Collings Crash And Safety Culture - AVweb

News Discussion
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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.

This is a companion discussion topic for the original entry at https://www.avweb.com/insider/collings-crash-and-safety-culture
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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.

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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.

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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??

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Well, yea. It your planes go up in balls of flames and kill people, then your not “safe”. The FAA does not want people to die because of demonstrably bad operations. Duh!

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Whoosh… the sound of sarcasm moving well over your head…

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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.

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I like the idea of a waiver to make sure passengers are informed that these planes do not meet modern FAA standards before engaging in the ride. It would be a real shame if these rides are stopped permanently.

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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.

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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.

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I agree 100%. Why on earth did pilot who had thousands of hours on B17s think it was Ok to fly in a aircraft that only 2 good engines.

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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.

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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.

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

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And why did he eschew a 90-degree turn to runway 33, in favor of a 180-degree turn to runway 6?

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>>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.

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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.

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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.

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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.

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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.