Nine O Nine NTSB final report

[New Englander]

Pretty damming of the the apparently pencil whipped maintenance and the pilot's handling of said lack of maintenance caused emergency. Sadly it seems the chief of maintenance, who was also the pilot, caused his and other's demise. I'm not Monday morning quarterbacking, this report stands on its own.

https://go.usa.gov/xHbMw

[Lars (midessa)]

I don’t recall this particular accident, was a passenger list ever released? Not sure if that list was in this report

[New Englander]

22 minutes ago, Lars (midessa) said:

I don’t recall this particular accident, was a passenger list ever released? Not sure if that list was in this report

Happened in CT. Collings Foundation B17 passenger ride. You can Google the pax list.

[Gearclash]

I saw that report.  Sure looks like McCauley had no business being around B-17s.

[TomH]

4 hours ago, Gearclash said:

I saw that report.  Sure looks like McCauley had no business being around B-17s.

Yet he had 7500 hrs in a B17!

 

Yes, I read the report and was highly disappointed in the findings since I have flown on that aircraft not once but twice. I will say that the whole experience was great but it did seem that safety was "relaxed" to say the least. I have also flown with the Commemorative Air Force. (B17 Sentimental Journey) They were much more concerned about safety and you were not allowed to leave the compartment you were seated in. 

 

[Art From Coleman]

Was this just released?  I remember Juan Brown (blancolirio) had done an update a month or so ago, so, if this is new, I will be looking for his response, if this IS the latest report.

[Rick G.]

Is this the same B-17 that went off the end of a runway and then down a slope or cliff some years ago, but then got rebuilt??? 

[twostepn2001]

18 minutes ago, TomH said:

I have also flown with the Commemorative Air Force.

l have quite a few hours in a CAF AT-6 mostly as a passenger but the owner/pilot would let me have the stick once we were in the air. Once we were at the airshow, the CAF hammered safety before, during and after each demonstration flight including pilot and crew briefings for safety procedures if something did pop up.

[TomH]

1 hour ago, Rick G. said:

Is this the same B-17 that went off the end of a runway and then down a slope or cliff some years ago, but then got rebuilt??? 

I do believe that 909 did skid off a runway back in the eighty's. Not sure of the particulars.

[FarmallFan]

12 minutes ago, TomH said:

I do believe that 909 did skid off a runway back in the eighty's. Not sure of the particulars.

https://en.wikipedia.org/wiki/Nine-O-Nine

[New Englander]

2 hours ago, Art From Coleman said:

if this IS the latest report.

Final, just released.

[New Englander]

7 hours ago, Gearclash said:

I saw that report.  Sure looks like McCauley had no business being around B-17s.

It's called normalization of deviance -  the gradual process by which the unacceptable becomes acceptable. "It's never been a problem". It happens in all professions and most of us have been guilty of it at some time or another no matter what we do for a living. We get away with something so often that gradually it becomes normal, until it bites us.

This accident is a good example as was the Challenger accident but there's examples in all industry or just in our daily activities. We take shortcuts, don't experience a catastrophe, repeat, and soon it's just the way we do it.

I have great respect for those who do it the right way no matter the circumstances.

[Art From Coleman]

This is the video I referred to.

Mr. Lirio is presently in Florida, so it may be a day or so before he comments on his channel.  

He did a short video of the latest quality control issues that Boeing is having on the 737 MAX (which will all go away when the 'no incorrect math answer" becomes accepted within the 'edumacational' system)

https://www.youtube.com/watch?v=xtcsVZcuVqI&ab_channel=blancolirio

 

[mike newman]

...that makes for sad reading.....a very comprehensive   and damning report

Mike

[Gearclash]

59 minutes ago, New Englander said:

It's called normalization of deviance -  the gradual process by which the unacceptable becomes acceptable. "It's never been a problem". It happens in all professions and most of us have been guilty of it at some time or another no matter what we do for a living. We get away with something so often that gradually it becomes normal, until it bites us.

This accident is a good example as was the Challenger accident but there's examples in all industry or just in our daily activities. We take shortcuts, don't experience a catastrophe, repeat, and soon it's just the way we do it.

I have great respect for those who do it the right way no matter the circumstances.

I would agree, at least as far as it pertains to the maintenance, but some of the things that happened after the plane left the ground and began experiencing problems seem to go beyond that.  Really seems like there was a lot of bad judgment all along that would make me question Mr. McCauley’s mental abilities, given his age.  As you likely know, airlines used to have a mandatory retirement age of 60 if I remember right.  This guy was way beyond that.

[New Englander]

13 hours ago, Gearclash said:

As you likely know, airlines used to have a mandatory retirement age of 60 if I remember right.

Now 65 under FAR 121 (airlines), no retirement age under FAR part 91 or 135, under which business jets operate, fortunately for me. That said I've seen pilots who should have hung it up at 50 and others who are going strong at 75, and sadly, some who perhaps should never have been. Personally I'm not far from hanging it up. I try to evaluate my performance on every flight and every simulator session, where you really get put to the test.

