Lessons Not Learned From The Past (Part 2)
Guest Editorial written by David H. Marion — The tragedy of the crash of Antilles Air Boats Flight 941 (Grumman G-21A Goose N7777V, c/n B-111) on September 2, 1978 near St. Thomas, U. S. Virgin Islands was further compounded when during the official investigation by the FAA and the NTSB an effort was made to re-validate the gross weight increase that had been “installed” on the aircraft by means of Supplemental Type Certificate (STC) no. SA3630WE.
A second Grumman Goose that belonged to Antilles Air Boats (N74676 c/n 1172) was completely overhauled at their St. Croix maintenance facility over the course of several weeks in the fall of 1978. This was done in order to get it into the best possible condition to insure that its performance was fully optimized. It was then used to fly a new test program to check and document its performance at various weights in excess of its original limit of 8,000 lbs.
Starting on November 2, 1978, FAA inspectors and Antilles pilots flew the freshly “optimized” Goose in an attempt to recreate the original flight tests supposedly conducted by the FAA Western Region in California to approve the STC in the first place. On a flight on November 5th, the aircraft experienced a double engine failure in flight. The left engine had been deliberately shut-down and the left prop feathered – instead of being configured just to simulate “zero thrust”. Supposedly, one of the FAA inspectors on board prematurely opened the prop unfeathering valve (in order to crossfeed oil pressure from the running right engine to the feathered prop on the other side) before the pilot had reset the controls for the left prop to where they needed to be. That caused the right engine to lose oil pressure too and in turn automatically “feather” the right prop too.
With both engines “dead” a forced landing was made in the open ocean approximately 10 miles north of Christiansted, St. Croix. Unfortunately, in what can be described only as a comedy of errors, in addition to the very real “emergency” that was intentionally created by actually shutting down the left engine (instead of just simulating “zero thrust”) and to the failure of the flight crew to follow the proper procedure to “unfeather” the left prop and restart the left engine, it turns out that just prior to the test flight the ground crew had failed to replace the drain plugs in the left wing float and that float quickly took on water.
As the airplane began to list to the left, the pilot and two FAA inspectors deployed a life raft and got out of the airplane as fast as they could. After being abandoned, the aircraft quickly succumbed to the 10-foot waves and the sinking left wing float. It was soon swamped and sank in 10,000 feet of water. That fortunately non-fatal incident was “witnessed” by Antilles’ Assistant Director of Maintenance Thomas P. Anusewicz. His personal account is published online here.
However, even beyond that tragic loss of a second Goose, the NTSB found numerous other, very disturbing factors that contributed to the crash of Flight 941. According to the NTSB, some of them were the FAA’s fault, at least in terms of inadequate supervision or oversight of the airline’s flight and maintenance operations. Still, the primary transgressions were judged to have been made by Antilles Air Boats Inc. and more specifically, by its senior management. In almost every case, the one person who made all of the important decisions, set policies, had the final word on everything, and created the culture in which the rest of the company operated was the owner and president, Charlie Blair himself – the pilot who paid the ultimate price for those critical decisions and died in the crash.
The findings of the NTSB were published in Report no. AAR-79-09 and included the following noteworthy facts:
During his First-Class medical examinations in June and December of 1976, Charlie Blair’s near vision was noted as being 20/60 and his medical certificates contained the restriction that he “must possess corrective lenses for near vision” while flying. (Emphasis added.) Incongruously, his subsequent medical examinations in November 1977 and May 1978 listed his near vision score as 20/20 – but still contained the telling restriction “holder shall wear corrective lenses for near vision while exercising the privileges of his airman’s certificate.” (Once again, emphasis added.) Yet the 13-year old passenger who rode in the co-pilot’s seat told investigators that he remembered Blair taking off sunglasses and putting them in his shirt pocket, but not putting on any other glasses prior to take-off from Christiansted harbor.
