradley, the Collings Foundation appealed to its supporters to voice their support for its application to the FAA to be able to continue to carry passengers on its aircraft.

The permission Collings operated under required it to comply with specific conditions, and the FAA found that it “was not fulfilling several requirements” or satisfying its policy of maintaining “a culture of safety.”

The crew chief aboard the flight that crashed had not been trained for his role and told FAA investigators he was “unaware of basic information concerning operations.” Instead, he received on-the-job training, according to the decision.

Ernest “Mac” McCauley, a veteran pilot who volunteers with the Collings Foundation, is shown in July working on one of the engines of the Collings Foundation B-17G Flying Fortress bomber at Spokane International Airport. The aircraft, with McCauley in the pilot's seat, crashed at Bradley International Airport in October, killing seven and injuring seven.(Jesse Tinsley / The Spokesman-Review)

Collings did not comply with its own “safety management system," the crew chief was not aware a safety and risk management program existed and Collings “failed to maintain and apply on a continuous basis a safety and risk management program that met or exceeded ... FAA policy."

The FAA also found “notable maintenance discrepancies existed with the B-17G, yet the Collings director of maintenance signed inspection records — dated as recently as Sept. 23, 2019 — indicating no findings of discrepancies.” Collings’ maintenance director was Ernest McCauley, 75, who was the chief pilot the day of the crash.

“Collings did not have a structure to ensure adequate oversight of his decisions to conduct passenger-carrying operations such as the October 2 flight," the FAA decision reads. “This indicates Collings lacked a safety culture when operating the B-17G.”

NTSB investigating whether B-17 that crashed at Bradley International Airport Wednesday had engine trouble prior to takeoff »

An inspection of the bomber’s engines found problems significant enough to cause the FAA to question “whether the engines were inspected adequately and in accordance with the applicable maintenance requirements.”

Specifically, the inspection found that magneto and ignition failures existed in the aircraft’s No. 4 engine. Magnetos, engine-driven electrical generators that produce voltage to fire the engine’s spark plugs, were not functioning properly. An attempt to jury rig one had left it inoperative, according to the report. A second magneto on the No. 4 engine, when tested, produced a weak or no spark to four of the nine cylinders it was supposed to fire.

Inspectors also found that all spark plugs required cleaning and that all of the electrode gaps were out of tolerance. Further engine inspection “indicated signs of detonation and associated damage," the decision reads.

Owner of B-17 that crashed at Bradley asks public for help in renewing FAA exemption allowing it to charge for flights on historic aircraft »

An inspection of the No. 3 engine showed “all spark plug electrode gaps were out of tolerance, fouled, and revealed various signs of detonation." Inspection of the engine also revealed problems with the cylinders, according to the report.

“As a result of these findings and other information, the FAA questions whether the engines were inspected adequately and in accordance with the applicable maintenance requirements,” the decision reads.

On the day of the crash, the flight crew radioed the Bradley tower that it needed to return to the airport, according to a National Transportation Safety Board preliminary report issued about two weeks after the crash.

 

 

Edited March 27, 2020 by ZachariasX

[Art-J]

Thanks for the quote, Zack. Bad news, but if there was some fishy signing off involved on those engines, that's the only possible outcome. How it impacts other operators and restorers, however, the way they'll be trusted and treated by FAA, is a mistery indeed.

[ZachariasX]

I see a clear trait in some of those old war horses that grew up in biplanes and made their career during the golden age of aviation. This is that they are extremely certain of themselves. They lived through a long career of of just doing things and it always worked 'cos they are great pilots. And if something happens a death on an aircraft in old age is acceptable. Not that they would put it that way officially, but just having them to get chutes installed for vintage aircraft they do some aerobatics with clearly tells you the state of things.

 

Also, If you did something for 50 years and always got away with creates a tremedous insensibility to actute danger. Just days before they crashed that Ju-52 HB-HOT, they crossed the Alps in a way that made everyone in the cabin lift their buts to make it over the ridge. "It always worked, you know?" "He he". These were the same pilots that ran out of air under them later on with HB-HOT.

 

Those Ju-52 pilots are selected, you cannot apply yourself. You are asked. Yet the circle of old war horses i see to be somewhat permissive to such behavior. These are former military pilots, airline captains and instructors, thes of thousands hours of flight time. Yet they fly sometimes in a rather irresponsible way. I remember one of those recounting when he got lost in a Vampire Jet in bad weather in the good old days. In a hilly area, he dropped below the cloud layer to read the road signs! And made it back insead of invading France. "Ha ha. Ha."