No doubt this was mishandled but unfortunately there's no B17 simulator to sharpen your skills on. Training of necessity has to be in the airplane which is risky at best. In the sim we are regularly exposed to situations you can't reasonably do in a plane without extreme risk if you can do them at all. Training accidents were common back in the days before simulators. In the sim we can have jammed controls, multiple engine failures, fires, decompressions, etc., with amazing realism but no real risk. Our department does double the requirement and we appreciate it even while somewhat dreading it.

Sadly this accident is the typical chain which could have been broken at many levels. Properly accomplishing the inspections and setting the magneto point gap, repairing the "P"leads ( the grounding leads that enable the magneto to be shut off) instead of wiring them in place, cleaning and gapping spark plugs properly, not extending the gear until the field was made, etc.

[hobbyfarm]

Thank you for sharing.  I just read through quite a bit of the report.  I am not a pilot and probably shouldn't be commenting but from the outside in it seems they became complacent with both maintenance and safety.

[Pukeko]

15 hours ago, Gearclash said:

I would agree, at least as far as it pertains to the maintenance, but some of the things that happened after the plane left the ground and began experiencing problems seem to go beyond that.  Really seems like there was a lot of bad judgment all along that would make me question Mr. McCauley’s mental abilities, given his age.  As you likely know, airlines used to have a mandatory retirement age of 60 if I remember right.  This guy was way beyond that.

That aircraft was obtained by the Collings Foundation in 1992  (ex Evergreen Helicopters air tanker) , so the pilot could have amassed considerable time on type .As New Englander correctly stated,lots of pilots that age still have it ,re flying abilities ,others even younger ,not so much,and others shouldnt be there at all.  You cant state catogorically that "this guy was way beyond that " as the sole cause of the accident,just because he was 75 but  that is a consideration. I am not defending him,but we had half of our guys flying when we were in Afghanistan for 5 years ,who were over 60 , me included,oldest 68,and we were flying lots ,most months hitting our max,or close to it, allowed under Transport Canada regs of 150 in a month,for us  it was  27days (we went home on the 28 th day of our rotation,back 28 days later). The big thing is being current on type .Almost always there is a "chain of events" leading up to it ,as the investigators determined.Obviously  there were proceedures that werent adhered to correctly in dealing with the emergency,but the emergency arose from way back .ie beginning on the maintenance side ,mags and plugs etc.Any time  mag points have insufficient "gap" there is always hard starting and power loss.Next thing was the "incorrect " mag checks  r.p.m wise .Then they were below the "critical" airspeed with one engine feathered,gear dropped early giving increased drag,etc,etc. The report gave the "detonation" from the plug condition,but I know from experience that it can also be caused  a combination  of low r.p.m.  and high boost pressures. I am familiar with those type of engines ,having run the 1820-84s . which are similiar to the 1820-97,s in this aircraft,but ran a little higher rpm at take off and 1500hp. Unfortunately .it shouldnt have happened ,and makes for a very sad situation for an awful lot of people,but at the end of the day,the pilot has the sole responsibility for the aircraft and occupants ,and in this case  the previous events and omissions  leading up to it all contributed.

[Gearclash]

50 minutes ago, Pukeko said:

You cant state catogorically that "this guy was way beyond that " as the sole cause of the accident,just because he was 75 but  that is a consideration.

I agree.  

A story.  One of my dad’s high school classmates went on to a career of aviation, including some time in the Air Force.  They happened to chat one time, not so long after the Flight 232 crash landing at SUX.  My dad asked his classmate what does a pilot do in a situation like that.  “Procedure! Procedure! Procedure!” was his response.  It sure seems like “procedure” was thrown out the window from the start in this particular instance, with tragic results.  The pilot’s extensive time on the B-17 just makes it more of a head shaker.

It does strike me as unusual that a pilot would also have maintenance responsibilities on an aircraft like this. A lot to keep track of.

[New Englander]

2 hours ago, Pukeko said:

combination  of low r.p.m.  and high boost pressures

I think you're on the mark here. I really don't see why wide plug gaps would lead to detonation as much as an over boost would, especially since it's not known exactly when the detonation took place. One witness stated he heard a power increase just before impact and that's when an extreme over boost could have occurred - in the last desperate seconds in an attempt to save it.

For those not familiar, at that point the props should have been in max RPM, sort of like low gear. Advancing the throttles on a supercharged engine to to a very high manifold pressure even in "low gear" can cause extreme detonation. I've seen cylinder heads actually pushed off the barrels due to extreme over boost.

[Gearclash]

1 hour ago, New Englander said:

I think you're on the mark here. I really don't see why wide plug gaps would lead to detonation as much as an over boost would, especially since it's not known exactly when the detonation took place. One witness stated he heard a power increase just before impact and that's when an extreme over boost could have occurred - in the last desperate seconds in an attempt to save it.