Similarly, those same recent medical examinations noted that Blair’s distance vision had deteriorated from 20/20 in his left eye and 20/30 in the right to 20/40 in both eyes over the same period of time. Even so, they did not make any restriction or requirement for his use of corrective lenses for distance vision in spite of the failure of his eyesight to meet the requirements of the First-Class medical certificate that he was required to have in order to exercise the privileges of his Airline Transport Pilot certificate. While that was nominally the fault of the doctor who examined him, Blair had to be aware of his own limitations, but apparently did not heed them.
The NTSB also found that not only was the aircraft not “airworthy” at the time of the flight, it was de facto company (i.e. Blair’s) policy to keep flying and operating unairworthy aircraft on a routine basis. As the NTSB noted, Antilles’ passenger service operations using its fleet mostly of very old and improperly maintained Grumman Goose aircraft were “conducted with complete disregard for public safety.” Corners were cut all the time not only with the knowledge of, but actually at the direction of, senior management. Most notably, aircraft that were nominally “due” for inspections and/or scheduled maintenance were flown in passenger service operations anyway and records were falsified to cover up the fact.
In the case of the primary accident airplane, N7777V, it had come due for a “6C” major inspection on August 28th, but Charlie Blair personally kept flying it in passenger service anyway and simply failed to log any more time in its records in the meantime. At the time of its accident, the NTSB determined that the airplane was something like 22.5 hours past its next scheduled, major inspection and “mandatory” maintenance.
In addition to the right propeller that was improperly maintained and excessively “dressed” (filed down) as discussed previously in Part 1 the NTSB also found that the left engine that failed when its number 5 cylinder “blew” off had been improperly maintained too. It was determined that when it was first installed as the left engine on N7777V on March 25, 1978, it had only 361.05 hours on it since its last overhaul. However, that overhaul had been accomplished more than 10 years earlier and the engine had been in storage for most of the time in between. The NTSB also found that the previous overhaul had been done NOT by a properly certified, FAA-approved repair station, but rather by its previous owner, the French Air Force. Just as disqualifying with regard to the issue of airworthiness, all of its records from that time were written in French.
The investigation determined that the engine had been purchased through a reputable aircraft parts source, but with the explicit caveat that it was not “airworthy” as such. The parts company told Antilles Air Boats that the engine in question should be used only as a “core” – i.e. that it should be sent out to an approved engine repair station to be freshly overhauled and properly documented in accordance with FAA regulations. Instead, it was sent to a company in Puerto Rico called Caribbean Airmotive Inc. that was also owned by Charlie Blair. Instead of actually overhauling it, they simply performed a basic, visual inspection and ran the engine on a test stand for approximately 1 hour to check its performance and for leaks.
Even when they were inspected, albeit “late” in most cases, the aircraft and engines in the Antilles fleet apparently did not get the attention or quality of maintenance that they should have or that was intended under the Federal Aviation Regulations. In the case of the failed no. 5 cylinder on the critical left engine of N7777V, post-accident forensic analysis found evidence of progressive deterioration of the cylinder mounting hardware. The evidence showed that at least one of the threaded studs used to attach the cylinder to the engine case had been completely cracked through and broken off for quite some time before the accident.
Other studs that were adjacent to the oldest failed stud also showed evidence of cascading failures, with other studs apparently being partially cracked or progressively broken prior to the complete failure of the engine. Still others were obviously overloaded and failed only after the sudden failure of the no. 5 cylinder that day. Both the base flange of the no. 5 cylinder and the matching mounting flange on the engine case showed evidence of extensive chafing and fretting, which suggested that the cylinder had been “loose” for quite some time beforehand.
This potential problem with cylinder hold-down studs on all Pratt & Whitney R-985 series engines in general was already well known and previously documented. It was the subject of mandatory special inspections because of FAA Airworthiness Directive no. 53-06-02. That number indicates that it was the second “AD” published and to become effective during the 6th biweekly period of 1953, i.e. toward the end of March of that year. In other words, the cylinder hold-down stud failure problems – and the special inspections necessary to deal with them – had been common knowledge for more than 25 years before the fatal accident with N7777V occurred.