[Bremspropeller]

Sky Gods and the Normalisation of Deviance.

 

1 hour ago, ZachariasX said:

I remember one of those recounting when he got lost in a Vampire Jet in bad weather in the good old days. In a hilly area, he dropped below the cloud layer to read the road signs! And made it back insead of invading France. "Ha ha. Ha."

 

Reminds me of a friend's grandpa, who flew 190s in Goering's Luftwaffe.

When they had a solid undercast, he'd spin (!) through it and resume own navigation when below. Seems like he always managed to find a valley by dumb luck...

[ZachariasX]

12 minutes ago, Bremspropeller said:

Seems like he always managed to find a valley by dumb luck...

And one evening, Klaus Holighaus found a mountain ridge.

 

Edit: I think that guy spun his 190 where really no hills were expected. You can influence your hand. But still... Spin is actually safer than a dive, as you do know the attitude where you will leave the clouds. It is very easy to get into a spiral dive in a cloud. If you exit nose straight down and there's 600 m left, it will be interesting. I'd much rather stop a spin than that.

Edited March 27, 2020 by ZachariasX

[Bremspropeller]

10 minutes ago, ZachariasX said:

And one evening, Klaus Holighaus found a mountain ridge.

 

So did my Aerodynamics prof in the French Alps in his Ventus 2...

 

10 minutes ago, ZachariasX said:

Edit: I think that guy spun his 190 where really no hills were expected. You can influence your hand. But still... Spin is actually safer than a dive, as you do know the attitude where you will leave the clouds. It is very easy to get into a spiral dive in a cloud. If you exit nose straight down and there's 600 m left, it will be interesting. I'd much rather stop a spin than that.

 

As far as the story goes, he "knew" he was above hilly terrain..

But it might all be down to "Fliegerlatein" and only half the story is actually true.

Edited March 27, 2020 by Bremspropeller

[RedKestrel]

4 hours ago, ZachariasX said:

This is terrible news indeed. Actually the worst imaginable. Today, there are hardly any folks left experienced with certifying those vintage aircraft. This means all the youngsters that fill the ranks at the FAA (or the BAZL over here) can only do one thing: check whether the plane matches vintage specification exactly or if there are discrepancies. This means, if you replace an item with a better version, that item is a deviation that could void the formal airworthiness of the aircraft. As one is required to replace most parts over the decades, it becomes increasingly hard to maintain an aircraft both exactly to original specification as well as for safe operation.

 

The only "experts" that we are left with are the ones operating the respective aircraft. FAA has to believe their word. If those are caught cheating, you're left with nothing. As I mentioned before in the Ju-52 thread, the main problem in getting those up again is finding someone signing off on the restored aircraft. Why should any youngster risk his career cutting a reastored aircraft some slack and signing it off? If there is a crash, the buck stops with that chairbone. Engine mods to ensure safe operation (like in Bücker, Fiesler Storch etc., you don't want an Argus or Hirth engines if you actually plan to fly those birds) will render an aircraft not safer, but grounded.

 

Back then, those aircraft were really throw away items. If something felt fishy, just generously replace everything of that. Nobody had to pay for those items, they just used what they were given. Not a problem of how much a mag costs, just a problem of "do I have a spare mag in my shelf?". Today, we have to preserve even the cheapest then makeshift products that in effect ensure a terrible maintenance ration. Fixing things to get decent maintenance and thus getting a somewhat decent uptime (that would allow for some sporadic operation) just turned into a risk for grounding the aircraft. In cars, you can replace a cheap 1960's Holley carb (just stamp pressed tin or whatever, over the years things bend and there's nothng you can do anymore) with a new build of that with high quality parts. A Holley made right.

 

Vintage aircraft have terrible operating costs. The idea that you can make a living with passenger flights has to go. If you require $5'000 for an hour with an oridinary Mustang, then $20'000 would be below the minimum for a B-17. If they have 5 passengers paying $500 each, you get $2'500 per flight. This pays the oil and gasoline for that flight. But no more. The less spares you have and the less people there are, capable of properly servicing that aircraft, the more this cost is to rise. Until today, those vintage aviators could operate like normal airlines. But I guess time has come that there will be change.

