GAA16LA525

NTSB accident investigation · Cessna 120 · Davis, CA · September 18, 2016

Accident · Serious injuriesLimited investigationFinal report
Date
September 18, 2016, 09:50 local (16:50 UTC)
Place
Davis, CA
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N76284Cessna 120
Defining event
Landing-landing roll: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed · report March 19, 2018
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
Textron Aviation, FAA
FAA report
20160918015729A
Case key
94200

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

On this page

Probable cause

The pilot's failure to maintain directional control during the landing roll, which resulted in a runway excursion and noseover. Contributing to the accident was the failure of the seatbelt anchor bracket.

Findings · 4

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.

Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 120: 11 casesAll aircraft: 3,958 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 120: 22 casesAll aircraft: 9,295 casesProbable cause
AircraftAircraft › Aircraft structures · FailureCessna 120: 1 caseAll aircraft: 72 cases
AircraftAircraft › Aircraft structures · Inadequate inspectionCessna 120: 1 caseAll aircraft: 72 cases

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 private pilot of the tailwheel-equipped airplane reported that, during the landing roll, the airplane "began suddenly swerving" and would not respond to opposite rudder inputs. The airplane veered off the runway into a freshly-plowed field where it nosed over and came to rest inverted. The pilot stated there were no mechanical malfunctions or anomalies that would have precluded normal operation of the airplane. The pilot further reported that, during the noseover, the center seatbelt anchor bracket failed, which resulted in both occupants falling out of their seats once the airplane became inverted. About 2 years before the accident, in response to a similar accident, the manufacturer issued a service bulletin that called for inspection of the center seat belt bracket to ensure that the latest type (steel) bracket was installed. The service bulletin had not been completed on the accident airplane.

Factual narrative

On September 18, 2016, about 0950 Pacific daylight time (PDT), a Cessna 120 airplane, N76284, veered off the runway during the landing roll, and nosed over at Yolo County Airport (DWA) in Davis, California. The empennage sustained substantial damage. The pilot sustained minor injuries and the sole passenger sustained serious injuries. The airplane was registered to a private individual, and was operated by the pilot as a visual flight rules (VFR), local, personal flight under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the flight; no flight plan was filed. The flight originated from DWA, about 0840 PDT. The pilot of the tailwheel-equipped airplane reported that, during the landing roll, the airplane "began suddenly swerving with increasingly tremendous centrifugal force to the left" and would not respond to opposite rudder inputs. The airplane veered off the runway to the left and into a freshly plowed field. During the runway excursion, the airplane crossed over a dirt trench, and then nosed over. During the nose over, the center safety belt bracket, which secures the pilot and front seat passenger's seatbelts to the cabin floor failed, and the pilot was released from his seatbelt. An examination of the restraint system revealed that the aluminum center safety belt bracket, which was likely installed when the airplane was manufactured in 1946, had failed in shearing overstress during the nose over, which resulted in the pilot being released from the restraint system. Examination of the airplane manufacturer's records revealed that shortly after the airplane was manufactured, the manufacturer began installing a steel center safety belt bracket in new production airplanes. (See Materials Laboratory Factual Report in public docket for additional information.) Following a similar accident (ERA14FA327), the manufacturer issued a service bulletin on February 17, 2015 that called for inspection of the center safety belt bracket on all Cessna 120 and 140 airplanes to determine if the latest type (steel) bracket was installed and replacement of any older type (aluminum) brackets found with the latest type. (See SEB-25-03 in public docket for additional information.) During a telephone conversation with the mechanic that completed the airplane's annual inspection, he stated that he was unaware of the service bulletin related to the center safety belt bracket. A review of the FAA aircraft registry database found that approximately 2,145 airplanes, which were manufactured with this center safety belt bracket, were currently registered in the United States. Of these, about 2,099 (98%) were manufactured before the effectivity of the material change.

Aircraft

Registration
N76284
Reported as
Cessna 120 (NO SERIES)
Category
Airplane
Serial number
10698
Built
1946
Airframe hours
6,259.4
Engine
Continental C-85-12F, 85 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 16, 2015
Departed
DWA · Davis, CA
Destination
DWA · Davis, CA
Airport
DWA · Yolo County, runway 34, 6,000 × 100 ft, asphalt
Equipment
None

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
45
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
May 23, 2016
Seat
Left
Restraint
Lap only
Flight hours
119 total · 5 in this make and model · 55 as pilot in command · 13 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
80° at 3 knots
Lowest ceiling
None
Temperature
75 °F, dew point 48 °F
Altimeter
30.00 inHg
Observed at
KEDU, 4 nm away

Docket · 6

The files NTSB released with the investigation on October 31, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.1 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.

Other investigations on N76284 · 1

Matched to the same aircraft by N-number and date.