Collings did not comply with its own "safety management system," the crew chief was not aware a safety and risk management program existed and Collings "failed to maintain and apply on a continuous basis a safety and risk management program that met or exceeded ... FAA policy."
The FAA also found "notable maintenance discrepancies existed with the B-17G, yet the Collings director of maintenance signed inspection records -- dated as recently as Sept. 23, 2019 -- indicating no findings of discrepancies." Collings' maintenance director was Ernest McCauley, 75, who was the chief pilot the day of the crash.
"Collings did not have a structure to ensure adequate oversight of his decisions to conduct passenger-carrying operations such as the October 2 flight," the FAA decision reads. "This indicates Collings lacked a safety culture when operating the B-17G."
An inspection of the bomber's engines found problems significant enough to cause the FAA to question "whether the engines were inspected adequately and in accordance with the applicable maintenance requirements."
Specifically, the inspection found that magneto and ignition failures existed in the aircraft's No. 4 engine. Magnetos, engine-driven electrical generators that produce voltage to fire the engine's spark plugs, were not functioning properly. An attempt to jury-rig one had left it inoperative, according to the report. A second magneto on the No. 4 engine, when tested, produced a weak or no spark to four of the nine cylinders it was supposed to fire.
Inspectors also found that all spark plugs required cleaning and that all of the electrode gaps were out of tolerance. Further engine inspection "indicated signs of detonation and associated damage," the decision reads.
An inspection of the No. 3 engine showed "all spark plug electrode gaps were out of tolerance, fouled, and revealed various signs of detonation." Inspection of the engine also revealed problems with the cylinders, according to the report.
"As a result of these findings and other information, the FAA questions whether the engines were inspected adequately and in accordance with the applicable maintenance requirements," the decision reads.
On the day of the crash, the flight crew radioed the Bradley tower that it needed to return to the airport, according to a National Transportation Safety Board preliminary report issued about two weeks after the crash.
"The controller then asked for the reason for the return to the airport, and the pilot replied that the airplane had a 'rough mag' on the No. 4 engine." "Mag" is short for magneto.