 

 

  Reveal hidden contents

 

Connecticut

FAA says owner of World War II bomber involved in deadly Bradley crash did not take safety seriously and can no longer carry passengers

By David Owens

Hartford Courant |

Mar 25, 2020 | 7:46 PM

 

 

 

In this Oct. 3, 2019, image taken from video released by National Transportation Safety Board, the wreckage of a World War II B-17 bomber plane that crashed remains on the tarmac at Bradley International Airport in Windsor Locks. The plane crashed and burned after experiencing mechanical trouble on takeoff. (NTSB via AP)(AP)

 

The Federal Aviation Administration, citing safety concerns, has revoked the Collings Foundation’s permission to carry passengers aboard its historic aircraft, one of which crashed and burned at Bradley International Airport in October, killing seven.

The World War II B-17G bomber Nine O Nine developed engine trouble shortly after takeoff from Bradley on Oct. 2 and crashed as the pilot tried to nurse the crippled aircraft back to the airport. Five passengers who paid $450 each to fly aboard the historic aircraft, the pilot and the co-pilot were killed in the resulting crash and fire.

Four passengers and the flight’s crew chief survived, although some suffered serious burns.

NTSB releases preliminary report about crash of B-17 at Bradley International Airport »

In a decision released Wednesday, Robert C. Carty, the FAA’s deputy executive director of flight service standards, found that there were problems with two of the aircraft’s four engines and that the Collings Foundation did not follow the requirements of its permission to operate the aircraft and carry passengers and “lacked a safety culture when operating the B-17G.”

Collings spokesman Hunter Chaney did not respond to an email request for comment Wednesday evening.

Collings, of Stow, Massachusetts, has operated a variety of historic aircraft for three decades and toured the country with what it called its “Wings of Freedom" tour. It has made dozens of stops in Connecticut over the years, including the stop at Bradley in the fall. The organization brought five World War II aircraft, including the B-17, a B-24J Liberator bomber, a P-51 Mustang fighter, a P-40 Warhawk fighter and a B-25 Mitchell bomber on Sept. 30 for several days of ground tours and morning and evening flights aboard the B-17 and B-24. Collings charged $450 for “living history flight experiences” on its bombers.

 

Historic plane flights grounded while investigation continues into deadly B-17 bomber crash at Bradley International Airport »

The FAA decision revokes the permission Collings had obtained to offer flights for pay, and denies the organization’s request to extend that permission for the 10 aircraft it owns, including a B-17 it obtained to replace the one that crashed at Bradley.

Less than two weeks after the crash at Bradley, the Collings Foundation appealed to its supporters to voice their support for its application to the FAA to be able to continue to carry passengers on its aircraft.

The permission Collings operated under required it to comply with specific conditions, and the FAA found that it “was not fulfilling several requirements” or satisfying its policy of maintaining “a culture of safety.”

The crew chief aboard the flight that crashed had not been trained for his role and told FAA investigators he was “unaware of basic information concerning operations.” Instead, he received on-the-job training, according to the decision.

Ernest “Mac” McCauley, a veteran pilot who volunteers with the Collings Foundation, is shown in July working on one of the engines of the Collings Foundation B-17G Flying Fortress bomber at Spokane International Airport. The aircraft, with McCauley in the pilot's seat, crashed at Bradley International Airport in October, killing seven and injuring seven.(Jesse Tinsley / The Spokesman-Review)

Collings did not comply with its own “safety management system," the crew chief was not aware a safety and risk management program existed and Collings “failed to maintain and apply on a continuous basis a safety and risk management program that met or exceeded ... FAA policy."

The FAA also found “notable maintenance discrepancies existed with the B-17G, yet the Collings director of maintenance signed inspection records — dated as recently as Sept. 23, 2019 — indicating no findings of discrepancies.” Collings’ maintenance director was Ernest McCauley, 75, who was the chief pilot the day of the crash.

“Collings did not have a structure to ensure adequate oversight of his decisions to conduct passenger-carrying operations such as the October 2 flight," the FAA decision reads. “This indicates Collings lacked a safety culture when operating the B-17G.”

NTSB investigating whether B-17 that crashed at Bradley International Airport Wednesday had engine trouble prior to takeoff »

An inspection of the bomber’s engines found problems significant enough to cause the FAA to question “whether the engines were inspected adequately and in accordance with the applicable maintenance requirements.”

