# NTSB ERA16FA141: Cessna 172N, N6238D, Charleston, WV, March 26, 2016 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 26, 2016, 12:08 local (16:08 UTC) - Place: Charleston, WV - Coordinates: 38.375831, -81.593055 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.3758&lon=-81.5931&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report August 28, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Textron Aviation, Lycoming Engines - ADs cited in the narratives: [AD 2011-10-09](https://openairdocs.org/ad/2011-10-09) (OpenAirDocs) - NTSB case key (mKey): 92895 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16FA141 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92895/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92895 - Page: https://openairdocs.org/ntsb/ERA16FA141 ## Probable cause The flight instructor's failure to ensure that her seat was properly secured before initiating the takeoff, which resulted in a subsequent loss of control. Contributing was the lack of an installed secondary seat stop. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Cessna 172N, 150 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072434), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Fuselage: seat/cargo attach fitting](https://openairdocs.org/ntsb-findings/01035347): Aircraft › Aircraft structures · Incorrect use/operation (probable cause); cases with it: [Cessna 172N, 3 cases](https://openairdocs.org/ntsb-findings/01035347/cases.md?model=2072434), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/01035347/cases.md) - [Fuselage: seat/cargo attach fitting](https://openairdocs.org/ntsb-findings/01035347): Aircraft › Aircraft structures · Not installed/available (probable cause); cases with it: [Cessna 172N, 3 cases](https://openairdocs.org/ntsb-findings/01035347/cases.md?model=2072434), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/01035347/cases.md) - [Health/Fitness: predisposing condition](https://openairdocs.org/ntsb-findings/02013035): Personnel issues › Physical · Pilot; cases with it: [Cessna 172N, 1 case](https://openairdocs.org/ntsb-findings/02013035/cases.md?model=2072434), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02013035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cessna 172N, 15 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2072434), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 172N, 45 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072434), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cessna 172N, 21 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2072434), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172N, 134 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072434), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The flight instructor, who was controlling the airplane, and the student pilot were conducting an instructional flight. During the takeoff the airplane lifted off about 1,000 ft down the runway, pitched nose up, and rolled left to an inverted attitude before it impacted terrain next to the runway in a nose-down attitude. The student pilot recalled that as the airplane rotated during the takeoff, he heard the flight instructor exclaim, but could not recall any subsequent events. Postaccident examination of the flight controls revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Examination of the wreckage revealed witness marks along the flight instructor's seat tracks that corresponded with the seat in the nearly full-aft position. Given the flight instructor's stature, it is unlikely that this position would allow her to fully actuate the flight controls, and it is therefore unlikely she purposefully initiated the takeoff with her seat in this position. While one of the two locking pins that would have secured the seat from sliding fore and aft was found fractured, it is likely that the jockeying of the seat during the victim extraction process resulted in the fracture of the locking pin, and left the witness marks observed on the seat track. Examination of the wreckage and maintenance documents also revealed that the airplane was not equipped with a manufacturer-recommended secondary seat stop mechanisms for either of the pilot seats. Review of operational and maintenance documents published by the airframe manufacturer showed the critical importance of ensuring that the pilot seats were secured prior to initiating a flight, and that accelerations such as those encountered during a takeoff could dislodge an unsecured seat. Had the flight instructor, who was performing the takeoff, not properly secured her seat prior to initiating the takeoff, it may have resulted in her seat sliding aft, and her inadvertent application of control inputs to the control yoke during the rotation and initial climb, consistent with steep climb, descent, and impact. The aft seat position could have also likely resulted in her inability to apply complete or sufficient control inputs to the rudder pedals, consistent with the left yaw/roll observed during the takeoff. ## Factual narrative The airplane's Pilot's Information Manual, before starting engine checklist, advised pilots to verify the seats, seat belts and shoulder harnesses are adjusted and locked. The Cessna Pilot Safety and Warnings Supplements document warned that a pilot should perform a visual check to verify that their seat was securely on the seat tracks and assure that the seat was locked in position. Failure to ensure that the seat was locked in position could result in the seat sliding aft during a critical phase of flight, such as initial climb. The airframe manufacturer also issued a Service Bulletin (SEB07-R06 Revision 6, issued June 11, 2015), which required the