N93012

Destroyed
Fatal

Boeing B17S/N: 32264

Accident Details

Date
Wednesday, October 2, 2019
NTSB Number
ERA20MA001
Location
Windsor Locks, CT
Event ID
20191002X11326
Coordinates
41.931667, -72.692222
Aircraft Damage
Destroyed
Highest Injury
Fatal
Fatalities
7
Serious Injuries
5
Minor Injuries
1
Uninjured
0
Total Aboard
13

Probable Cause and Findings

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. Contributing to the accident was the pilot/maintenance director’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 (SMS), which failed to identify and mitigate safety risks; and the Federal Aviation Administration’s inadequate oversight of the Collings Foundation’s SMS.

Aircraft Information

Registration
Make
BOEING
Serial Number
32264
Engine Type
Reciprocating
Year Built
1944
Model / ICAO
B17B17
Aircraft Type
Fixed Wing Multi Engine
No. of Engines
4
Seats
36
FAA Model
B-17G

Registered Owner (Current)

Name
CCT OF 1979 B-17 SERIES LLC B-17 SERIES
Address
PO BOX 248
City
STOW
State / Zip Code
MA 01775-0248
Country
United States

Analysis

HISTORY OF FLIGHT

On October 2, 2019, about 0953 eastern daylight time, a Boeing B-17G, N93012, was destroyed when it impacted terrain short of runway 6 at Bradley International Airport (BDL), Windsor Locks, Connecticut. The commercial pilot, airline transport pilot, and five passengers were fatally injured; the crew chief/flight engineer and four passengers were seriously injured; and one passenger and one person on the ground sustained minor injuries. The airplane was operated by the Collings Foundation as a Title 14 Code of Federal Regulations (CFR) Part 91 local commercial sightseeing flight.

The accident airplane, shown in figure 1, was a vintage, former US military bomber that was on a tour that allowed members of the public to purchase an excursion aboard the airplane for a living history flight experience (LHFE). After the passengers boarded the airplane, they were seated by the crew chief/flight engineer (referred to as the loadmaster). The 20- to 25minute flight included a planned in-flight walking tour of the airplane.

Source: Ms. Macey Lorden

Figure 1. Accident airplane

On the morning of the accident flight, a lineman at BDL assisted the loadmaster as he added 160 gallons of 100 lowlead aviation fuel to the accident airplane. The loadmaster stated, during a postaccident interview, that the pilot had difficulty starting the Nos. 3 and 4 engines (both of which were on the right wing of the airplane) because of moisture in the magnetos due to rain the day before. (A magneto is an electrical generator that uses a rotating magnet to produce high-voltage electricity that is distributed to the spark plugs). The loadmaster, who held a mechanic certificate with airframe and powerplant ratings, dried the magnetos by blowing compressed nitrogen into them, after which the engines started normally. Before takeoff, the pilot performed a magneto check at an engine speed of 1,700 rpm, and the loadmaster reported that everything seemed normal.

The accident flight was the airplane’s first flight of the day. The flight departed from runway 6 about 0947. During the initial climb, one of the pilots retracted the landing gear, and the loadmaster, who had been standing between the pilot and copilot in the cockpit, moved into the cabin to tell the passengers that they could leave their seats and walk through the airplane.

According to a transcript of radio communications between air traffic controllers and the pilots, at 0949:19, one of the pilots stated, “we would like to return to the field.” Automatic dependent surveillance-broadcast (ADS-B) data showed that, at the time, the airplane was about 600 ft above ground level (agl) on the right crosswind leg of the airport traffic pattern for runway 6. The approach controller asked the pilot if he required any assistance, to which the pilot replied “negative.” The controller then asked why the airplane would be returning to the airport, and the pilot replied that the airplane had a “rough mag[neto]” on the No. 4 engine.

During a postaccident interview, the loadmaster stated that, when he returned to the cockpit, he realized that the airplane was no longer climbing and that the pilot, realizing the same, instructed the copilot to extend the landing gear, which he did. The loadmaster also stated that he left the cockpit to instruct the passengers to return to their seats and fasten their seat belts. According to the loadmaster, after returning to the cockpit, the pilot indicated that the No. 4 engine was losing power and that he wanted to shut down that engine. (The loadmaster looked at the rpm gauge and confirmed that the No. 4 engine was losing power.) The pilot then shut down the No. 4 engine without any further coordination or discussion.

At 0949:42, the controller instructed the pilot to fly a right downwind leg for runway 6 and asked whether the airplane needed an immediate landing. One of the pilots responded that he wanted the airplane “to be on the ground as soon as possible.” The controller subsequently canceled another airplane’s approach to the airport and advised the pilot to “proceed however necessary” to runway 6.

