Warbird Information Exchange

Only three engines were overhauled according to the NTSB - the one that failed was not touched

Wolf, he's saying the 4 engines went to Mike Nixon for the post accident investigation.

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So, it seems there are a couple trains of thought on this. What was going on inside the engines, how were they being operated , maintained , and operated. The number four engine may have been fine and airworthy but wS out of tune, especially the magnetos and the fine tuning of this part of the system. It’s not like it blew a piston or other catastrophic failure.
The umber 3 engine. It needs to be discerned what was going on with this engine and prop. Let’s hope they didn’t feather and shut down the wrong engine. Worse would be a prop that wouldn’t feather correctly or come out of feather. Yes, I’ve heard of pilots continuing to fly airplanes that needed work and the prop feathering equipment was faulty. That’s on the before takeoff checklist on the King Air, etc.
There’s no evidence the number 4 engine was failing . There’s evidence it’s rigged electrical system was in failure. One question I have about the spark plugs being fouled out; is it possible that they were being cleaned at regular intervals but the engines were being run too rich , say full rich even at cruise , and this practice caused them to be loading up? Last, are we concluding that the aircraft commander wS also the aircraft manager, dispatcher, and chief mechanic on the airplane? That’s an incredible workload for one person, especially a 77 year old. Please clarify.

Who owns the Type Certificate? There is your expert from a regulatory standpoint.

Which would be Transcontinental and Western Air, Inc.

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Chuck Giese --- Volunteer helping to restore B-17G 44-85734 "Liberty Belle".

now if I wanted an B-17 airframe expert, I would vote for Chuck

First of all, hello everyone! I am new to the forum, it's been very educational reading through this thread and others... truly a great repository of knowledge here.

So to discuss the results of the report as they are relevant to this response, it's probably best to talk about what the ignition system issues identified with the No. 4 engine mean. There's talk of a "tuning issue." When we speak of tuning issues, we're talking about issues with the ignition timing, and the ignition system is assumed to be fully functional. "Tuning issues," while mechanically minor, can actually cause an engine to be inoperable, as anybody who has tried to rebuild a distributor can attest. What was going on with the No. 4 engine, according to the FAA, was NOT a tuning issue. To say that "the No. 4 engine was not failing, its electrical system was" is missing the point entirely: for the engine to have a hope of running, it needs fuel, air, and spark. So, from that standpoint, the No. 4 engine was not airworthy.

As for the No. 3 engine, others have pointed out that the spark plug problems could have been caused by a variety of reasons. Whatever the reason, they remain just that: Spark Plug Problems. Crud on the plugs points to poor operation/output of the engine caused by cold, rich running for a long period. The phrase "Italian Tune-Up" describes thrashing an engine to remove these kinds of carbon deposits from the plugs, as would be found on an engine that has been run conservatively for a long period. Think of a grandma taking an otherwise-mint Rambler down the block to church every Sunday- the engine never gets warm, the choke is never used, ect. The gaps being out-of-spec would have compounded the ignition problems experienced by the No. 3 engine. For an engine to run right, the spark has to happen strongly and reliably at the correct time. Gunked-up plugs will prevent this from happening, and as a result, could fire unpredictably or not at all, resulting in the detonation seen during the teardown.

So, having discussed briefly the implications of the FAA's findings, it brings us to the point- how did these problems cause the airplane to crash? That has more to do with the human side of the operation than the mechanical side. That's actually the implicit conclusion of the FAA's rescission. Witnesses reported that there were issues starting the No. 4 engine before the fatal flight. The pilot, who was also responsible for the maintenance of the aircraft, mis-diagnosed the terminal ignition system failure of the No. 4 engine as condensation in the magnetos. While vapor condensation can cause a magneto to fail to produce a reliable spark, the inspection completed by the engine shop showed that this was not the cause of the No. 4 engine's ignition system failure. The pilot thought that in order for the No. 4 engine to be operable, it required the magnetos to be "blown out," or cleared of water- in reality, the entire ignition system required an overhaul.

