# NTSB ERA18LA253: Cirrus SR22, N161DL, Montauk, NY, September 16, 2018 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: September 16, 2018, 16:06 local (20:06 UTC) - Place: Montauk, NY - Coordinates: 41.076667, -71.920555 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.0767&lon=-71.9206&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: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report April 13, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Cirrus Aircraft - NTSB case key (mKey): 98309 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA253 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98309/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98309 - Page: https://openairdocs.org/ntsb/ERA18LA253 ## Probable cause The pilot's failure to properly secure his seat before initiating the takeoff, which resulted in the seat sliding back as the airplane accelerated during takeoff, his inability to reach the pedals, and the subsequent loss of directional control and impact with trees and shrubs. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuselage: seat/cargo attach fitting](https://openairdocs.org/ntsb-findings/01035347): Aircraft › Aircraft structures · Incorrect use/operation (probable cause); cases with it: [Cirrus Design SR22, 1 case](https://openairdocs.org/ntsb-findings/01035347/cases.md?model=2130001), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/01035347/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cirrus Design SR22, 13 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2130001), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR22, 35 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2130001), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Effect on operation (probable cause); cases with it: [Cirrus Design SR22, 11 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=2130001), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/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: [Cirrus Design SR22, 32 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2130001), [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: [Cirrus Design SR22, 40 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2130001), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cirrus Design SR22, 113 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2130001), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot was taking off for a personal, cross-country flight. He reported that, at rotation, the pilot's seat "abruptly slid backwards to the outermost distance from the controls." As a result, the pilot could no longer reach the pedals to maintain directional control, and his aileron input could not counteract the airplane's left-turning tendency. The airplane subsequently departed the left side of the runway, struck trees and shrubs, and then came to rest upright. The wings, fuselage, and empennage sustained substantial damage. According to the pilot, except for the pilot seat, the airplane performed as designed with no other anomalies noted. Examination of the pilot's seat revealed no anomalies with the installation, dimensions, or operation. The seat moved freely fore and aft with no binding or anomalous operation noted. During postaccident functional testing of the seat, when twisting forces to the right were applied to the seat and while being slid forward, the seat position locking pin could be partially engaged, but not all the pins would seat, and the control handle would not go fully down nor could it be forced into position. Straightening or forward movement of the seat resulted in full pin engagement with the control handle in the fully down position. Given this information, it is likely that the pilot applied a twisting force when moving the seat and did not fully engage the seat position locking pins before initiating the takeoff, which resulted in the seat subsequently sliding back as the airplane accelerated during takeoff and the pilot's subsequent loss of directional control. ## Factual narrative On September 16, 2018, at 1606 eastern daylight time, a Cirrus SR22, N161DL, was substantially damaged during collision with trees and terrain during takeoff from Montauk Airport (MTP), Montauk, New York. The pilot was not injured, and a passenger sustained minor injuries. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.The pilot provided a written statement and was interviewed by telephone. He said he completed the preflight inspection, engine run-up, and before-takeoff checks with no anomalies noted, and then positioned the airplane for takeoff from runway 24. The pilot advanced the throttle and tracked the runway centerline during the takeoff roll. At rotation, the pilot's seat "abruptly slid backwards to the outermost distance from the controls." The pilot said that he could no longer reach the pedals to maintain directional control, and that aileron input was inadequate to counteract the airplane's left-turning tendency. The airplane departed the left side of the runway, struck trees and shrubs, and came to rest upright. According to the pilot, except for the pilot seat, the airplane performed as designed with no other anomalies noted. The pilot stated that he had adjusted his seat prior to the flight "as normal" and had never had difficulty with the seat at any time in the past. He added that this was the third Cirrus SR22 that he had owned and had no history of seat issues with either of his previous two airplanes. The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane. His most recent Federal Aviation Administration (FAA) third class medical certificate was issued January 4, 2018. He reported 750 total hours of flight experience, all of which was in the accident airplane make and model. According to FAA records, the airplane was manufactured in 2014. Its most recent annual inspection was completed October 15, 2017 at 187.9 total aircraft hours. At 1654, the weather recorded at MTP included clear skies and variable winds at 4 knots. The temperature was 24°C, and the dew point was 19°C. The altimeter setting was 30.21 inches of mercury. Examination of photographs revealed that the wings, fuselage, and empennage all sustained substantial impact damage. An FAA inspector who responded to the site said he could not enter the cockpit, as the door was either locked or impinged by impact damage. Examination of the pilot's seat was performed by a manufacturer's representative under the supervision of an NTSB air safety investigator, and cabin safety specialist. The examination revealed no anomalies with the installation, dimensions, or operation of the pilot's seat. The seat moved freely fore and aft, with no binding or anomalous operation noted. While seated in the pilot's seat, the manufacturer's representative applied fore, aft, and twisting forces tothe seat to "unlock" the seat from a locked position. When "twisted to right while being slid forward" partial seat position locking pin engagement could be induced, but not all pins would seat and the control handle would not be fully down, and neither could it be forced into position. Straightening or forward movement of the seat resulted in full pin engagement with the control handle in the fully-down position. According to the Pilot Operating Handbook and the placard on the center console, "CREW SEATS MUST BE LOCKED IN POSITION AND CONTROL HANDLES FULLY DOWN BEFORE FLIGHT" ## Aircraft - Registration: [N161DL](https://openairdocs.org/deregistered/N161DL-2022-03-05), registration cancelled 2022-03-05, S/N 4128, built 2014 (OpenAirDocs) - Reported make and model: Cirrus SR22 (Undesignat) - Registry model: [Cirrus Design SR22](https://openairdocs.org/model/cirrus-design-sr22) (registry code 2130001) (OpenAirDocs) - Registry engine: [Continental IO-550-N](https://openairdocs.org/engine/continental-io-550-n) (registry code 17215, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 4128 - Year built: 2014 - Airframe hours: 248 - Engines: Continental IO-550-N 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 15, 2017 - Departed: MTP, Montauk, NY - Destination: HTO, East Hampton, NY - Airport: MTP, Montauk, runway 24, 3,246 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; flight hours: 750 total, 750 in this make and model ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 75 °F, dew point 66 °F - Altimeter: 30.20 inHg - Observed at: KMTP ## 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 20180916013749A](https://openairdocs.org/incident/20180916013749A), Sep 16, 2018: Cirrus Design Corp SR22, Montauk, NY, Substantial damage. Aircraft taxied onto runway 24 advanced the throttle and tracked the centerline with right rudder input. Upon rotation pilot seat abruptly slid backwards to… ## Docket (6 files) The files NTSB released with the investigation on November 29, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98309. 4.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478482&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memorandum for Record – Telephone Interview, Pilot (item 2, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478483&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Pilot-Master.PDF - Reports from Parties to the Investigation (item 3, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478484&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation-Master.PDF - Photos (item 4, .PDF, 346 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478485&FileExtension=.PDF&FileName=Photos-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478486&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478487&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.