Specifically, the inspection found that magneto and ignition failures existed in the aircraft’s No. 4 engine. Magnetos, engine-driven electrical generators that produce voltage to fire the engine’s spark plugs, were not functioning properly. An attempt to jury rig one had left it inoperative, according to the report. A second magneto on the No. 4 engine, when tested, produced a weak or no spark to four of the nine cylinders it was supposed to fire.

Inspectors also found that all spark plugs required cleaning and that all of the electrode gaps were out of tolerance. Further engine inspection “indicated signs of detonation and associated damage," the decision reads.

Owner of B-17 that crashed at Bradley asks public for help in renewing FAA exemption allowing it to charge for flights on historic aircraft »

An inspection of the No. 3 engine showed “all spark plug electrode gaps were out of tolerance, fouled, and revealed various signs of detonation." Inspection of the engine also revealed problems with the cylinders, according to the report.

“As a result of these findings and other information, the FAA questions whether the engines were inspected adequately and in accordance with the applicable maintenance requirements,” the decision reads.

On the day of the crash, the flight crew radioed the Bradley tower that it needed to return to the airport, according to a National Transportation Safety Board preliminary report issued about two weeks after the crash.

 

 

This quote stands out to me:

"An inspection of the No. 3 engine showed “all spark plug electrode gaps were out of tolerance, fouled, and revealed various signs of detonation." Inspection of the engine also revealed problems with the cylinders, according to the report.

“As a result of these findings and other information, the FAA questions whether the engines were inspected adequately and in accordance with the applicable maintenance requirements,” the decision reads."

I'm not an expert but this honestly looks to be a rather egregious failure of routine maintenance and operation of the engines. There's nothing so special about these engines that means you have to fly with fouled spark plugs, or improper electrode gaps, or damage from detonation. This would have caused a problem in 1944 too. It turns it from a tragedy to outright negligence. 

You are right that these planes were not built to fly forever, and that's something that even I myself didn't really grasp until a little while back. A lot of people assume that everything that is old was made better, tougher, and to last longer. But they were building these planes expecting them to last for a limited number of combat missions. There was no point in making 1 plane perfect when it was likely to get destroyed within a dozen missions, when you could make 2 planes adequately and have them last the exact same amount of time. The lay person does not understand what it means that these planes were made during a wartime emergency and the grim mathematics of attrition never calculated for people taking them for joyrides 70 years later. The people getting on that plane may have assured themselves that this was a rugged, dependable machine from America's golden age of heavy industry, that they were safer on that plane than on an airliner.
 

3 hours ago, ZachariasX said:

I see a clear trait in some of those old war horses that grew up in biplanes and made their career during the golden age of aviation. This is that they are extremely certain of themselves. They lived through a long career of of just doing things and it always worked 'cos they are great pilots. And if something happens a death on an aircraft in old age is acceptable. Not that they would put it that way officially, but just having them to get chutes installed for vintage aircraft they do some aerobatics with clearly tells you the state of things.

 

Also, If you did something for 50 years and always got away with creates a tremedous insensibility to actute danger. Just days before they crashed that Ju-52 HB-HOT, they crossed the Alps in a way that made everyone in the cabin lift their buts to make it over the ridge. "It always worked, you know?" "He he". These were the same pilots that ran out of air under them later on with HB-HOT.

 

Those Ju-52 pilots are selected, you cannot apply yourself. You are asked. Yet the circle of old war horses i see to be somewhat permissive to such behavior. These are former military pilots, airline captains and instructors, thes of thousands hours of flight time. Yet they fly sometimes in a rather irresponsible way. I remember one of those recounting when he got lost in a Vampire Jet in bad weather in the good old days. In a hilly area, he dropped below the cloud layer to read the road signs! And made it back insead of invading France. "Ha ha. Ha."

There is a similar undercurrent of this in nearly every industry that involves some kind of dangerous or risky work, but some professions seem to attract a larger share of these individuals. Everyone knows that old electrician who works on live equipment without safety precautions and has been shocked a hundred times but its never killed him yet, or the guy who works in dusty environment without a ventilator because he breathes just fine. It's the deadliest sort of confirmation bias. I think you see this more in risky jobs, especially glamorous ones, because the people who fully understand the risk are less likely to even do that job. You get a higher proportion of cavalier people in the industry, and if they are lucky they will do it for 40 years or more and unfortunately train countless other risk-takers to do the same thing. Young people (let's be real, especially guys) who are new in a trade or job are extremely vulnerable to the macho BS that these guys dispense. They don't have the experience to know the danger and they fear ridicule more than mortality.