installation of a secondary seat stop for the pilot seat, and recommended one for the co-pilot seat. A secondary seat stop was not installed on either of the accident airplane's front pilot seats. The supplement also warned that there had been previous reported events involving seats slipping rearward or forward during acceleration or deceleration related to discrepancies in the seat mechanisms. The investigations following these events revealed discrepancies such as gouged lockpin holes, bent lockpins, excessive clearance between seat rollers and tracks, and missing seat stops. Also, dust, dirt, and debris accumulations on the seat tracks and in the intermediate adjustment hoes have been found to contribute to the problem. The four-seat, high-wing, tricycle landing gear-equipped airplane was manufactured in 1979. It was powered by a 160-horsepower Lycoming O-320-H2AD engine and was equipped with a two-bladed McCauley propeller. Review of maintenance records revealed that the airplane's most recent annual inspection was completed on October 20, 2015. At that time, the airframe had accumulated 10,995.9 total hours of operation, and the engine had accumulated 1540.4 hours since major overhaul. The airplane had been operated about 7 hours since the last annual inspection was completed. Examination of the airframe logbooks revealed that the seat tracks were replaced on February 12, 2015. Airworthiness Directive (AD) 2011-10-09 was accomplished about 8 months later during the most recent annual inspection. The AD required the inspection of the seat tracks, including but not limited to, the visual inspection of the holes in each track for excessive wear, the seat tracks for dirt or debris, and the seat locking pin for limited vertical play. The pilot and copilot seats were mounted onto a set of seat tracks, which allowed the seats to slide fore and aft. An adjustment bar was used to raise and lower two locking pins into one of twelve positions along each of the seat tracks, which would secure the seat to the desired position. The locking pins downward travel and positive locking action was aided via a spring mechanism that tensioned the adjustment bar (see figure 1). Figure 1. Illustrated Parts Catalog, Seat Diagram. On March 26, 2016, about 1208 eastern daylight time, a Cessna 172N, N6238D, impactedterrain during an attempted takeoff at Yeager Airport (CRW), Charleston, West Virginia. The flight instructor was fatally injured, and the student pilot was seriously injured. The airplane was registered to Skylane Aviation LLC and the flight was being conducted as a 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions existed at the airport about the time of the accident, and no flight plan had been filed for the local flight. The student pilot stated that the flight instructor let him taxi the airplane out from the fixed-base operator. The student was having difficulty with the brakes, so the instructor took over the controls and taxied the rest of the way to the runway and run-up area. The student pilot stated that he did not remember much after that. However, he did remember that air traffic control told them to expedite the takeoff because another aircraft was coming in for a landing and that the flight instructor then taxied out for takeoff. He recalled that as the airplane rotated during the takeoff, he heard the flight instructor exclaim, but could not recall any subsequent events. Review of airport security surveillance video revealed that the airplane lifted off about 1,000 ft down runway 5, pitched up, rolled left, and then became inverted before it impacted terrain next to the runway in a nose-down attitude. The Office of the Chief Medical Examiner, Charleston, West Virginia, performed an autopsy on the flight instructor. The cause of death was reported to be "multiple injuries." The report also noted that the flight instructor's height was 69 inches. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, conducted toxicology testing on specimens from the pilot. The results were negative for carbon monoxide and drugs. Flight Instructor According to Federal Aviation Administration (FAA) records, the flight instructor held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. She also held a flight instructor certificate with airplane single-engine and instrument airplane ratings. She was issued an FAA second-class medical certificate on June 11, 2015. At the time of the medical examination, the flight instructor reported 1,694 total hours of flight experience. The flight instructor's personal flight logs were not located. Student Pilot The student pilot held a student pilot/FAA third-class medical certificate, issued on March 9, 2016. The student's logbook had two entries indicating 3 total hours of flight experience. The wreckage was contained in a small area, and ground scars were consistent with the airplane impacting in a nose-low, right-wing-down attitude. The airplane impacted the ground about 20 yards left and midfield of runway 5 and came to rest inverted. The engine and propeller were forced up and into the instrument panel and cockpit area. The leading edges of both wings were crushed due toimpact forces. The fuselage had one wrinkle in the skin behind the rear window. The rudder and elevator were intact and unremarkable. The flaps and aileron were intact and unremarkable. Control cable continuity was established to all flight controls. Measurement of the elevator trim jackscrew corresponded to an approximate neutral trim setting. When the engine crankshaft was rotated by hand, valve train continuity was established, and thumb compression was attained on all cylinders. The propeller exhibited rotational scoring, and one blade tip was