# NTSB ERA19LA131: Cessna 182, N8905X, Brevard, NC, March 13, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: March 13, 2019, 18:10 local (22:10 UTC) - Place: Brevard, NC - Coordinates: 35.269721, -82.643608 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.2697&lon=-82.6436&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: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - ADs cited in the narratives: [AD 2011-10-09](https://openairdocs.org/ad/2011-10-09) (OpenAirDocs) - NTSB case key (mKey): 99139 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA131 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99139/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99139 - Page: https://openairdocs.org/ntsb/ERA19LA131 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 182D, 1 case](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=2072710), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 182D, 4 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2072710), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Fuselage: seat/cargo attach fitting](https://openairdocs.org/ntsb-findings/01035347): Aircraft › Aircraft structures · Incorrect service/maintenance (probable cause); cases with it: [Cessna 182D, 1 case](https://openairdocs.org/ntsb-findings/01035347/cases.md?model=2072710), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/01035347/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 182D, 6 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2072710), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/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 182D, 8 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072710), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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 182D, 5 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2072710), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna 182D, 6 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2072710), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## 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](https://openairdocs.org/deregistered/N8905X-2022-07-02), registration cancelled 2022-07-02, S/N 18253305, built 1961 (OpenAirDocs) - Reported make and model: Cessna 182 (D) - Registry model: [Cessna 182D](https://openairdocs.org/model/cessna-182d) (registry code 2072710) (OpenAirDocs) - Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18253305 - Year built: 1961 - Airframe hours: 4265 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: none; 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 ## 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 20190313001279A](https://openairdocs.org/incident/20190313001279A), Mar 13, 2019: Cessna 182D, Brevard, NC, Substantial damage. Pilot reports that after he applied takeoff power and began his takeoff roll that the pilot seat slid aft. This resulted in a loss of control due to pilot… ## Docket (5 files) The files NTSB released with the investigation on October 9, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99139. 20.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 16.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8839022&FileExtension=pdf&FileName=NTSB%20Accident%20report%208905X0001_Redacted-Rel.pdf - FAA inspector notes and memo for record (item 2, PDF, 3 pages, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8839837&FileExtension=pdf&FileName=FAA%20inspector%20notes%20and%20memo-Rel.pdf - Maintenance records excerpts (item 3, PDF, 2 pages, 554 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8839889&FileExtension=pdf&FileName=Most%20Recent%20Mx%20Records_Redacted-Rel.pdf - Owner's manual excerpt (item 4, PDF, 1 page, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8841084&FileExtension=pdf&FileName=Owners%20Manual%20Excerpt-Rel.pdf - Investigative photographs (item 5, PDF, 3 pages, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8839419&FileExtension=pdf&FileName=Photo%20Array%20LA131-Rel.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.