As an aside, I know it's not just guys - I know one 'country girl' who openly ridiculed me for suggesting that one should wear a visor, hardhat and chainsaw chaps when operating a chainsaw to fell trees. She called me something I don't like to repeat on a forum and asserted that she just wore a t-shirt and shorts when felling trees and bucking logs. She also had scars on her legs where she'd been laid open by her chain saw more than once. But it was good enough for her grandfather, who taught her the best way to use a chainsaw (i.e. like a moron). 

(Its worth noting that the incident that inspired this conversation was a discussion of how her grandfather was currently in the hospital after a chainsaw accident, where he nearly bled out alone in the woods, if not for her dad being nearby and rushing him to the hospital. )

I couldn't even take the insult personally really - I just laughed, it was absurd to realize that nothing could be said and nothing could happen to these people that would convince them to take absolutely minimal, low-cost safety precautions. They were more concerned with looking tough to their friends.  One of these days one of them are going to die or lose a limb, and everyone in their social circle will tell themselves it was an unavoidable tragedy (I have seen this exact same thing happen). No one will say the obvious - that it was a simple matter of dumb stubbornness and carelessness in the face of a completely predictable incident.

It really saddens me to say, but I think the vintage aircraft community has to do some real soul searching on how, when, and if the foundations operating these planes should be offering passenger rides, and even if the planes should be in the air at all. As you've pointed out there's no real way to economically operate these aircraft at the rates they're charging. There's an incentive to cheap out, there's a possible subset of their people who are cavalier when it comes to maintenance and safety, and the general public and even modern aviation professionals have very little knowledge of how these planes need to be operated and maintained. 

[ZachariasX]

13 minutes ago, RedKestrel said:

I'm not an expert but this honestly looks to be a rather egregious failure of routine maintenance and operation of the engines.

I would agree on that in principle. Then again, i would not put any blame on the people operating the aircraft. I am absolutely sure that they did (to the best of their knowledge) their very best to ensure safe operation.

 

But vintage mechanics is a can of worms. Literally. For instance with my vintage US car. It turned 50 a while ago. I am not cheap with that one, almost every year I bring it in to the shop with the instructions "Do EVERYTHING!" in order to have a remotely safe drive in today’s traffic. Yet, there are instances when suddenly you find things totally broken. You drive and your car jingles. The harmonic damper was about to come off (it is a heavy steel disc on the crankshaft with a middle section made of rubber damping the inner and the outer metal sections). Yeah, one fine day, nobody knows when, it will come apart. Not gradually. But in one hour. The joints in the axle... They are fine... until one day when they all come apart at once seemingly.

 

The point of this is, that you ALWAYS have a surprise element, as you are far outside ANY maintenance schedule and you have to decide yourself what you will exchange. Not repair. Exchange. If the harmonic damper loosens on a big block engine, then you know you have to exchange the whole front section of the engine. All connected to V-belts preferably as well as opening everything to get the damper removes those parts anyway. This means these aircraft that share such antics are always just "one little thing happening" away from being a total write off.

 

Because they all have peculiarities, one can also be adjusted to things not always working fine. A friend of mine was driving his Aston DB6 on 5 cylinders for two years and he didn't notice. If you think he's an idiot for not noticing, then I have to tell you to be strong now becuause this kind of car has a certain intrinsic Englishness that clearly put noticing one cylinder not firing low on the list.

 

I really think there must be some drastic change in operating these aircraft. A sea change. Really. There must be procedures in place that ensure basic maintenance if you want to endanger anyone but yourself. As long as you have your warranty card, you can tick those points. But after decades go by, this manual expires and what you actually do with the airframe becomes far more important.

 

The Ju-52's are currently undergoing total rebuild. Initially, they knew that the wing spar of the newest CASA built one was a bit rusty and decommissioned that aircraft and put it up for static display. They told themselves "Ha, Spanish crap. The German Junkers ones are certainly ok. We needn't check (as we are afraid to find out)!" Then HB-HOT crashed. Everything had to be put under the microscope. All wing spars were fund with corrosion besides some other, I'd consider minor stuff. Besides other parts, they now get new spars. Thank God, someone sells enough luggage cases to finance that. Once a plane is riveted together, it is hard to assess what is REALLY inside. Drilling out the rivets will effectively destroy the aircraft and all you can have is a rebuild.