missing. All four roller housing tangs (feet) on the flight instructor's seat were spread and bent. The seat tracks were gouged where they were in contact with the locking pins. One locking pin was fractured off at the roll pin. There were lockpin contact marks in the eleventh hole location from the front to back of the inboard seat rail, consistent with the seat being near the full-aft position at impact. The inboard seat-position locking pin and outboard seat-post from the flight instructor's seat were sent to the National Transportation Safety Board's Materials Laboratory for examination. The inboard seat position locking pin had fractured, and the overall deformation pattern adjacent to the fracture was consistent with bending deformation where the outboard side of the locking pin was in tension and the inboard side was in compression. The stop-pin hole below the fracture surface on the outboard side of the rod showed necking deformation, whereas the upper side of the hole remained close to its original diameter, consistent with the stop pin being in the upper side of the hole as the locking pin was bent. Contact marks were observed on the lower side of the stop-pin hole at the inboard end of the hole, consistent with contact along the roll pin split line on the compression side of the bending fracture. ## Aircraft - Registration: [N6238D](https://openairdocs.org/deregistered/N6238D-2016-05-23), registration cancelled 2016-05-23, S/N 17272656, built 1979 (OpenAirDocs) - Reported make and model: CESSNA 172N (N) - Registry model: [Cessna 172N](https://openairdocs.org/model/cessna-172n) (registry code 2072434) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17272656 - Year built: 1979 - Airframe hours: 10995.9 - Engines: LYCOMING O-320 160 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 20, 2016, 7 hours before - Departed: CRW, Charleston, WV - Destination: CRW, Charleston, WV - Airport: CRW, Yeager, runway 5, 6,300 × 150 ft, asphalt - Equipment: Stall warning system, Electronic flight bag or handheld device, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 56; injuries: fatal; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: right; restraint: 3-point; toxicology performed; flight hours: 1,800 total, 600 in this make and model, 900 as pilot in command - Student pilot; age 42; injuries: serious; student; medical: class 3, without waivers/limitations; seat: left; restraint: 3-point; flight hours: 2 total, 2 in this make and model, 2 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 37 °F - Altimeter: 30.17 inHg - Observed at: CRW ## 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 20160326002399A](https://openairdocs.org/incident/20160326002399A), Mar 26, 2016: Cessna 172N, Charleston, WV, Destroyed, 1 fatal. The CFI performed an expedited takeoff roll on runway 05 manipulating the airplane controls from the right seat. After an approximate 600 foot takeoff roll the… ## Docket (15 files) The files NTSB released with the investigation on August 10, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92895. 67.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 669 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455188&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memorandum for Record – Telephone Interview, Student Pilot (item 2, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454895&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Student%20Pilot-Master.PDF - AD 2011-10-09 (item 3, .PDF, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454898&FileExtension=.PDF&FileName=AD%202011-10-09-Master.PDF - SEB07-R06 (item 4, .PDF, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454907&FileExtension=.PDF&FileName=SEB07-R06-Master.PDF - Excerpts From Maintenance Manual (item 5, .PDF, 363 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454910&FileExtension=.PDF&FileName=Excerpts%20From%20Maintenance%20Manual-Master.PDF - Excerpts from Information, and Safety and Warnings Manuals (item 6, .PDF, 390 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454911&FileExtension=.PDF&FileName=Excerpts%20from%20Information,%20and%20Safety%20and%20Warnings%20Manuals-Master.PDF - Excerpts From Parts Catalog (item 7, .PDF, 234 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454916&FileExtension=.PDF&FileName=Excerpts%20From%20Parts%20Catalog-Master.PDF - Maintenance Records (item 8, .PDF, 17.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455026&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Investigative Photos (item 9, .PDF, 6 photos, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455033&FileExtension=.PDF&FileName=Investigative%20Photos-Master.PDF - Materials Laboratory Factual Report 16-037 (item 10, .PDF, 5 photos, 752 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455034&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2016-037-Master.PDF - Excerpts From Airport Security Video (item 11, MP4, 44.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455035&FileExtension=mp4&FileName=Excerpts%20From%20Airport%20Security%20Video-Master - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 510 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455036&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 307 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455189&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Evidence Control Form (item 14, .PDF, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455190&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF - Toxicological Report (item 15, .PDF, 225 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455191&FileExtension=.PDF&FileName=Toxicological%20Report-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.