As for the No. 3 engine, the spark plug issues lead to a family of possible conclusions, none of which are compatible with safe operation of the aircraft. Almost certainly, the poor condition of the spark plugs can be directly attributed to a chronic lack of maintenance. Discounting the proximal causes of the spark plug fouling and damage, the fouled and damaged plugs would only have been present if they hadn't been repaired or replaced, as would have been the case if the engine were being competently maintained. It is difficult to pinpoint those proximal causes- however, the most likely explanation is that the spark plugs became damaged due to the engine being operated continuously at the lower edge of its performance envelope. The R-1820 was never designed to be babied around. It (the -97 version) was designed to run heavily boosted, with very high-octane fuel. Similarly, the airframe was designed and tested around engines that were producing 1200 horsepower. Deviate from that design intent for a long period of time, and you enter the world of "results not guaranteed."

None of the issues identified in the FAA's report would have caused a fatal accident on their own. However, their rescission of the Colling's Foundation's exemption points to a foregone conclusion: that the manner in which the aircraft was operated and maintained (somehow by the same person) 1) caused the subsystem failures and 2) contributed directly to the fatal crash. The report does not fully identify the causes of the accident, however it establishes sufficient reason to place responsibility for these contributing factors directly on the operating organization. In other words, if there is a way to safely operate warbirds for display or ride-along flights, this wasn't it.

This was an extremely tragic event. I have many fond memories of seeing Nine-O-Nine at our local airfield, including a couple of times with my late Grandfather- a combat-veteran B-17 pilot. It makes me extremely sad to realize that this crash could jeopardize continuing that experience for future generations, and their connection to a heroic past. Hopefully, there can be a silver lining from this accident and subsequent investigation: that lessons will be learned, and pave the way to safer continued operation of these historic machines.

Thanks for posting Paul. And welcome to WIX.

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Better is the enemy of Good.

I'll second that Paul.
Welcome to the forum and thanks for the very informative post.

Andy

I read the whole FAA report. I've read alot of CG Mishap Reports and investigations and am pretty familiar with how they work. I've been on both sides of the fence with them too. In that context, I found this FAA report of interest. Specifically the human and organizational side of it. Figured I'd throw a thought or two out for conversation sake.


I don't know how the Collings Foundation training and maintenance programs are set up or what they are required to comply with. We are always taught about the chain of events in a mishap and breaking the chain anywhere often prevents the mishap. In the CG Aviation world, Airsta organization has some checks and balances built into it. There are various aviation depts (Ops, Engineering, Safety) with sub-offices below them. Relative to this mishap, we have an Aviation Training Office/Officer who works under the Ops Dept. The Avi Training O' is responsible for all Pilot/Aircrew training of Ops and Engineering people. Under him/her there is a Unit STAN Team or Standardization Team comprised of O's from the Ops Dept and E's from the hanger deck. They make sure all of the pilot/aircrew air/ground training is completed, semiannual mins, annual check-rides, initial flt syllabus training, dunker, high-pressure training, wet drills, survival training...things of that nature. Everything is computer tracked these days so as someone completes some training or check ride, it's entered into their e-file that can be accessed by anyone needing to run a status report for the individual or unit. If a Pilot or Aircrewman doesn't complete their required training or fails it, they get grounded and can't fly until the discrepancy is corrected. That can equate to a loss of Flt Pay and an extra burden on the other guys/gals who then have to pick up his/her slack. If Collings does not already have something like this, I can see that type of training and tracking system would be useful to them.

I noticed in the FAA report the person who signed an aircraft maintenance record, was the Director of Maintenance and the Mishap PIC was the same person. That might be normal ops and FAA acceptable...I can't speak to that as I don't know. At a CG AirSta....part of that would not happen. A Pilot rarely signs off a maintenance discrep unless he/she was doing a required test flt, maybe ops checking an aircraft system/part that has to be done in flight. Normal maintenance work is done (and signed off) by a qualified mech and a QA person who was not involved in any aspect of the maintenance. We have two levels of QA folks....a primary and secondary. A primary QA person is someone who has alot of experience in the aircraft. He/she can sign off any maintenance discrep including grounding discreps. They work for the QA Office and are not part of the workforce. The secondary QA is part of the workforce and can QA most work EXCEPT grounding discreps. They are part of the workforce/shop. If the secondary works on the aircraft, another QA has to inspect the work. A QA can't do the maintenance and then sign off as a QA. That is a big no-no. CG aircraft maintenance is set up to be done hourly, weekly, monthly, annually or cycles or starts...just depends what it is that is being tracked and the type of aircraft involved.