 

The problem with that is that you are effectively destroying the original aircraft and what you build is in a certain sense a replica. New rivets, new wires, a lot of new skin, rebuilt engine, new propeller... etc. At some point you have to ask yourself whether it is not better just making a copy and decommission the whole "original". With cars, as long as frame and engine block numbers match, you can play a lot with restoring. But with planes... at some point you will have exchanged EVERYTHING and then that aircraft has de facto nothing in common anymore with the original. Maybe the seats or some flooring. It will be new otherwise, a copy of itself in itself.

Just taping what comes apart can only work for some time, and then the poor man’s way of flying them is at an end. Until maybe 20 years ago, the plain substance of these aircraft was good enough to hold together. However, these days, the problems are getting deeper and there is a point where not even duct tape can mend an aircraft. It is important that we cannot allow the old war horses to miss this moment, when in fact serious work is required, likely serious enough to preclude further operation as it ws done before.

 

We need a new plan for having them in the air.

 

[Bremspropeller]

The topic concerning the psychology is several PhDs on their own, so I think we won't need to discuss it further.

 

The part about old mechanical things isn't all that hard. Let's be honest: Those old aircraft, cars and whatever equipment you're talking about are deathtraps by today's standards.

They're not around today because they're extremely tough, strong or well-built*, but because somebody was willing to pay the ca$h for it.

 

Those airplanes are mostly not supported by any OEM, their parts are either old ones from a scrapyard or newly-built ones. Kind of up to spec and mostly hand-made (costly, so you might want to fly them longer than reasonable).

 

There are less than optimal maintenance-instructions on those airplanes, motors and components. They haven't been updated for the better part of a century and the maintenance-program leaves a lot to be desired. Those airplanes were designed when fatigue-life wasn't even a thing. Corrosion - what's that?

 

What kind of reasonable Safety Management System can be there under those circumstances?

______

*They were hammered together by the lowest bidder and any excees-strength was down to guesswork by the engineering-department.

Edited March 27, 2020 by Bremspropeller

[RedKestrel]

1 hour ago, ZachariasX said:

I would agree on that in principle. Then again, i would not put any blame on the people operating the aircraft. I am absolutely sure that they did (to the best of their knowledge) their very best to ensure safe operation.

 

I understand where you're coming from, and I agree in general especially regarding vintage planes and cars, but I'm not sure that this was the case here. Having now read the actual report from the FAA some parts  are pretty damning. I understand the reluctance to assign blame in a situation like this, especially when some of the people involved in the maintenance program were on board and died in the crash. But it really does look like a case of negligence at at least some point in the chain - if not in the actual people maintaining the plane, then surely in the people whose job it was to make sure it operated safely.

For example, at the top of page 4 on the FAA report:

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. 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. As a result of these findings and other information, the FAA questions
whether the engines were inspected adequately and in accordance with the applicable
maintenance requirements.

Right there, just in the bolded part, we have someone who knew something was wrong with an engine and jury-rigged it to work, in such a way that it was likely to fail. It was not an unseen piece that failed silently or suddenly, it was a part that was inspected and then repaired improperly. Magneto trouble on the 4th engine is what the pilot reported as the problem that required returning to the airfield. It's not much of a stretch to say that this deficiency, along with the u/s right magneto, led directly to the crash. Basically only one functioning magneto  on that engine, and that one was quite literally tied on with wire. 

Engine 3 wasn't mentioned by the pilot in his distress call but was found to have been feathered by crash investigators, indicating the pilot thought it had failed or was failing. And we see that it too, had fouling of spark plugs, improper spacing of electrodes, and had signs of detonation. 

Maybe it was someone who was just doing their best and didn't know better, but the director of maintenance signed off that nothing was deviating from the requirements. None of the conclusions to be drawn from that are good ones. Did he sign off on inspections that were not done properly? Or did he sign off knowing this was wrong, and let the plane fly anyway? Or did he just not know enough about the engines to see that this was an issue that could lead to failure? 

