NTSB: Pilot, maintenance issues caused deadly B-17 crash
WINDSOR LOCKS — Investigators determined the deadly World War IIera B-17 bomber crash at Bradley International Airport in 2019 was caused by the pilot’s actions, but maintenance issues, a lack of oversight and an ineffective safety management system were also contributing factors, a newly released National Transportation Safety Board show.s
The NTSB released its findings Tuesday in a report that indicated the investigation into the Oct. 2, 2019, crash that killed seven people and hurt seven others revealed the need for increased Federal Aviation Administration oversight and regulatory framework of living history flight experiences operations that allow planes like this to carry passengers.
In its 24-page report, the board said it found the cause of the fatal crash of the Boeing B-17 bomber to be the pilot’s “failure to properly manage the airplane’s configuration and airspeed after he shut down the No. 4 engine following its partial loss of power during the initial climb.”
Further contributing factors were the pilot’s “inadequate maintenance while the airplane was on tour, “which resulted in the partial loss of power to the Nos. 3 and 4 engines,” the Collings Foundation’s “ineffective safety management system, which failed to mitigate safety risks” and the Federal Aviation Administration’s “inadequate oversight” of the Collings Foundation’s safety management systems, the report said.
In a statement Tuesday, the Foundation said it is reviewing the NTSB’s findings.
“We knew Ernest ‘Mac’ McCauley to be the most experienced B-17 pilot in the world who was passionate about the care and condition of all aircraft,” the statement said. “Responsible flight and maintenance operations have always been a top priority of the Collings Foundation, reflected by over 30 years’ worth of a safe operating record, and always will be.”
McCauley, 75, of Long Beach, Calif., and his copilot, 71-year-old Michael Foster, of Jacksonvilla, Fla., were killed in the crash that day.
The others killed were passengers on the flight: David Broderick, 56, of West Springfield, Mass.; Robert Riddell, 59, of East Granby; Gary Mazzone, 66, of East Windsor; James Roberts, 48, of Ludlow, Mass.; and Robert Rubner, 64, of Tolland.
A statement issued by two law firms that represent nine of the 10 plaintiffs in a wrongful death lawsuit, filed against the Collings Foundation in 2020, indicated the report is one more step in what will likely be a lengthy legal process.
“The NTSB report and findings will help our clients get some closure after this terrible tragedy and will offer protection to other families going forward,” the statement said.
The day of the fatal crash, the vintage aircraft was on a tour that took off with passengers from the Bradley airport through the living history flight experiences offered by the Collings Foundation. It was the aircraft’s first flight of the day.
During the initial climb, passengers were told they could leave their seats and walk around the aircraft, the report said. Soon after, a pilot got on the radio and told air traffic control the airplane had to return to the airport. Passengers were ushered back to their seats and told to buckle up.
The pilot recognized an issue with engine four and shut down power to that engine, the report said.
“Witness video showed that the landing gear had already been extended by that time, even though the airplane still had about 2.7 nautical miles to fly in the traffic pattern before reaching the runway 6 threshold,” the report said.
When investigators later examined engine four, the report said they found a short in the system that would have caused “rough engine operation and a partial loss of engine power that would have been exacerbated by the weak right magneto, which is likely what prompted the pilot to shut down the No. 4 engine and return to the airport.”
An examination of engine three led investigators to find evidence of “detonation on four of the nine cylinders”. Investigators also discovered that the spark plugs were worn and had gaps between the electrodes beyond manufacturer specifications.
“The pilot likely did not recognize, or recognized too late, the extent of the loss of engine power on the airplane’s right side,” the report said.
Investigators said if the pilots had been required to perform the engine ground test check at a higher rpm, they may have noticed the problems “and taken action before the flight to resolve the issues,” the report said.
As the pilot returned to the airport, he flew at 100 mph and below “and he allowed the airspeed to decay far below that required to minimize the loss of altitude over a given distance flown,” the report said.
It also indicated that the aircraft likely wasn’t able to maintain altitude at the lower airspeeds because “the pilot could apply only a limited amount of power to the left-wing engines.” The report also said the pilot should not have extended the landing gear early because it created additional drag.
“(T)he pilot did not appropriately manage the airplane’s configuration and airspeed after he shut down the No. 4 engine,” the report said. “The accident pilot was also the Collings Foundation’s director of maintenance and was responsible for performing the airplane’s maintenance while it was on tour. However, the teardown examinations of the Nos. 3 and 4 engines revealed maintenance issues that were not addressed during the airplane’s current tour.”
During its final approach, the aircraft hit approach lights about 1,000 feet before the runway, then hit the ground about 500 feet before the runway before traveling along the right edge of the runway and veering to the right, colliding with vehicles and a deicing fluid station. The aircraft caught fire after the crash.
The report said engine four had a 25-hour inspection nine days before the fatal accident, but that the check was “either not performed or was improperly performed.”