# NTSB CEN15LA024: Cessna 172K, N79534, Xenia, OH, October 19, 2014 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: October 19, 2014, 18:05 local (22:05 UTC) - Place: Xenia, OH - Coordinates: 39.679164, -83.870834 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.6792&lon=-83.8708&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report April 4, 2016 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA - Cincinnati, OH - ADs cited in the narratives: [AD 2011-10-09](https://openairdocs.org/ad/2011-10-09) (OpenAirDocs) - NTSB case key (mKey): 90289 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA024 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90289/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90289 - Page: https://openairdocs.org/ntsb/CEN15LA024 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Aircraft](https://openairdocs.org/ntsb-findings/01030000): Aircraft › Aircraft structures · Failure (probable cause); cases with it: [Cessna 172K, 1 case](https://openairdocs.org/ntsb-findings/01030000/cases.md?model=2072430), [All aircraft, 72 cases](https://openairdocs.org/ntsb-findings/01030000/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 172K, 33 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072430), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Cessna 172K, 13 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2072430), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna 172K, 16 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2072430), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Cessna 172K, 15 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2072430), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## 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](https://openairdocs.org/deregistered/N79534-2018-03-06), registration cancelled 2018-03-06, S/N 17258157, built 1969 (OpenAirDocs) - Reported make and model: CESSNA 172K (P) - Registry model: [Cessna 172K](https://openairdocs.org/model/cessna-172k) (registry code 2072430) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17258157 - Year built: 1969 - Airframe hours: 5565 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: serious; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20141019019529A](https://openairdocs.org/incident/20141019019529A), Oct 19, 2014: Cessna 172K, Xenia, OH, Substantial damage. The aircraft was departing on runway 25 when on take off roll the aircraft ran off the left side of the runway into the grass through a large ditch where the… ## Docket (3 files) The files NTSB released with the investigation on February 23, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90289. 633 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 339 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436902&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Airworthiness Directive (item 2, .PDF, 220 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436901&FileExtension=.PDF&FileName=FAA%20Airworthiness%20Directive-Master.PDF - Aircraft Discrepancy Log (item 3, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436903&FileExtension=.PDF&FileName=Aircraft%20Discrepancy%20Log-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.