NTSB Factual Report B-17G Crash 'Nine-O-Nine' Part I -16 Dec 2020

it's tuesday the 15th of december my name is juan brown you're watching the blanco lyrio channel and just recently the ntsb has released the factual report on the tragic loss of the b-17 909 back on 2 october of 2019 bradley field windsor locks connecticut [Music] [Music] so let's start with a brief summary from the chairman's factual report on october 2nd 2019 at 0 9 53 eastern daylight time a boeing b-17g november 93012 operated by the callings foundation was destroyed during a precautionary landing and subsequent runway excursion at bradley international airport bdl windsor locks connecticut the commercial pilot that's the pilot in the left seat the air transport pilot that'd be the pilot in the right seat and five passengers were fatally injured the flight mechanics load master and four passengers were seriously injured while one passenger and one person on the ground incurred minor injuries the local commercial sightseeing flight was conducted under the provisions of title 14 code of federal regulations part 91 that's general aviation in accordance with the living history flight experience exemption granted by the federal aviation administration faa visual meteorological conditions prevailed in the area and no flight plan was filed for the flight which departed bdl at 0 9 47. so the weather was not a factor for this accident now a little bit about the living history flight exemption from the faa we've talked about this before in this channel for years warbirds have been operating but it's been the um the purview of very wealthy people to be able to operate these warbirds they're extremely expensive in order to continue to operate warbirds warbird folks work together with the faa and i believe around 1995 or 1997 they worked with the faa and get got together this living history flight exemption program which allows you to take a warbird type aircraft like a b-17 or a b-24 these are aircraft that were designed for wartime and have no uh provisions similar to a air transport category aircraft or an airline type aircraft and allow operators to carry passengers for hire on a donation basis similar to a part 135 type of operation but in order to comply with the living history flight exemption the folks operating these programs developed a flight management program very similar to a part 135 operation complete with all the manuals explaining all the training and all the different safety programs that they needed to comply with and all this is overseen by the faa now a brief rundown on the flight itself the crew arrived at the aircraft about eight o'clock in the morning and they put about a hundred over 130 gallons of fuel on board the aircraft to bring the total fuel on board the aircraft up to about 800 gallons plenty of fuel for all four of these engines each fuel tank on this system is tank to engine operated on the b-17 so that gives each engine about 200 gallons of fuel a piece the fuel report the extensive fuel spectra spectrometry that was done by the ntsb indicates that the fuel was the correct octane and that it was in good condition and no water was in the fuel at the time of this flight the 10 passengers were assembled in the terminal and the crew chief flight engineer gathered them up and headed them on out to the aircraft to get them loaded up all the passenger witness statements state that they were not briefed on emergency procedures of how to egress the b-17 nor were they briefed on how to use the military-style bayonet web old-school seat belts and some of the passengers testified that they had a lot of trouble working with these seat belts they also were unable to cinch these seat belts up tight and were told to not bother cinching the seat belts up tight because they're too difficult to unsinge once the passengers were loaded into the airplane the engine start sequence was attempted on the b17 you have four engines and from left to right they are numbered engine number one number two number three and number four on the b17 the normal starting sequence is to start number three engine first because it has the generator on border it has a generator on board that can recharge the battery plus it's usually the co-pilot that's starting the engines and he wants to start that engine closest to him first so he can hear what's going on followed first starting number three engine you then start number four engine then number one engine and then number two engine the crew reported some moisture in the morning air there at bradley and a common problem or a fairly common procedure for radial engines is to do something called blowing out the mags the magnetos the ignition system which we're going to talk about extensively inside and that moisture trapped in the mags produces a weak start a weak spark while trying to start the engines and makes the engines hard to start so the crew attempted to start number three engine it wouldn't start and so mack directed the crew chief or the flight engineer mitch the person who whose crew position is standing in between the two pilots to go out and blow out the mags this is mitch's first time at doing this operation so mack talks him through it the crew gets the mag blown out on number three engine and gets number three engine started they go then to start the number four engine the second engine start and that engine won't start so they have to shut down number three engine and blow the mag out the mags that each engine has two magnetos again we'll talk about this more they blow out the mags in number four engine come back they get number three engine started and number four engine started and number one and number two engine started they get all four engines started and head out and do their run up run up checks good according to all the witness testimony in this report when i say run up that means you do it typically you do a run up to check the magnetos and the propeller carb heat oil pressure and temperatures get all your pre-flight checks done and this crew elected to taxi out and do a intersection departure on runway 0-6 at bradley with a little more than half of the remaining total amount of runway left within a matter of a minute or two after takeoff and we'll go inside and look at this in detail the crew begins to have trouble with the with at least one of the engines if not two of the engines as soon as the gear comes up mitch the flight