Per the report, periodic audits and inspections just weren't done (or weren't recorded, which makes followups or training new people a nightmare), and required training was not done (the crew chief on the flight didn't even know some of the safety procedures existed, much less how they were to be applied.) 

Regardless, you're right about the sea change required. If we DO want to keep these things flying, we either have to commit to a lot more maintenance, a lot more work, and frankly higher costs for the public to ride on it. So much of the work for these organizations is done by volunteers. We have to consider if it is really possible to keep a plane like this in flying shape through volunteer labor. Not saying it isn't, but we need to have hard conversations about it.

In a plane this size  there is also no realistic way to limit risk to only one's self. If it comes down over a populated area or just crashes at an airport as happened here, many lives are at risk.

I think its an interesting point you raise about flying a replica vs. flying 'the real thing', and how much replacement is tolerable, especially when something is rare and historically important. It's basically the B-17G of Theseus. It's something I think about a lot as someone interested in history, particularly material culture. When you find an old tool with a worn handle and rust, do you replace the handle and grind it down, so it can be used again for its original purpose? Or do you simply treat the corrosion and put it in a museum with only the original parts, and make a replica as best you can? Is one more authentic than the other? Can you ever truly make an accurate replica? Is something special imparted to the original object and materials or is it the way it was made and used that's improtant?  

For a flyable plane, I personally would feel just as happy flying a replica plane as an original, as long as the plane flew and was operated nearly identically. The point for me is not necessarily to fly the real thing but to experience the feeling people had when they were operating the real thing. But this is an opinion, and surely many people would prize the original thing over other priorities.

 

51 minutes ago, Bremspropeller said:

The topic concerning the psychology is several PhDs on their own, so I think we won't need to discuss it further.

 

The part about old mechanical things isn't all that hard. Let's be honest: Those old aircraft, cars and whatever equipment you're talking about are deathtraps by today's standards.

They're not around today because they're extremely tough, strong or well-built*, but because somebody was willing to pay the ca$h for it.

 

Those airplanes are mostly not supported by any OEM, their parts are either old ones from a scrapyard or newly-built ones. Kind of up to spec and mostly hand-made (costly, so you might want to fly them longer than reasonable).

 

There are less than optimal maintenance-instructions on those airplanes, motors and components. They haven't been updated for the better part of a century and the maintenance-program leaves a lot to be desired. Those airplanes were designed when fatigue-life wasn't even a thing. Corrosion - what's that?

 

What kind of reasonable Safety Management System can be there under those circumstances?

______

*They were hammered together by the lowest bidder and any excees-strength was down to guesswork by the engineering-department.

Agreed on the psychology. The "why" is important but not really solvable on a flight sim forum. I do think that, as I mentioned above, we CAN solve the age-old ship of theseus conundrum. How hard can philosophy be, anyway? Even if we have to swap out some of the original forum posters for copies, it should still work - oh, wait. Hmm.

Regardless the "How" looks pretty apparent from the report - inadequate maintenance lead to an engine failure, possibly two, which caused the crash. 

All other matters aside, even if it is impossible to implement a reasonable safety management system, it's quite apparent that they weren't even using the one they had.You can build better standards all day but if people aren't following them its just words on paper. 
 

Edited March 27, 2020 by RedKestrel
EDIT, took out speculation on fouled plugs and detonation, mixed it up with preignition

[ZachariasX]

40 minutes ago, RedKestrel said:

but I'm not sure that this was the case here.

I quiet agree that in this case, there was a fatal blunder on the side of operating the aircraft. But in order to allow for such a blunder, one that actually kills the one responsible as well, it can only be happening if the conditions or prodedures are permissive. I don't feel going too much into detail about the actual errors here because I ceratinly lack info for a qualified judgement.

 

52 minutes ago, RedKestrel said:

someone had attempted to rig the magneto leads in place with safety wire.

This just indicates me that jury-rigging the mag was certainly not a first on this aircraft, but people did so before. I can't imagine some dude lucky enough to work the on such an aircraft just doing such and not telling anyone. His aircraft is broke, the only natural reaction would be to tell world and their dog and find a solution. If that solution is wrapping a wire around the problem, then we have a systemic problem, not a psychlogical one or just a broken mag. ("It always worked like that. Ha ha.")

 

We have gone great lenghts to make flying in new aircraft incredibly safe. A good way to operate the old ones efficiently is not commonly familiar, especially at an age where the understanding (not: knowledge) about them is dying out.

