CEN15LA024

NTSB accident investigation · Cessna 172K · Xenia, OH · October 19, 2014

Accident · Serious injuriesLimited investigationFinal report
Date
October 19, 2014, 18:05 local (22:05 UTC)
Place
Xenia, OH
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N79534Cessna 172K
Defining event
Takeoff: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed · report April 4, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA - Cincinnati, OH
FAA report
20141019019529A
Case key
90289

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The failure of the seat track mechanism, which led the pilot to inadvertently apply aft yoke and lift his feet off the rudder pedals and resulted in a loss of directional control during takeoff.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

AircraftAircraft › Aircraft structures · FailureCessna 172K: 1 caseAll aircraft: 72 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 172K: 33 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleCessna 172K: 13 casesAll aircraft: 3,958 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot reported that, during takeoff for the local personal flight, his seat unexpectedly moved rearward, and the seat back tipped rearward. As the seat slid rearward, the pilot inadvertently applied aft yoke and his feet came off the rudder pedals, which resulted in a loss of directional control. The airplane went off the left side of the runway and struck a ditch, which resulted in substantial damage to the airplane. A postaccident examination of the pilot seat revealed that the forward outboard metal tang on the seat base that retained the base to the track was deformed. The forward outboard position of the base also contained the locking pin mechanism that adjusted the seat fore and aft and locked the seat into position. The deformation of the metal tang likely allowed the seat to become detached from the track and disengaged the locking pin, which allowed the seat to slide rearward. The seat back structure would not lock in any position after the accident. The reason why the seat back could not lock in position could not be determined. The Federal Aviation Administration had previously issued an airworthiness directive (AD), which required repetitive inspections of the seat mechanism, including inspections of the tangs on the seat base. A review of airplane's maintenance records showed that the inspections had been performed in accordance with the AD. The deformation of the tang was consistent with a lateral deformation due to a sideways force, but it could not be determined if the deformation was present during the most recent inspection. A review of the airplane maintenance discrepancy records showed that, the day before the accident, a different pilot had entered a maintenance discrepancy, which noted that the "left seat slid back three times during flight." The following day, a mechanic repaired the hold-down spring and returned the airplane to service. After that repair and before the accident flight, another pilot entered a maintenance discrepancy, which noted that the "left front seat was in the reclined position and would not lock in the upright position." The records showed that the discrepancy had not been corrected before the accident flight. It could not be determined whether or not the accident pilot was aware of the previous discrepancy reports.

Factual narrative

On October 19, 2014, about 1805 eastern daylight time, a Cessna 172K airplane, N79534, was substantially damaged during a loss of control on takeoff at the Greene County-Lewis A. Jackson Regional Airport (I19), near Xenia, Ohio. The pilot, who was the sole occupant, received serious injuries. The aircraft was registered to and operated by MacAir Aviation LLC under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, which was not on a flight plan. The local flight was originating at the time of the accident. The pilot reported that during takeoff, about the time that he was rotating for takeoff, the seat unexpectedly slid rearward and the seat back tipped aft. This resulted in his inadvertent application of rearward yoke, his inability to reach the rudder pedals, and the subsequent loss of control. The airplane went off the left side of the runway and struck a ditch bank, resulting in substantial damage to the airplane. Aircraft records showed that on the day before the accident, a different pilot had entered a maintenance discrepancy with a notation that the "left seat slid back three times during flight". On the following day, prior to the accident flight, a mechanic made a repair to the hold-down spring and returned the airplane to service. After that repair and prior to the accident flight another maintenance discrepancy was noted by another different pilot that the "left front seat was in the reclined position and would not lock in the upright position". Records showed that discrepancy had not been corrected before the accident flight. It was undetermined whether or not the accident pilot was aware of those previous discrepancy reports. Postaccident examination of the airplane revealed that a metal tang adjacent to the forward outboard seat track roller had deformed. The tang was part of the seat base and the formed lip retained the seat base to the T-shaped seat track. The deformation was consistent with lateral deformation due to a sideways force. It was not possible to determine if the deformation would have been present during the examination required by the AD. The forward outboard position of the base also retained the pin mechanism that allowed for fore-aft adjustment of the seat position. The pin engaged holes in the track to lock the fore/aft position of the seat. Postaccident examination also showed that the pilot's seat back structure could not be locked in any position. No determination was made as to why the seat back would not lock. The seat mechanism in the accident airplane was the subject of an Airworthiness Directive (AD) AD 2011-10-09, implemented by the Federal Aviation Administration to prevent seat slippage or the seat roller housing from departing the seat rail. The AD stated that such a failure could cause the pilot/copilot to be unable to reach all the controls and lead to the pilot/copilot losing control of the airplane. The ADinstituted repetitive inspections of the seat mechanism to prevent such occurrences. One of the items to be inspected was the tang length from the inner edge of the tang to the outer edge (the bend area) of the roller housing. The AD specified a minimum tang length that would affect the width of the opening between the outer and inner tangs. Review of an airworthiness directive compliance sheet for the accident airplane confirmed that the inspections detailed in the AD had been complied with within the required time frame.

Aircraft

Registration
N79534
Reported as
Cessna 172K (P)
Category
Airplane
Serial number
17258157
Built
1969
Airframe hours
5,565
Engine
Lycoming O-320 SERIES, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Macair Aviation LLC
Registered owner
Macair Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 16, 2014
Departed
I19 · Xenia, OH
Destination
I19 · Xenia, OH
Airport
I19 · Greene County, runway 25, 4,500 × 75 ft, asphalt
Equipment
Unknown

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
55
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 2, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
178 total · 17 in this make and model · 68 as pilot in command · 6 in the last 90 days · 2 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 5 knots
Visibility
10 statute miles
Lowest ceiling
25,000 ft broken
Temperature
54 °F, dew point 36 °F
Altimeter
30.11 inHg
Observed at
FFO, 11 nm away

Docket · 3

The files NTSB released with the investigation on February 23, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 633 KB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.