engineer crew chief and the normal procedure is on these living history flights is to begin to allow passengers to to roam about the airplane and check out the different battle stations on board the airplane so he does that and folks start moving up into the nose turret mitch comes back up to see how things are going on takeoff or on climb out there and mack tells mitch mack the aircraft commander in the left seat mac mccauley who's got years of experience flying the b-17 informs mitch the crew chief flight engineer that he wants to shut down number four engine mitch thinks no we're not ready for that yet we're still climbing out it's not clear if mitch voices this to mack but mitch says in his testimony that mack reaches up and quote cages number four engine so mack the pilot flying the aircraft and the aircraft commander doesn't direct the number four engine to be shut down but simply does it himself more on that later as soon as mitch realizes that number four engine is shut down and they were still climbing out at a fairly low airspeed they're perhaps about 125 miles an hour at this point mitch goes down and regroups all the passengers and have them get back to their seats and strap in at this point it's unclear as to what is going on with number three engine there is some discussion as to whether there was additional problems with the number three engine but regardless the crew elected to come back around for a precautionary landing the crew did not declare an emergency with the tower and they instead staggered around the pattern and came all the way back around and landed on runway zero six and we'll take a close look at the adsb data they got no higher than about 600 feet above the ground and they achieved no airspeed faster than 125 miles an hour and spent most of their time in the pattern and you'll see the eyewitness video at speeds of about 100 miles per hour or less somewhere on the downwind leg the gear was extended now for a two engine landing and pattern and approach on a b-17 you would typically not want to extend the landing gear until you have landing assured but regardless the landing gear was extended on the downwind and the crew basically was trading altitude for air speed in an effort to maintain flying speed and minimum control air speed on a multi-engine aircraft if you lose power on one side of the aircraft and you have a lot of power on the remaining engine or engines this thrust will tend to roll the aircraft over and there is a minimum speed that once obtained if you put enough thrust on these engines it will roll the aircraft over and you cannot stop it this vmca number is not well was never really specified in a b17 because again this is a warbird type aircraft and it's not an airline type aircraft where they're required to have all these numbers worked out but mack is doing the best he can to keep the aircraft flying on the downwind and it's presumed that mack is carefully reducing the power potentially on the number one outboard engine reducing that power to prevent this aircraft from losing control of this aircraft to a vmca role or minimum controllable air speed in the air type of role his pattern unfortunately is already set up where he's got to do a right hand pattern return to runway six turning into the dead engines which is which is going to exacerbate this vmca problem and he ends up basically the crew ends up running out of altitude airspeed and ideas about a thousand feet short of the runway the b-17 begins hitting the runway obstruction lights it's still in a bit of a right bank turn and according to eyewitness testimony sounds like mac pushes the power up to full power on the remaining one and two engines and what power we could get out of number three we're still unclear if number three was producing power at all once the aircraft touched down and just swerved it and it appears as though the aircraft accelerated into the tanks that it ended up hitting perhaps as if he was trying to clear the tanks this at this point is very unclear so let's go inside and take a closer look at the data here's the ntsb factual report docket 56 docket items with hundreds of pages of testimony and data so where do we start for those unfamiliar let's start with the b-17 aircraft itself november 93012 known as 909 in the warbird circuit is a 1944 b17 g model powered by four right 1820 engines these are radial engines using a hamilton standard full feathering propeller the landing gear it's a tail dragger configuration type aircraft with the tail wheel in the back and the main landing gear is raised and lowered electrically interesting tidbit about the electric raising and lowering of the landing gear on the b17 once the gear is lowered i believe there is a thermal time limit on the electric motor that lowers the gear you cannot quickly retract the gear once the gear is lowered you have to wait and cool those electric motors off that lower the landing gear before you retract the landing gear so once you lower the landing gear you're fairly well committed for a while the four right 1820 engines number one two and three on this aircraft were overhauled around the 2018-2019 time period and had around 250 to 290 hours since major overhaul number four engine was overhauled in 2015 and had about 1100 hours since major overhaul the tbo the time the recommended time between overhauls is not published in this report and i don't know if it's a hard set number for these 1820 engines however the tbo for these older radial engines would be about on the order of 1200 to 1400 hours would be the recommended time between overhauls this is an example of what i mean by a full feathering propeller here we see number two engine feathered number two engine is shut down and feathered you need to feather a failed engine in order to minimize the drag of the wind milling propeller if you do not feather an engine and that propeller continues to windmill especially if it's in the high rpm low pitch setting of the propeller that creates a tremendous amount of aerodynamic drag feathering the propeller reduces that aerodynamic drag and makes controlling the aircraft easier 909 was modified to carry passengers up to 10 passengers back in 1995 as part of the living history flight exemption this modification was approved by the orlando florida flight standards district office back in 1995. so here's your forward entry point for the b17 here's sliding cockpit windows both on