 

 

All I can point out is where in the general trends such behavior would fit and how they can be explained. I certainly agree with @Bremspropeller that the psychology per se is out of scope for me and certainly for this discussion. However, the ops side of things is not. When you are looking at any company and how they work, you will find mechanisms that are permissive for certain type of abuse leading to inefficiency.

 

This is basically what bugs me most about operating these maginifcent aircraft. You know, initially, those planes are new and you can't buy them. Then they are out of service and you can buy one. You find spares in the dump and all you need is duct tape and it flies. Nobody minds, 'cos at that time nobody really cared. Old is cheap. Two decades down the road, somobody cared, but you, the old punk, was left to do as you like because who should know better than you? Then another decade passes and now there are no more spares on the dump. You have to find someone who makes them for a lot of money. Then you start using parts longer. But by the grace uf duct tape, you keep her flying. Another decade down the road, you're patching duct tape on duct tape and realize you have a huge problem now. What to do? Selling to someone who owns an oil well? Or find some friends who are good with all things metal and have lots of time for free? At that point you have completely lost control of the inner state of your aircraft and you are flying her from failure to failure. Everything you did until now cannot save you anymore. With cars, they just get used towing you. No problem. But with aircraft...
 

[RedKestrel]

6 minutes ago, ZachariasX said:

 

This is basically what bugs me most about operating these maginifcent aircraft. You know, initially, those planes are new and you can't buy them. Then they are out of service and you can buy one. You find spares in the dump and all you need is duct tape and it flies. Nobody minds, 'cos at that time nobody really cared. Old is cheap. Two decades down the road, somobody cared, but you, the old punk, was left to do as you like because who should know better than you? Then another decade passes and now there are no more spares on the dump. You have to find someone who makes them for a lot of money. Then you start using parts longer. But by the grace uf duct tape, you keep her flying. Another decade down the road, you're patching duct tape on duct tape and realize you have a huge problem now. What to do? Selling to someone who owns an oil well? Or find some friends who are good with all things metal and have lots of time for free? At that point you have completely lost control of the inner state of your aircraft and you are flying her from failure to failure. Everything you did until now cannot save you anymore. With cars, they just get used towing you. No problem. But with aircraft...
 

Yeah, it's a combination of times changing (society is a lot more safety conscious now, which has its downsides too) and age catching up with the aircraft. At the confluence of that is a massive increase in costs and labor time to operate something - you have to take something that even brand new wouldn't have been safe enough for modern public use, and make it safe while its suffering from age, fatigue, and a lack of spares. Pretty well everyone who designed, built, maintained and flew these aircraft in the beginning have passed away, so it's slowly passing from 'vintage wings' to 'flying archaeology'.

[Bremspropeller]

7 hours ago, RedKestrel said:

All other matters aside, even if it is impossible to implement a reasonable safety management system, it's quite apparent that they weren't even using the one they had.You can build better standards all day but if people aren't following them its just words on paper.

 

You could. But I can assure you that unfortunately, what's written on paper and what's actually lived in operations may be a universe apart.

[ZachariasX]

6 hours ago, Bremspropeller said:

 

You could. But I can assure you that unfortunately, what's written on paper and what's actually lived in operations may be a universe apart.

Depends. You can enforce it. It has been done in several fields, drug production and medtech for instance. It was GxP guidelines were drafted after the industry was caught cheating and people died. Yes, there were tears. But they got used to it.

 

The only thing that happened over time is that this system now is also used to create its own new industry and the unnecessary overhead is tolerable as it serves as entry bar for new competition. Same happened to the banking industry after they were caught cheating and everyone but them lost money. They do live the new regime, especially since it doesn‘t serve its original purpose but acts as entry bar and is great for blame shifting.

 

Also, ops is led by the head of the company, not by the guidelines. Guidelines are just used to ensure verifiability. Now, you just have someone in charge signing off on things and all is well. But it says nothing about how work is done. Hence my comment about the „clean floor“. A signature don‘t mean squat. You should be able to prove the origin of any part and know how long it is supposed to last. At any time. With proper ops, you can know these things. But it takes some hurt for old hares to adjust to such. But done right, everyone is happy, as everything that is ever asked from a worker is easy to do, as it has a documented way of doing it. And the floor stays clean.