Suppose you or I had taken off on a solo flight, and within minutes, had to execute an emergency landing that resulted in serious injuries and a banged-up airplane. There was no harm to anyone on the ground, and no buildings or vehicles were hit. When the NTSB finished its investigation, the narrative probably would be about a half-page long and the materials gathered during the investigation likely would consist of little more than the required NTSB Form 6120.1 “Pilot Operator Aircraft Accident/Incident Report,” maybe a local police report and perhaps some notes from an FAA inspector who visited the accident site.
Contrary to what many people think, the NTSB isn’t top-heavy with people just waiting to rush to the scene of every accident. The Safety Board usually conducts a “Limited Investigation,” where only an FAA inspector goes to the scene. Lower on the totem pole is a “Data Collection Investigation,” where no one goes to the scene and there are no significant investigative efforts. In its Fiscal Year 2017 budget request, the Safety Board tries to convince the controllers of the government’s purse strings not to cut its aviation safety investigation staff of only 129 full-time-equivalent employees. It reports that of the 1,301 total aviation accidents during the Fiscal Year through September 2015, only 209 were full-fledged field investigations. The rest were either “limited” or “data collection” investigations. Now you know one reason why so many accident reports are short.
All of which brings us to the Harrison Ford accident. In my opinion, if there’s one thing the Safety Board has figured out over the years, it’s which accidents are going to generate a lot of news media attention and public fascination. You or I banging up an airplane and surviving wouldn’t be one of those. But, it’s a different story if the pilot happens to be the top male movie box office star soon to be seen in a new blockbuster Star Wars episode. The NTSB knows there will be a great demand for answers. If it doesn’t provide them because it hasn’t devoted enough attention to the investigation, that’s not good for public relations, the propagation of the agency and, at least tangentially, the cause of aviation safety.
The in-depth investigation, detailed materials docket and substantive final report the NTSB prepared on the March 5, 2015, accident involving Ford actually does serve both the agency’s image and the cause of aviation safety. The Safety Board got worldwide news coverage, and aviators have a chance to think about how to handle an emergency.
Ford was flying a restored Ryan Aeronautical ST3KR. At about 2:22 p.m., during initial climb-out from runway 21 at Santa Monica Municipal Airport (KSMO), Santa Monica, California, the engine quit. Unable to make it back to the airport, Ford executed an emergency landing to the Penmar Golf Course. The airplane struck a treetop and came to rest, upright, adjacent to the 8th tee. The impact site was about 800 feet short of runway 03 at KSMO. The airplane was substantially damaged and Ford was hospitalized with serious injuries.
The 1942 low-wing, fixed-gear taildragger had forward and aft seats. When flown solo, the pilot is in the rear seat. The first version of the airplane appeared in 1933. There were several models leading up to the version that Ford was flying. The designation “ST” stands for “Sport Trainer, the “3” represents the version, and the “KR” indicates that it’s equipped with a Kinner radial engine. Kinner was a major engine manufacturer at the time. The Kinner R-55 radial used on Ford’s plane produced 160 horsepower using five cylinders. The military version of the airplane was designated the PT-22 Recruit, and more than 1,000 were produced during WWII. They were used by the U.S. Army Air Corps and the U.S. Navy. Special versions were built to teach students crosswind control and ground loop avoidance. Some restoration enthusiasts say the airplane’s reputation as a killer is undeserved, but it must be flown precisely. It’s known for unstable stalls, being quick to enter a flat spin and being bouncy on touchdown. Power-off stall speed is 64 mph clean and 62 mph with flaps out in the landing configuration.
“...Ford handled the emergency with the coolness and concentration you see reflected in any number of his on-screen characters.”
According to the NTSB, Ford’s airplane had undergone restoration approximately 17 years before the accident. The FAA’s Aircraft Registry shows it was declared airworthy on June 4, 1998. On November 19, 2009, a registration certificate was issued to the Delaware corporation Ford controlled, which owned this and at least some of his other airplanes. Ford’s collection included, among others, a Cessna Citation 680 Sovereign, a 1929 WACO and a Bell 407 helicopter. A Director of Operations (DO) was employed to oversee maintenance and make sure whichever aircraft Ford wanted to fly was ready to go. The Ryan’s registration was canceled on February 10, 2016, in the aftermath of the accident.
Ford was 72 years old when the accident occurred. He held a private pilot certificate with ratings for airplane single-engine land and sea, multi-engine land, helicopter and instrument airplane. He was type-rated in Cessna 525 and 680 jets. He had logged 5,000 total flight hours, with 75 in the Ryan. In the 90 days before the accident, he had flown 55.3 hours.
The NTSB Form 6120.1 contains a statement from Ford. He says, “After a normal taxi and run-up, I departed from runway 21 at KSMO. After rotating and lifting off, I accelerated to 80 mph and began a normal climb-out, following the published noise-abatement procedures for KSMO. While on the departure leg, at approximately 1,100 feet MSL, the engine failed without any prior indication of any problem. I immediately lowered the nose, accelerated to 85 mph and initiated a 180-degree left turn. I reported engine failure and requested an immediate return to the airport, and continued the descent at 85 mph. I have no further recollection of the flight or any of the events immediately before or after the landing.”
NTSB Investigator Albert P. Nixon interviewed both Ford and his DO. Ford stated that he arrived at the airport at about 1 p.m., for a short flight. He said his DO had the airplane serviced, fueled and checked the oil. Ford performed his own walkaround inspection of the airplane, checking the flight control surfaces, tailwheel and other components. The DO helped Ford strap in with his seat belt and shoulder harness, and plugged in the communication leads from the helmet Ford was wearing. The DO waited for a “clear” sign from Ford, then primed the engine and stepped back to the left wingtip. Ford then started the engine, which came right up to between 800 and 900 rpm. Ford told the investigator that he let the engine warm up for about 10 minutes; the DO said it was 8 minutes. Then, Ford radioed the ground controller for taxi clearance.