the left and right side which also allows another point of egress here's what it looks like up in the nose section of the aircraft you cannot occupy this section of the aircraft for takeoff or landing but is one of the sections you want to go see during the tour here's the radio room this has been modified to have two additional seats here one on the left and i believe one on the right and i believe overhead of the radio room is a plexiglass hatch making there you can see the shadow of it another point of egress for the aircraft the seat cushion i believe is shown out of the way here in the radio room there you can see the military style web belt that the passengers were struggling with here in the aft section of the aircraft i believe is five more crew seats available again shown with the flight with the seat cushions in the up position you're basically sitting on the floor in the back of the aircraft so as you can see this is obviously not airline style seating or safety equipment this is why these limited category aircraft that's the certification that their level they're certified at limited category why these aircraft need a living history flight exemption from the faa in order to operate and carry passengers another view of the aft section showing the waste gunner positions and up to five passengers would sit back here for takeoff and landing again strapped in with the web belt bayonet style military seat belts and here's a closer look at what that how that seat belt operates here's the lever or bayonet that snaps down into these into this notch here which latches this belt here and normally you would have shoulder harnesses and they would strap in right here they would loop um through this through this buckle right here and give you a pair of shoulder harnesses though i do not think this aircraft had shoulder harnesses only this lap belt and not shown in this picture is the cinching apparatus which the passengers were told to just leave it alone don't bother trying to cinch these seat belts up because they're too hard to uncinch and looking aft here from the waist gunner's position we see the other egress door the rear door to the b17 that would be on the right rear side of the aircraft from 2016 to 2019 over a three year period 909 flew 838 hours and was averaging a little under 300 hours per year the aircraft weighs empty weight 34 000 pounds the wartime gross weight the maximum that you can load this aircraft down to during wartime is 59 000 pounds on the day of the accident the aircraft weight and balance was estimated to be a total ramp weight of 46 135 pounds well under the 59 000 pound max wartime gross weight and the aircraft center of gravity appears to be balanced at an estimated 25 to 27 percent of mean aerodynamic cord right here and the range for the b17 is 20 to 32 percent mean aerodynamic cord so the weight and balance for this aircraft was good the whole idea of having the living history flight experience exemption is to provide the vehicle for faa oversight of your operation now this av faa oversight was performed by the fizdo the flight standards district office out of orlando florida the faa office in orlando now in order to comply with the the exemption the callings foundation has to produce create and the faa needs to monitor the the following manuals a general operations manual a training manual qualifications manual a maintenance manual a management manual and the inspection program plus safety management but what happened to the orlando fisdo office of oversight the orlando florida fisdo had jurisdictional oversight over the callings foundation remember we talked about that back in 1995 the approving of the seats during an interview with the orlando fisdo office manager and assistance office manager they indicated that prior to 2017 there was a point of contact assigned to the callings foundation with the responsibility for answering regulatory questions but that poc did not do any ramp inspections or conduct any end route surveillance that poc then passed away in 2017 and was not replaced by the flight standards district office during the interview when asked how the callings foundation was to get in touch with the fisdo since there was no poc assign the office manager indicated that we have a front desk that people can call into the callings foundation chief pilot stated that in a conversation that after the poc passed away the fizdo advised him to use a general email mailbox for their correspondence with the fizdo the chief pilot further stated that they would send notifications that were required by their exemption letter to the general mailbox but after several of the emails and notifications were not answered the callings foundation stopped using the general mailbox as a result the callings foundation operated with minimal to no faa oversight let's take a quick look at the background of the flight crews the accident crew consisted of a captain co-pilot and loadmaster now i called mitch a flight engineer as he's operating between the two pilots but he's technically a load master in this position crew chief handling the passengers the captain held a b-17 type rating remember this is mac mccauley the highest time b-17 pilot in the united states uh as of today the co-pilot was not type rated in the b-17 nor was he required to be according to the faa the loadmaster was not required was not a required crew member by regulation however every flight had a loadmaster assigned and his duty was to assist with the passenger handling and briefings according to the callings foundation chief pilot i believe that is a requirement of their living history exemption that the load master be on the aircraft so mack has a clean record he's 75 years old 14 500 hours of flying time he did have a dui back in 1998 but if you look at his ratings he's back comes up through the civilian ranks he's a private pilot by 1969 and then gets a commercial rating in 1996 multi-engine in 1999 multi-engine instrument and then the b17 rating in 2003. mack also has an airframe and power plant's mechanics license not only is mac the aircraft commander of the b-17 and flies it the most he's also the director of maintenance for the entire overseeing the entire maintenance operation of the b17909 the co-pilot was 71 years old and he's a retired airline pilot you can tell by his ratings so private pilot in 1967 commercial 1968 73 so a steady progression through the