Collings Foundation B-17G 909 Has Crashed :-( 10/2/2019

[bdk]

I don't know why there's such a rush to throw under the bus.

Nobody is being thrown under the bus. This is a discussion and reflects our own individual opinions. None of us are working in an official capacity. I’ve read every word of the report and I am dismayed with some of the things it contains. A morning of fun turned into much suffering. What can we learn to prevent future occurrences?

[Fearless Tower]

Thanks Jim.

I don't know why there's such a rush to throw under the bus. Yes, mistakes appear to have been made, but ye old "Golden Rule" ought to be applied to our comments. Think how you'd want to be treated if you made a similar mistake and survived.

Here is what I think is going on: People are in shock. They read through the NTSB information (which, based on my personal experience in recent years, is unfortunately biased and pushing an agenda) and they come away with this vision that CF is an absolute train wreck waiting to kill more people. I'm not sure that is entirely true. I think CF was probably cutting some corners in order to make the rides happen. Might have been too non-challant about things, but I just can't trust the NTSB enough anymore to believe that the issues were systemic....just because the NTSB says so.

The other, perhaps bigger danger, is that when people start to come to a conclusion that the issue was something stupid and egregious, then it becomes easier to dismiss and say that 'that will never happen to me, I'm not that stupid'. And then they go on about their business.

I never knew Mac, but from my friends that knew him well, I don't think the NTSB characterization was a fair one and quite frankly, in typical NTSB fashion, by pushing that narrative, they miss the greater teaching point for the community.

Every vintage/warbird aircraft type has a handful, in some cases one or two, devoted experts. We all know them. B-17, B-25, DC-3, TBM, Beech 18...etc. They all have at least one expert that everyone turns to. Mac was one of those for the B-17 world. We need those people to keep 'em flying. They are critical to keeping these airplanes in the air. BUT, the downside of that is that some of these guys are really flying these complicated airplanes single pilot because their experience so far surpasses anyone that might occupy the other seat. For me, that is the biggest takeaway from 9-0-9. Mac was not using CRM and essentially single pilot flying that airplane and because of his vast experience, he was that much more susceptible to confirmation bias. Based on the events of that morning, he had every reason to believe the issue was a mag issue on number 4 and he feathered it without realizing the real issue was detonation on number 3.

If we want to keep these airplanes flying, we have got to employ the many lessons learned about CRM that have been learned since the airplanes were built.

Gunny Perdue has an excellent video analysis on the crash. Worth watching:

https://www.youtube.com/watch?v=y3p-hGR3ZyY

[M Moore]

I generally avoid responding to threads of this nature. In this case, I feel compelled to reply.

In 1978 a UAL DC-8 ran out of gas on approach to PDX. The Captain was hated and this led to the breakdown of crew coordination. In the aftermath of this accident United created what we now as Crew Resource Management. I hope there can be a similar cultural shift after this accident.

Even if only half of what this report uncovered is true, there is quite a bit to be concerned about. Many moons ago, I had a friend who was getting checked out by Mac in the right seat of 909. While the pilot respected Mac, there were a few stories of his training that raised red flags for me, primarily about how they operated as a crew. I have also had the privilege to act as SIC on a crew warbird on a few coactions. However, my experience in this area is very limited. With that disclaimer, it has been my experience that in the warbird community crews do not operate using the CRM lessons learned by the airlines. I hope I am wrong and that these were isolated incidents, but that has been my personal observation. Even with two engines out, the crew should have been able to return for a safe landing. The crew concept is there to help prevent such errors as not declaring an emergency, properly securing an engine, lowering the gear below safe two engine out speed, etc.

While some believe that Mac is being thrown under the bus, this accident needs to studied. Seven lives were lost. At the airlines every accident, incident, and potential accident is studied. The combination of this analysis and utilizing CRM has greatly reduced the accident rate at the airlines. The same needs to be done in the warbird community.

I am a strong supporter of these types of historical flights. I would love to see the Collings foundation recover from this. Aside from the rapidly increasing operating costs, two of the biggest threats to the warbird community are the insurance companies and the FAA. The warbird community needs to change their culture much like the airlines did in the late 70’s. They need to do this prior to mandates from the insurance companies or the FAA. It sounds like Mac was loved and respected. I would think he would want other pilots to learn from his mistakes. Had I been in command of this flight, I know I would have.

[RyanShort1]

The other, perhaps bigger danger, is that when people start to come to a conclusion that the issue was something stupid and egregious, then it becomes easier to dismiss and say that 'that will never happen to me, I'm not that stupid'. And then they go on about their business.

I think that this is more what I intended to say. We need to have a touch of humanity, and humility. Whatever wrongs were committed, I would bet a large sum of money that they "didn't think" it was "dangerous" enough to cause a loss of life, or thought they might die when they took off that last time. Clearly they were wrong, but we are all capable of the same kinds of mistakes.

[Stephan Wilkinson]

In 1978 a UAL DC-8 ran out of gas on approach to PDX. The Captain was hated and this led to the breakdown of crew coordination. In the aftermath of this accident United created what we now as Crew Resource Management.

