Two minutes after being cleared for takeoff, a maintenance error from 24 years ago suddenly presented itself.
The transmission was clear and precise. The pilot, a doctor alone in his 1978 Cessna T310R light twin, sounded firmly in control. He had just lifted off from Santa Fe Regional Airport (KSAF) in New Mexico into a beautiful July morning.
The slightly startled tower controller said, “Say again.”
Pilot: “Five One Charlie’s got an engine failure.”
Tower: “Five One Charlie…Roger, you can make the left turn to Runway 33.”
It was a remarkably unruffled conversation. The Cessna had been cleared to depart with a right turn but had made a left bob above the runway on the failure of the left engine and then continued to gently track left of the extended centerline.
Tower: “Five One Charlie, you are cleared to land any runway you want. The winds are calm.”
Pilot: “Five One Charlie, I’m gonna get some altitude…All right. OK. Five One Charlie, that’ll be one engine…one engine.
The pilot made no more transmissions, clearly focused on flying the airplane straight ahead. The Cessna barely climbed, never reaching over 200 feet above the ground.
As it made a left turn, the plane slowed and started to lose altitude. A wing dropped, and the plane departed controlled flight. It impacted a double-wide mobile home and burst into flames. The pilot died in the crash.
The immediate narrative was “doctor in light twin loses engine and can’t make it back to airport.” That is broadly correct. However, two years after the accident, the recently released National Transportation Safety Board (NTSB) final report fills in a lot of details.
The engines were stripped down by the manufacturer and three NTSB investigators. Initial visual examination of the right engine and propeller did not reveal any preimpact anomalies. The left engine had seized. It had three holes in the top of the crankcase, the largest above the No. 3 connecting rod.
On disassembly the counterweight assemblies between cylinders Nos. 3 and 4 were found separated from the crankshaft attachment flanges. Examination of the counterweight that remained attached to the crankshaft flange showed that the retaining rings on the aft side of the counterweights were installed incorrectly. Impossible to preflight check, deep in the engine, this error eventually caused the catastrophic failure.
The investigators then disassembled the right engine. The same issue was found. The engines were rebuilt/zero-timed in 1998 by Teledyne Continental Motors, but it’s almost impossible that this same mistake on two engines was made then.
The aircraft logbook showed in 1999 cylinders Nos. 1 and 3 were removed along with associated hardware to comply with a critical service bulletin requiring ultrasonic inspection of crankshaft cheeks. It seems that during reassembly the error was made.
Certainly, that was the last time the engines were opened up and inspected. The most recent 1,000 hours of the Cessna’s life were uneventfully flown by its owner, a Beverly Hills, California, cosmetic surgeon.
This wasn’t the stereotypical Hollywood tummy tuck doc. This was a surgical innovator renowned for complex postaccident or birth-defect reconstruction. Author of two textbooks, the director of an LA hospital department, he had developed new clinical, research, and training programs. He loved traveling the world caring for children with deformities. The global surgery and training charity Operation Smile has an award named after him. A glowing 1994 profile in the Los Angeles Times also covered his other passion—flying.
“There is nothing like standing on the runway right before dawn, getting ready to get into the airplane to go to Vancouver or Anchorage or Aspen or Mexico or even San Bernardino,” he told the newspaper. “A runway is that kind of magic door.”
He had over 5,000 hours of flight time, with ratings in seaplanes, helicopters, gliders, a business jet, the DC-3, the Grumman Hellcat and Bearcat, and the Boeing B-17 and B-25. There is no doubt he was trained and experienced in handling engine failures in multiengine aircraft. This was not a dilettante caught flying too much airplane.
Aerobatic star Sean Tucker told the NTSB the pilot was “one of the most qualified pilots that he has known” and was a “by-the-book professional who was well respected by everyone who knew him.”
So what happened?
The engine failed at the worst time. On the runway, it would be inconvenient. In cruise, there’s enough altitude and airspeed to safely divert to a single-engine landing. But right after takeoff is bad.
Also working against the pilot is the fact that Santa Fe sits at 6,200 feet, and while it was only 9 o’clock in the morning, the temperature was already 79 degrees Fahrenheit. So the density altitude was almost 9,000 feet. This hurts many aspects of airplane performance. The 310 was also fairly heavy, as it was carrying almost 1,000 pounds of fuel in its standard and auxiliary tanks.
However, the pilot was alone in the airplane, meaning the four other seats were empty. He carried only a small amount of luggage. So the plane was below maximum takeoff weight. And the engines were turbocharged, providing more power at altitude than if normally aspirated.
The landing gear was up, and in the final report the NTSB says the left prop was feathered. The performance charts, for a new plane with a new engine, using test pilot perfect technique, give the T310R’s climb rate single-engine under these conditions as 300 feet per minute.
That July morning the plane did not climb past 200 feet above the rocky ground. Maybe the right engine wasn’t producing full power. Maybe (as a technical report in the full docket states) one of the propeller blades didn’t feather. Maybe the ball wasn’t exactly half out with 5 degrees of bank giving perfect performance.
The pilot, despite his considerable skills and experience, was stuck in limbo—unable to climb, trapped in a horrible place between the ground and the sky.
The pilot turned toward the airport. The bank meant level flight became a descent. Possibly turning tighter to line up with land alongside the highway, the airspeed fell below VMC.
At this point the plane fell out of the sky. After 24 years with no issues, improper installation of some counterweight retaining rings created an engine failure at a truly terrible time. Maybe a survivable crash landing could have been possible by continuing straight on into the desert, and coming down under control.
Maybe.