The NTSB also determined that the left engine that failed on N7777V on September 2, 1978, had something like 921.5 hours Time in Service (TIS) on it since its last “overhaul” and 560.45 hours TIS since its installation on N7777V in March 1978. Also that it had been through ten supposed inspections prior to the accident – yet none of the Antilles mechanics or inspectors had managed to detect a problem with broken studs or the evidently loose cylinder. Finally as well, that the cylinder in question (no. 5) was itself doubly critical since it was also the “master cylinder” containing the “master rod” off of which all of the other internal connecting rods and pistons in the engine were attached; its failure necessarily meant the complete and total failure of the whole engine.
Beyond Antilles’ own ill-advised corporate culture of cutting corners and costs to continue passenger carrying operations without regard for maintenance and inspection requirements of the aircraft or federal regulations, the NTSB also found a significant amount of fault with the FAA for its lax oversight both of Antilles’ flight operations and their maintenance. On the one hand, the NTSB acknowledged the logistical challenges of overseeing so many geographically diverse and widespread commercial operations in the Caribbean region – with too few inspectors at the FAA district office. For example, the inspector who was assigned to Antilles Air Boats was also responsible for four other air taxi operators.
On the other hand, there was some suggestion that way too much deference or leeway was accorded Charlie Blair because of his personal reputation and fame. The FAA was at least aware of Antilles’ record of previous maintenance and operational violations, which included both fatal and non-fatal accidents and which resulted in the total loss of many of the aircraft involved. There were also “recent” findings (earlier in 1978) that included operation of sixty-eight scheduled passenger flights with improperly executed Weight and Balance reports and operation of a Shorts S-25 Sandringham flying boat in commercial passenger service without FAA approval.
In spite of the seriousness of the repeated violations and potential fines in excess of hundreds of thousands of dollars, the FAA frequently “settled” with Antilles Air Boats for pennies on the dollar, reducing actual fines to less than 10% of its own formal guidelines (Ref. 14 CFR Part 13) all of which amounted to slaps on the wrist for numerous, potentially serious violations.
The NTSB also found fault with the FAA for failing to detect the gross and rampant falsification of official maintenance records by Antilles Air Boats Inc. and by Caribbean Airmotive Inc. It cited as contributing factors the fact that Antilles had no full-time Director of Maintenance. All such responsibility was held by the owner, Charlie Blair, in spite of the fact that he worked a full-time flight schedule as a line pilot as his primary responsibility at the company.
In the case of the inadequately validated STC (SA3630WE) that had been used to increase the operating weight limits of the G-21A aircraft in the Antilles fleet, the NTSB found that there was also no formal quality control or program management on the part of the FAA Western Region, which approved the STC in question without following proper procedures and documentation requirements for such a flight test program. Needless to say that when the STC in question was eventually revoked, it was a case of “too little too late.”
The very hard lessons that should be readily apparent to anyone who reads AAR-79-09 are that, just as with almost every other aircraft accident ever, there was a chain of unfortunate or unintended events that could and in fact should have been broken long before they culminated in fatalities that fateful day. It should be equally obvious that “cutting corners” like that will almost always come back to bite you in the ass one day – usually when you least expect it. There is never any justification for taking those kinds of risks with an airplane (any airplane!) but especially not in commercial passenger carrying operations or with something as maintenance critical as seaplanes operating in salt-water.
The whole point of scheduled inspections and maintenance is to find and correct problems BEFORE they trap you between a rock and a hard place. You can’t take such maintenance or inspections for granted – and you have got to make a sincere and educated effort to fulfill the expectations of the aircraft’s manufacturer, the FAA, and so too of the customers who pay you to fly those aircraft. Anything less is a betrayal of their trust and your professional responsibilities.
Dave Marion is the Technical Content Editor at Seaplanemagazine.com. As A&P and IA with more than 30 years of experience in aircraft maintenance, he is also a Commercial Pilot with Airplane, Single & Multi-Engine Land, and Instrument ratings. He has a BA from Colgate University in 1984 and also graduated cum laude from Embry-Riddle Aeronautical University (DAB) with a BS in Aviation Technology in 1990. He can be reached along with all of the editors via E-Mail: [email protected]