ERA19LA131

NTSB accident investigation · Cessna 182 · Brevard, NC · March 13, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
March 13, 2019, 18:10 local (22:10 UTC)
Place
Brevard, NC
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N8905XCessna 182
Defining event
Takeoff: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20190313001279A
Case key
99139

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

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Probable cause

The mechanic's failure to notice that the left front seat left front roller housing disengaged from the seat rail during recent maintenance, and the pilot's failure to detect the disengaged roller housing during the preflight inspection, which resulted in the seat sliding backward during takeoff and a subsequent loss of airplane directional control.

Findings · 5

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.

Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelCessna 182D: 1 caseAll aircraft: 70 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotCessna 182D: 4 casesAll aircraft: 551 casesProbable cause
Fuselage: seat/cargo attach fittingAircraft › Aircraft structures · Incorrect service/maintenanceCessna 182D: 1 caseAll aircraft: 27 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleCessna 182D: 6 casesAll aircraft: 3,958 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 182D: 8 casesAll aircraft: 9,295 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 pilot performed a preflight inspection after the airplane had undergone maintenance and no anomalies were noted. He boarded the airplane, adjusted the seat, and then verified that it was locked in position. Shortly after beginning the takeoff roll, his seat slid backward. He was unable to reach the rudder pedals, and the airplane departed the left side of the runway, nosed over, and came to rest inverted. Examination revealed that the pilot seat’s left front roller housing was disengaged from the seat rail. The seat rail exhibited scoring on top of the rail, which likely occurred during the accident sequence. No scoring was noted on the sides of the rail. The roller housing was not splayed or damaged, indicating that it did not pull off the rail during the accident sequence. Although the seat rail holes were slightly worn, the pin did not exhibit any anomalies. The mechanic stated that he did not remove the pilot's seat to perform the maintenance that he completed before the accident flight; however, given the lack of side damage to the rails and the fact that the left front seat roller housing was not splayed, it is likely that the roller housing came off the rails during the maintenance and went unnoticed by both the mechanic and the pilot, which resulted in the seat sliding backward during takeoff.

Factual narrative

On March 13, 2019, about 1810 eastern daylight time, a Cessna 182D, N8905X, was substantially damaged after it impacted terrain during takeoff from Transylvania Community Airport (3NR3), Brevard, North Carolina. The private pilot was not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was originating at the time of the accident. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the pilot, he completed a preflight inspection with no anomalies noted. When he boarded the airplane, the pilot seat was in its aft most position, since that was how he would typically exit the airplane. The pilot then slid the seat forward until he "could see 3 holes" in the rail, which was his typical seating position. He then "rocked the seat back and forth" to verify it was locked in position, and then proceeded to start the engine, taxi, and perform an engine runup. He then taxied onto the runway and began the takeoff roll. About 4-5 seconds into the takeoff roll, his seat slid backwards. At that point, he was unable to reach the rudder pedals, and the airplane departed the left side of the runway, nosed over, and came to rest inverted. According to a Federal Aviation Administration (FAA) inspector who responded to the accident location, the airplane sustained substantial damage to the wings and fuselage. According to FAA airworthiness records, the airplane was manufactured in 1961 and registered to the pilot in January 2019. The airplane's most recent annual inspection was completed on August 18, 2018, at a total time of 4,251.8 hours. In addition, the annual inspection maintenance log entry indicated that an inspection in accordance with airworthiness directive (AD) 2011-10-09, associated with a seat rail inspection, had been completed. At the time of the accident, the airplane had accumulated 4,265 total hours. In an interview with the FAA inspector, a mechanic was working on the airplane the day before the accident to replace the transponder. He stated that sometimes he does have to remove the front seats to perform the work, however, he did not have the left front seat out of the airplane during the maintenance work, he only had the right front seat out of the airplane. An examination of the left front seat rails revealed that the housings remained engaged on the seat rails except the left forward roller housing, which was disengaged from the seat rail. The housing tangs were not worn, distorted, or splayed. The pin that engaged into the track had no anomalies, the pin spring had positive engaging forces, and the holes were slightly worn. The seat rail was not damaged along the sides of the rail; however, the top of the rail had scoring marks. According to the airplane owner's manual, the before engine start checklist stated, "Adjust seat to a comfortable position, check to see the seat locking mechanism is secure, and fasten safety belt."

Aircraft

Registration
N8905X
Reported as
Cessna 182 (D)
Category
Airplane
Serial number
18253305
Built
1961
Airframe hours
4,265
Engine
Continental O-470 SERIES, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 18, 2018 · 13 hours before
Departed
3NR3 · Brevard, NC
Destination
AVL · Asheville, NC
Airport
3NR3 · Transylvania Community, runway 27, 2,903 × 50 ft, asphalt
Equipment
Stall warning system, Handheld GPS

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
60
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
April 18, 2018
Seat
Left
Flight hours
294 total · 294 in this make and model · 240 as pilot in command · 14 in the last 90 days · 1 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 32 °F
Altimeter
30.21 inHg
Observed at
AVL, 11 nm away

Docket · 5

The files NTSB released with the investigation on October 9, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.3 MB 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.