For those not familiar, at that point the props should have been in max RPM, sort of like low gear. Advancing the throttles on a supercharged engine to to a very high manifold pressure even in "low gear" can cause extreme detonation. I've seen cylinder heads actually pushed off the barrels due to extreme over boost.

I have a question.  Did this plane even have functional turbo-superchargers?  I ask because in 2009 I was able to tour a functional B-29, which almost certainly was Fifi although I didn’t realize it at the time.  Being of a curious and mechanical nature I was looking it all over and noticed the turbo-supercharger housings.  It appeared there was nothing in them. I asked a crew member who was happily answering questions what the deal was with the empty turbo housings.  He said, “oh, we don’t use them any more.  We alway fly at low altitude and at no more power than we absolutely need to in an effort to prolong engine life.  We don’t need the boost that the turbo-superchargers give so we eliminated them.”  So I wonder if they do the same on other planes of that vintage?

[New Englander]

2 minutes ago, Gearclash said:

I have a question.  Did this plane even have functional turbo-superchargers?  I ask because in 2009 I was able to tour a functional B-29, which almost certainly was Fifi although I didn’t realize it at the time.  Being of a curious and mechanical nature I was looking it all over and noticed the turbo-supercharger housings.  It appeared there was nothing in them. I asked a crew member who was happily answering questions what the deal was with the empty turbo housings.  He said, “oh, we don’t use them any more.  We alway fly at low altitude and at no more power than we absolutely need to in an effort to prolong engine life.  We don’t need the boost that the turbo-superchargers give so we eliminated them.”  So I wonder if they do the same on other planes of that vintage?

The 1820 should, as I remember, have a single stage supercharger and an additional turbo supercharger which may well have been removed as unnecessary for low altitude use. The supercharger is integral and is still needed to obtain takeoff power.

[Pukeko]

3 hours ago, New Englander said:

I think you're on the mark here. I really don't see why wide plug gaps would lead to detonation as much as an over boost would, especially since it's not known exactly when the detonation took place. One witness stated he heard a power increase just before impact and that's when an extreme over boost could have occurred - in the last desperate seconds in an attempt to save it.

For those not familiar, at that point the props should have been in max RPM, sort of like low gear. Advancing the throttles on a supercharged engine to to a very high manifold pressure even in "low gear" can cause extreme detonation. I've seen cylinder heads actually pushed off the barrels due to extreme over boost.

We used to use the term "blowing jugs".On the 1820,s we had , ( in the S58 Sikorskys) the manual required the r.p.m at takeoff and landing to go into the top of the "red " range (the red was 25-2800rpm) to get our max 1525hp.One operator I flew for didnt like the rpm to go  out of the "green" arc ,( 2200-2500 rpm) and they were constantly "blowing jugs" through overboosting (low rpm,high boost)  on waterbombing  pulling out with a load,and to them it was a great mystery.One old pilot /operator I worked for in the ag spray business always used to advocate  and I quote "with a Wright engine ,if you need to boost the **** out of it ,make sure you have a ton of revs on and you and it  will be okay" It seemed to hold true for the most part,as some of the guys seemed to get in to a situation crop spraying/dusting  where that was neccessary to recover from.

[New Englander]

13 minutes ago, Pukeko said:

We used to use the term "blowing jugs".On the 1820,s we had , ( in the S58 Sikorskys) the manual required the r.p.m at takeoff and landing to go into the top of the "red " range (the red was 25-2800rpm) to get our max 1450-1500hp.One operator I flew for didnt like the rpm to go  out of the "green" arc ,( 2200-2500 rpm) and they were constantly "blowing jugs" through overboosting (low rpm,high boost)  on waterbombing  pulling out with a load,and to them it was a great mystery.One old pilot /operator I worked for in the ag spray business always used to advocate  and I quote "with a Wright engine ,if you need to boost the **** out of it ,make sure you have a ton of revs on and you and it  will be okay" It seemed to hold true for the most part,as some of the guys seemed to get in to a situation crop spraying/dusting  where that was neccessary to recover from.

Where would the rotor RPM be with the engine at the top of the red?

Reminds me of a pilot who said while spraying they sometimes operated in the black. Of course I bit and said "what's operating in the black?" The reply: That's the area ABOVE the red.?

EDIT; Of course in a helicopter the dual tach would have BOTH needles in the same place. Fixed wing guy here. Maintenance only on rotor wing stuff.

[TomH]

I have a lot of pictures of "909". This one shows the exhaust and supercharger, I looked the aircraft over intently because it reminded me so much of my Dad who had extensive experience maintaining B 17's during the war. This was taken when I had my first flight in October of 2014.  On my second flight  in October of 2018. One thing that I did take note of: they had a bit of trouble starting #4 engine. It would cough and and smoke and die for about 4 "try's" After about the 5'th starting attempt it caught and started with a Humongous cloud of smoke. Numbers 1 ,2 and 3 started right up on the first spin of the starter. #4 was the engine with the most time, installed in January of 2016.