# NTSB GAA16LA525: Cessna 120, N76284, Davis, CA, September 18, 2016 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 18, 2016, 09:50 local (16:50 UTC) - Place: Davis, CA - Coordinates: 38.572498, -121.856941 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.5725&lon=-121.8569&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report March 19, 2018 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: Textron Aviation, FAA - NTSB case key (mKey): 94200 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16LA525 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94200/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94200 - Page: https://openairdocs.org/ntsb/GAA16LA525 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 120, 11 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2071402), [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 120, 22 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2071402), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Aircraft](https://openairdocs.org/ntsb-findings/01030000): Aircraft › Aircraft structures · Failure; cases with it: [Cessna 120, 1 case](https://openairdocs.org/ntsb-findings/01030000/cases.md?model=2071402), [All aircraft, 72 cases](https://openairdocs.org/ntsb-findings/01030000/cases.md) - [Aircraft](https://openairdocs.org/ntsb-findings/01030000): Aircraft › Aircraft structures · Inadequate inspection; cases with it: [Cessna 120, 1 case](https://openairdocs.org/ntsb-findings/01030000/cases.md?model=2071402), [All aircraft, 72 cases](https://openairdocs.org/ntsb-findings/01030000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna 120, 19 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2071402), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 120, 20 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2071402), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) - [Landing-landing roll: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cessna 120, 2 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2071402), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## 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](https://openairdocs.org/aircraft/N76284), registered now, S/N 10698, built 1946 (OpenAirDocs) - Reported make and model: CESSNA 120 (NO SERIES) - Registry model: [Cessna 120](https://openairdocs.org/model/cessna-120) (registry code 2071402) (OpenAirDocs) - Registry engine: [Continental C85 series](https://openairdocs.org/engine/continental-c85-series) (registry code 17008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 10698 - Year built: 1946 - Airframe hours: 6259.4 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: minor; 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 ## 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 20160918015729A](https://openairdocs.org/incident/20160918015729A), Sep 18, 2016: Cessna 120, Yolo, CA, Substantial damage. On 9/18/16 the pilot lost control on the rollout and went off of the runway into the dirt and fliped the aircraft upside down where it came to rest. The… ## Other investigations on N76284 (1) 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. - [NTSB LAX68D0427](https://openairdocs.org/ntsb/LAX68D0427), May 11, 1968: Cessna 120 (N76284), Tucson, AZ, substantial damage ## Docket (6 files) The files NTSB released with the investigation on October 31, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94200. 6.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 869 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457523&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (Pilot A&P) (item 2, .PDF, 454 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457524&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Pilot%20A%26P)-Master.PDF - Excerpts from Illustrated Parts Catalog - Center Safety Belt Bracket (item 3, .PDF, 559 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457525&FileExtension=.PDF&FileName=Excerpts%20from%20Illustrated%20Parts%20Catalog%20-%20Center%20Safety%20Belt%20Bracket-Master.PDF - Accident Photos (item 4, .PDF, 2 photos, 539 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457526&FileExtension=.PDF&FileName=Accident%20Photos-Master.PDF - SEB-25-03 (item 5, .PDF, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457527&FileExtension=.PDF&FileName=SEB-25-03-Master.PDF - Materials Laboratory Factual Report (item 6, .PDF, 9 photos, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457528&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%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.