You need to read Julie Whipple's excellent book about the accident, "Crash Course." She is the daughter of one of the lead lawyers involved in the case and thus had access to vast documentation. The truth of the matter is far different than your simplistic interpretation. I remember absolutely nothing in the book about the captain being "hated." Quite the contrary, and the widespread feeing immediately after the accident was that he had been unfairly thrown under the bus. And he handled the actual crash landing incredibly well.

You'll be surprised to read what the actual cause of the crash was--the holes in the Swiss cheese began to line up even before the flight was dispatched--as is so often the case in which the public immediately interprets the cause of an accident based on superficial information. Go to Amazon and read the reviews, if nothing else. They are overwhelmingly positive.

[hbtcoveralls]

was anyone else surprised by the fact that the FAA was providing no oversight for as long as two years for Collings program under the LHFE flights?

Apparently there was a POC (point of contact) appointed but that person died and nobody from the FAA office followed up beyond providing a group E-mail where everything sent to them went unanswered.

Contributing cause? almost certainly not, but troubling nonetheless

[Matt Gunsch]

was anyone else surprised by the fact that the FAA was providing no oversight for as long as two years for Collings program under the LHFE flights?

Apparently there was a POC (point of contact) appointed but that person died and nobody from the FAA office followed up beyond providing a group E-mail where everything sent to them went unanswered.

Contributing cause? almost certainly not, but troubling nonetheless

The FAA has a history of someone retiring and then not replacing them. Who remembers the monthly Maint Alerts that the FAA used to publish ? it was the defect reports that were submitted and put together in a monthly magazine format. The FAA no longer does that, the reason ? one guess.
Both the FAA and NTSB are making it hard to retrieve information.

[Firebird]

Shocked that the FAA seem to have walked away from their responsibilities in recent years.....

But, I suppose the details that have emerged about the FAA and Boeing over the 737 Max debacle - then one shouldn't be surprised at all.

Terrible state of affairs, but I'm sure no one will be held accountable for the demise of a once world renowned organisation.

Still no excuse for Collings to drop the ball either in their operations, which it also clearly had over the past number of years.


Similar types of 'dropping the ball' lapses between the CAA and operator maintenance/pilot currency/training etc have emerged here in the UK as a result of the AAIB and legal/court proceedings surrounding the crash of the Hawker Hunter onto the main road at Shoreham back in 2015.

[lucky52]

While on a trip,was Mac responsible for all the maintaince required to be performed by an A&P and also all the flying?

[phil65]

I believe Mac was director of maintenance, so yes.

Phil

[phil65]

was anyone else surprised by the fact that the FAA was providing no oversight for as long as two years for Collings program under the LHFE flights?

Apparently there was a POC (point of contact) appointed but that person died and nobody from the FAA office followed up beyond providing a group E-mail where everything sent to them went unanswered.

Contributing cause? almost certainly not, but troubling nonetheless

The FAA has a history of someone retiring and then not replacing them. Who remembers the monthly Maint Alerts that the FAA used to publish ? it was the defect reports that were submitted and put together in a monthly magazine format. The FAA no longer does that, the reason ? one guess.
Both the FAA and NTSB are making it hard to retrieve information.

The last one I got is from November 2012.

Phil

[marine air]

Scott Perdue's video pretty much sums up what happened. The only thing I can add is that a heavy mass tends to go in a straight or somewhat straight line. After the accident I looked at the runway and the de-icing equipment and there is a right turning arc of about 60 degrees. They were in a right turn so , in theory, if they hit the ground short it should have tracked left of the runway. The fact that it went to the extreme right is evidence of the extremely bad decision to cob the power on engines #1 and #2 at the last moment.
My only interest is for this discussion to enhance safety and training. I hope these flights can resume, in time.

[Craig59]

Scott Perdue's video pretty much sums up what happened. The only thing I can add is that a heavy mass tends to go in a straight or somewhat straight line. After the accident I looked at the runway and the de-icing equipment and there is a right turning arc of about 60 degrees. They were in a right turn so , in theory, if they hit the ground short it should have tracked left of the runway. The fact that it went to the extreme right is evidence of the extremely bad decision to cob the power on engines #1 and #2 at the last moment.
My only interest is for this discussion to enhance safety and training. I hope these flights can resume, in time.

I just finished watching Scott’s video and am reminded why I so enjoyed having him as my FO many moons ago. Outstanding analysis!

[ZRX61]

Scott Perdue's video pretty much sums up what happened. The only thing I can add is that a heavy mass tends to go in a straight or somewhat straight line. After the accident I looked at the runway and the de-icing equipment and there is a right turning arc of about 60 degrees. They were in a right turn so , in theory, if they hit the ground short it should have tracked left of the runway. The fact that it went to the extreme right is evidence of the extremely bad decision to cob the power on engines #1 and #2 at the last moment.
My only interest is for this discussion to enhance safety and training. I hope these flights can resume, in time.

Crash video appears to show left rudder input as it went towards the tanks, but it looked momentary?

[ZRX61]

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