According to the FAA, Ford contacted ground control at 2:11 p.m., reporting he had ATIS information Victor. He was cleared to taxi to runway 21, and told to conduct his run-up behind the aircraft holding short of the IFR hold line on taxiway Alpha. Four minutes later, when Ford had reported ready for takeoff, the controller told him to maneuver around the aircraft in front and continue taxiing to runway 21. At 2:19 p.m., Ford radioed the tower local controller reporting that he was ready to go for left closed traffic. The controller instructed him to line up and wait on runway 21. At 2:20 p.m., Ford was cleared for takeoff.
At 2:21 p.m., Ford radioed, “Ryan 178, engine failure, immediate return.” The controller replied, “Ryan 178, runway two one, clear to land.” Ford replied, “I have to go to (runway) 3.” The controller radioed, “Ryan 178, runway 3, clear to land.”
In the interview, Ford told the NTSB that during the climb-out, he had maintained 80 mph. During the upwind climb, while in a shallow left turn for noise abatement, at about 1,100 feet MSL, the engine suddenly lost power with no sputtering or other indication that there was a problem. Ford said he wasn’t sure if the propeller had stopped or not. He said he looked back at the runway, made the radio call and immediately started to turn back for the airport, to runway 03. He said he didn’t attempt to restart the engine, and didn’t recall which fuel tank he had selected.
When the plane went down on the golf course, the tower local controller advised police and the Santa Monica Fire Department of the crash location.
Runway 03/21 was 4,973 feet long and 150 feet wide. The approach end of runway 03 was on a plateau about 75 feet higher than the elevation of the accident site. The airport itself had a published field elevation of 177 feet MSL. The hourly weather observation prior to the accident included wind from 220 degrees at 10 knots, visibility 10 miles, clear sky, temperature 23 degrees C, dew point minus 8 degrees C and altimeter 30.20.
The NTSB interviewed several witnesses who were playing golf. Some ran to the accident site. One reported there was fuel leaking “everywhere.” He said Ford was in the rear seat, bent forward. When two other people arrived, they helped get Ford out. Another witness reported Ford was confused, but was able to say his name. Other witnesses reported hearing the engine sounding loud as the airplane passed overhead, then sputter and become silent. Fire department personnel reported they shut off the fuel supply using a cockpit control.
“The NTSB determined the probable cause of this accident was a total loss of engine power during initial climb when the carburetor main metering jet became unseated...”
After the wreckage was removed from the golf course, the NTSB conducted an extensive examination of the airframe and engine. At first, they didn’t find anything obviously wrong.
The Holley 419 carburetor was found separated from its mounts. When they opened up the carburetor, they found that the main metering jet was unscrewed from its seat and had turned about 90 degrees. They couldn’t find evidence that thread locking compound had been used to help secure the metering jet when it had been installed. Investigators dug out an instruction manual for Holley carburetors from 1943. It explained that metering of the fuel is accomplished by a main metering jet located in the passage between the discharge nozzle and the float chamber. The metering system provides a constant fuel/air mixture ratio at various engine operating speeds. The investigators couldn’t find any instructions for installation or ongoing maintenance for a jet assembly. The investigation discovered that during the airplane’s restoration in 1998, the engine was overhauled and a new float and gasket were installed in the carburetor. They couldn’t find any entries in the aircraft’s records indicating carburetor inspections since 1998.
When the airplane was built in 1942, it didn’t have shoulder harnesses. Investigators couldn’t find any paperwork regarding the shoulder harnesses that had been installed. There were no logbook entries, a supplemental type certificate or other documents. The FAA does allow retrofitted shoulder harnesses to be treated as minor alterations in some circumstances, provided no welding or drilling of holes into the aircraft structure is needed. Ford’s shoulder harness was attached to the lower portion of the seatback assembly, which was made of thin aluminum. There was no reinforcement, allowing the attachment bolt, washers and stop nut to be pulled upward and through the seatback structure during the impact sequence. The Safety Board said this improper installation likely contributed to the severity of Ford’s injuries, which included cuts and gashes on his head, and broken bones.
The NTSB determined that the probable cause of this accident was a total loss of engine power during initial climb when the carburetor main metering jet became unseated, which led to an extremely rich fuel-to-air ratio. Contributing to the accident was the lack of adequate carburetor maintenance instructions. Contributing to the severity of the pilot’s injuries was the improperly installed shoulder harness.
This investigation established that Ford handled the emergency with the coolness and concentration you see reflected in any number of his on-screen characters. While the NTSB report didn’t analyze or praise his actions, it might have been nice for them to give him some credit for doing things right. Even so, you and I certainly can learn from his handling of the situation. Ford quickly detected his position with respect to the airport and made the decision that he was close enough and high enough to attempt a return. He took charge when the controller at first cleared him to land on a runway he could never have made, and told the controller where he was going to go. He focused on nailing the best glide speed in an airplane that has a reputation for needing precise control. He didn’t become distracted with what would have been a futile attempt at troubleshooting and trying to restart the engine. And, when the airplane clipped a tree, although he says he doesn’t remember what happened, he obviously kept control until the airplane had descended the last 65 feet to the ground. Han Solo, Indiana Jones or Dr. Richard Kimble couldn’t have done it better.
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.