ranks flight engineer air transport pilot and then his career as a airline pilot 737 dc 10 757 767 an instructor as well so atp rating flight instructor and a second class medical again these are all volunteer positions at the callings foundation his check ride performance is satisfactory and he indicates a total flight time of 22 000 hours now let's take a look at the jepson plate for windsor locks airport this aircraft taxied out i believe on this runway and did an intersection take off where these two runways intersect on runway zero six runway zero six intersection takeoff that distance looks like 1.17 miles or a little over 6 000 feet plenty of room for a b-17 departure however investigators are still questioning the judgment of the pilot to use an intersection departure as opposed to all of the runway especially given the trouble starting the engines note also that the elevation of the approach end of runway zero six is 173 feet above sea level now let's take a look at the adsb data orange numbers on the left here indicate time orange numbers on the right indicate altitude gps altitude mean sea level so remember the airport elevation is about 180 feet this entire pattern from start to finish from 48 minutes to 53 minutes should be just around only a six minute long flight total so we see the altitude increasing until about this point here reaching a maximum altitude of about 745 feet above sea level and then a steady loss of altitude as they return back to the airport on the right downwind for runway zero six now investigators are already monday morning quarterbacking this thing and saying this crew would have been better off had they just hooked it around and come right back into this runway here with plenty of distance to land on this runway rather than continue all this maneuvering around back to runway six so remember the configuration that max fighting with here he's got number four engine feathered pretty quickly like about a minute after takeoff we'll take a look at that in a second number three engine appears to be wind milling and creating a lot of drag and at some point the video evidence suggests or shows for a fact that the landing gear is down somewhere here on the downwind so this sets him up for a pretty sharp turn to final here for the last bit of the arrival onto runway zero six so let's take a closer look at that and here it shows a steady turn into the ils lights here on runway zero six and that turn continues on into the de-icing tanks where they ended up right here there's also an acceleration in speed through this section of the adsb data let's take a look at that here's the altitude shown in a graphical representation gps altitude in msl height above sea level here's the terrain from the google earth so it shows a maximum altitude reached of about 750 feet and then a steady downhill descent on downwind back to runway zero six here's an old chart straight from the b17 manual showing the best four engine rate of climb air speed here at 40 000 pound weight at sea level four engines indicates the best rate of climb air speed in miles per hour is about 120. here's the adsb airspeed data showing the highest speed reach shortly after takeoff 125 miles an hour at best rate of climb speed 125 reach there and then it's just a steady decrease in air speed all the way through the downwind and final base turn and then here just before zero 953 there is this one last acceleration all the way down from just under 95 a little over 90 knots all the way back up to 105 knots and this speed is getting very close to the aircraft stall speed and of course mack is also fighting the as we discussed earlier vmca the rolling tendency of the aircraft given the thrust on the good engines versus the lack of thrust on the dead engines here's the rate of climb and feet per minute he initially achieved about a thousand foot per minute rate of climb which corresponds with the charts for a normal four inch in rate of climb and then it decays rapidly less than one minute after takeoff as matt cage's number four engine that rate of climb he starts exchanging altitude for air speed right away and here's the zero rate of climb line right here so he's varying closely well he's descending all the way back to the runway zero six now let's take a look at the weighty eyewitness video of the actual touchdown of the b-17 here's the aircraft and the right-hand turn just about to begin hitting the lights off of the end of runway zero six a thousand feet short of the runway now we can't critique these eyewitness videos remember they're witnessing a tragic event they're watching it with their own two eyes and not paying very close attention to where the viewfinder of the camera is so we lose the view of the aircraft for a few seconds in this shot so let's do that again you can hear the roar of the engines he gets the aircraft righted as he heads into the de-icing tanks so what could have brought this b17 down what caused these engine or engines to begin to fail so quickly after takeoff and i've gone on long enough today so we'll have to stay tuned for part two we're gonna dive deep into the power plant investigation regarding specifically engines number three and four what the folks down at vintage radials found in their investigation of these radial engines tearing them apart and we're going to get deep into the engines ignition system the maintenance of that ignition system and how that ignition system works on the boeing b17 so stay tuned stay here for part two again thanks for your support on patreon that makes this content possible because most of my content here in december has all been demonetized by youtube thank you for your support see you here [Music] you

Channel: blancolirio

Views: 386,022

Keywords: Blancolirio, B-17, B-25, NTSB

Id: G3dD98IqEUk

Length: 32min 39sec (1959 seconds)

Published: Thu Dec 17 2020

Reddit Comments

[u/afterburners_engaged]

Dude makes some good content

[u/A444SQ]

one of the most disturbing parts was the Collings foundation wasn't telling the passengers how to use the seatbelts nor how to get out of the aircraft in an emergency and that is all the more disturbing to me personally as I and my dad have been on as far as I can remember 2 pleasure flights of the charitable organisation Classic Wings on their De Havilland Dh-89 Dragon Rapide and in both cases they told us how to use the seatbelts and how to exit the aircraft in an emergency