At 0950:50, the approach controller instructed the pilot to contact the tower (local) controller, and the pilot acknowledged the instruction. After the pilot established contact, the tower controller reported that the wind was calm and that the airplane was cleared to land on runway 6. According to ADS-B data, starting about 0951:00, the airplane’s airspeed was at or below 100 mph. At 0951:08, the pilot acknowledged the landing clearance; ADS-B data indicated that the airplane was at an altitude of about 400 ft agl on a midfield right downwind leg for runway 6 at that time. Witness video confirmed the loadmaster’s report that the airplane’s landing gear had been extended by the time the airplane had entered the downwind leg of the airport traffic pattern (about 2.7 nautical miles in the traffic pattern from the runway 6 threshold).

At 0951:28, the tower controller asked about the airplane’s progress to the runway; 6 seconds later, one of the pilots replied, “we’ll get there midfield downwind now.” No further communications were received from the airplane.

The airplane was descending through an altitude of 300 ft as it turned onto the base leg of the traffic pattern for runway 6. The airplane then turned onto final approach at an altitude of 150 ft; at that time, the airplane was about 0.4 nautical mile from the runway threshold. Figure 2 depicts the airplane’s ADS-B-derived flightpath overlaid onto aerial imagery of the airport and surrounding area along with relevant voice radio transmissions between air traffic control (ATC) and the airplane.

Figure 2. ADS-B-derived flightpath and select voice radio transmissions

Note: The public docket for this accident contains the full ATC transcript. The crash location is shown in figure 4.

Witness statements and video indicated that the airplane struck the runway 6 approach lights in a rightwing-down attitude about 1,000 ft before the runway. The airplane contacted the ground about 500 ft before reaching runway 6. The engine noise increased, and the airplane accelerated as it veered to the right of the runway. The airplane then collided with vehicles and a deicing fluid tank before coming to rest upright about 940 ft to the right of the runway 6 centerline and oriented to the east. A postcrash fire ensued.

PILOT INFORMATION

The pilot held a commercial pilot certificate with ratings that included airplane multiengine land as well as a type rating for the Boeing B-17. He also held a mechanic certificate with airframe and powerplant ratings. The pilot’s logbook was not recovered. The operator reported that the pilot had 7,300 hours of flight experience in the B-17G and that he completed his annual proficiency check in the airplane on February 26, 2019. The pilot was the director of maintenance for the Collings Foundation, which was a paid position. (The pilot flew the B-17G as a volunteer.)

The copilot held an airline transport pilot certificate with ratings that included airplane multiengine land as well as five type ratings for transport-category airplanes. He did not hold a type rating for the Boeing B-17 and was not required to hold that rating as a copilot. The copilot’s logbook was not recovered. The operator reported that the copilot had 23 hours of flight experience in the B17G and that he completed his annual proficiency check in the airplane on February 24, 2019.

AIRCRAFT INFORMATION

The Federal Aviation Administration (FAA) issued a limited airworthiness certificate for the airplane in 1994, and most of the passenger seats were installed in 1995. According to operator and maintenance records, the airplane had 15 seats in the following configuration (forward to aft):

2 original-equipment seats in the lower nose area, which were not used for passengers;

2 original-equipment pilot seats on the flight deck (above the lower nose area);

2 aft-facing floor seats mounted to the structure behind the pilot seats;

3 seats in the radio room (2 side-facing seats on the floor and 1 swivel-style originalequipment radio operator seat);

1 aft-facing seat on the left-side bulkhead panel near the ball turret, which the operator reported was not used for passengers but was available to the loadmaster; and

5 side-facing seats on the floor in the waist gunner area (3 right-side seats and 2 left-side seats).

The passenger seats that were not original equipment were installed in the airplane according to an engineering document that conformed with the structural requirements of Civil Aviation Regulation 4b. Some of the seats consisted of a 5/8-inch-thick plywood seatback attached to the airframe with aluminum angles and brackets, as shown in figure 3. The other seats were secured directly to the structure on an airplane sidewall or bulkhead. All of the passenger seats included a seatback cushion secured with hook and loop fasteners and a seat bottom cushion secured to a floor panel. The passenger seats were equipped with a two-point military/aerobatic-style lap belt affixed to either the seat or structural areas on or near the floor.

Source: The Collings Foundation.

Figure 3. Accident airplane interior (forward looking aft)

The pilot and copilot seats were equipped with a four-point restraint—a two-point military/aerobatic-style lap belt and shoulder harnesses—but the loadmaster reported that the pilots did not use the shoulder harnesses. The loadmaster also reported that he did not have a dedicated seat (and thus no available restraint) and that he would “stand in between the copilot and the pilot” during flights.

The airplane was on tour each year for 10 months, and the pilot was responsible for performing the airplane’s maintenance during that time. (As previously stated, the pilot held a mechanic certificate and was the Collings Foundation’s director of maintenance.) The airplane...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA20MA001