The head of the AviEng Dept is the EO...Engineering Officer. The EO has an Asst EO and a Maintenance Officer that works below him. The EO and Asst EO are qualified aviators and are required to fly. The MO is not an aviator (could be an Aviation Observer). In the CG it is usually a CWO....Chief Warrant Officer. The EO is in charge of the whole AviEng Dept and answers to the Commanding Officer. The Asst EO is usually an EO trainee and helps with paperwork, test flts and such. The MO is in charge of the aircraft maintenance and anything that takes place on the hanger deck or ramp. The different shops due maintenance work under the MO. The MO's sit in Maintenance Control and must have situational awareness of everything to do with the aircraft. He/she is the EO's direct rep and acts as a filter for the EO so the EO doesn't get bogged down in the minutia of the hanger deck. Once the work has been completed, checked and QA'd, the MO (or EO/Asst EO) will then Maintenance Release the aircraft for flight. The aircraft then gets a pre/post flt inspection and then put in B-0 status....it's ready to launch.

I suspect in the civilian maintenance world one person has to wear several hats as their organization doesn't have the resources or man power to be like a military air station/unit. I guess the Collings Foundation is like that....one person has to wear a few hats. They may have to re-think their organization so there will be back-ups and cross-checks to everything that takes place. IMO it might not be advisable for one person to wear too many important hats without someone else to cross-check and put the brakes on if they see any issues. The other problem managers (and directors) have to stay on top of is complacency. The people at the top always have to keep an eye out for it. That is another reason why it might not be advisable for one person carry too much of the load. Another person or set of eyes to help with the heavy burdens and to raise question if need be might be in order.

I'd guess that the FAA/NTSB is gonna be all up in the A&P's business at CF. I have no idea how many A&P's they have, but I'd be surprised if it was fewer than 10 given the number of aircraft. I would think there are names other than Mac's on the paperwork... but with that said, I saw someone describe Mitch Melton's crew role (at least on pax flights) as "glorified flight attendant".

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I haven't seen it asked yet...do the folks at American Aero have any role in aircraft maintenance once the aircraft hit's the airshow circuit?

Just for the record, we didn't do airshows, I think the last show was Thunder in 2010.

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In a nutshell, the process runs something like this;
The operator creates a program and manual for it that says, "We will do X,Y and Z". In the course of doing X,Y and Z, we will use THIS documentation to perform THESE functions. THESE people (positions really -more anon) will be responsible X, THOSE for Y and Them for Z. There will be qualifications required for, and/or training necessary - AND TRAINING PROGRAM for those positions. There will also be provisions for documenting parts, and procedures etc.
The manual is submitted to the FAA for approval, and after wrangling and re-writes it's APPROVED. It is now the Bible and you WILL follow it. Failure to follow the manual (that you created in the first place, mind you) is reason for censure, disciplinary action ,or even revocation. A representative from the FAA will (should at least) periodically check that you are following your own manual. Officially this is 'surveillance', in real world terms its an audit.
The roster of people responsible for different roles is submitted to the FAA upon change, but is not explicitly approved. Your manual states you have a training program that has been approved.
The manual should, and the periodic audits should have reinforced, that you should have independent checks and not have a conflict of interests within the people responsible for the operation.

The FAA only needs to know that the approved manual was not followed to order the rescission, and denial of extension.

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Lest Hero-worship raise it's head and cloud our vision, remember that World War II was fought and won by the same sort of twenty-something punks we wouldn't let our daughters date.

Thanks for the explanation. Do these self-developed manuals have to go thru any type of future FAA review to check for currency or out of date info? I would think someone or somebody has to do that every so often (tri-bi-annually?) and sign off the manual has been reviewed and updated.