LAX06LA192

NTSB accident investigation · Cessna 180A · Marina, CA · June 4, 2006

Accident · No injuriesLimited investigationFinal report
Date
June 4, 2006, 14:00 local (21:00 UTC)
Place
Marina, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N180LGCessna 180A
Weather
Visual (VMC) · Day
Status
Completed · report February 26, 2007
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20060604011739A
Case key
63850

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 installation of the unapproved forward seat stop by unknown maintenance personnel, which did not allow for full depth engagement of the seat lock pin, resulting in the seat slipping aft during the takeoff roll and subsequent loss of directional control. A contributing factor to the accident was the pilot's failure to secure the backup seat stop.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - on ground/waterTakeoff - roll/run
Miscellaneous,bolt/nut/fastener/clamp/spring - improperCause
Maintenance,installation - improperOther maintenance personnelCause
Fuselage,seat - not securedCause
Preflight planning/preparation - inadequatePilot in commandFactor
Safety system(other) - not engagedFactor
Aircraft control - not possiblePilot in command
On ground/water encounter with terrain/waterTakeoff - roll/run
Terrain condition - ground
Nose overTakeoff - roll/run

Analysis

The pilot's seat slid aft during the takeoff roll and the airplane nosed over after veering off the runway surface. As the pilot powered the airplane for the takeoff roll, his seat slid aft and he was unable to reach the controls to maintain control of the airplane. It veered left off the runway and came to rest inverted. Post accident examination of the seat track showed that the seat locking pin positively engaged in all of the seat track holes. The most forward hole contained a bolt used as a forward seat stop to prevent the seat from coming off of the seat track. When the seat pin was engaged in this hole, full depth engagement was not possible. Rub marks were present on the bolt shank that was visible through the seat track hole. The pilot normally flew the airplane with the seat in its forward most position. The airplane manufacturer did not design the seat stop and there was no installation record of the bolt used as a seat stop in the airplane maintenance records. The airplane was equipped with an after-market backup seat stop to prevent the seat from slipping aft if the primary seat locking mechanism failed. Although there were no mechanical problems noted with the device, the backup stop was not secured to the seat track.

Factual narrative

On June 4, 2006, at 1400 Pacific daylight time, a Cessna 180A, N180LG, sustained substantial damage when the pilot's seat slid aft and the airplane veered from the runway during the takeoff roll at Marina Municipal Airport, Marina, California. The airplane came to rest inverted. The private pilot and one passenger were not injured. The pilot, who was also the registered owner of the airplane, was operating it under the provisions of 14 CFR Part 91. Visual meteorological conditions prevailed, and no flight plan had been filed for the local area personal flight. The flight was destined for Frazier Lake Airpark, Hollister, California.

The pilot stated that during the takeoff roll, his seat slipped aft and the throttle control slipped from his grasp so he was unable to pull it to the closed position. The airplane veered left from the runway and nosed over. He had adjusted his seat prior to takeoff and noted no slippage. He believed that he had also secured the after market seat stop called a SAF-T-STOP on the seat track but was not certain. The pilot stated that he normally flew the airplane with the seat in its forward most position. The seat and seat track were last inspected during the annual inspection in September 2005.

The seat track and locking mechanism were examined on June 20, 2005, by the National Transportation Safety Board investigator, and compared with data obtained from airworthiness directive (AD) 87-20-03 R2. AD 87-20-03 R2 defines the airworthiness requirements and minimum acceptable wear on the seat locking mechanism and seat track components. The seat track roller assembly was intact and operational. The seat track holes were measured using an electronic micrometer. The holes were all within specified tolerances. The roller housing had a light coat of dust and grime. The rollers turned freely on their axle bolts. The spring that keeps the locking pin in place provided positive engagement. The tang thickness was greater than 1/2 of the roller housing thickness.

Two bolts were installed through the seat track; one through the most forward hole and one through the most aft hole. The purpose of the bolts was to serve as the fore and aft seat stops. The bolts fit perpendicular to the seat track and were secured to the track using nuts. The forward bolt shank that was visible through the seat track hole had noticeable rub marks on its upper surface. When the bolt was removed and examined, there were no rub marks on the bottom portion of the bolt.

The seat lock pin was engaged in each of the seat track holes and did not disengage with an applied force. The investigator noted that when the seat pin was engaged in the most forward hole with the bolt through it, specified depth engagement of the seat pin was not possible. When the locking pin passed through the hole, it would hit the shank of the bolt prior to reaching its full locking depth. There was no installation record of the bolt seat stop in the airplane maintenance records.

The airplane inside seat track was equipped with a SAF-T-STOP. The stop was not tightened on the track and was free to move fore and aft. When the investigator tightened the stop on the seat track, the seat did not move past the stop. The purpose of the SAF-T-STOP is to prevent the seat from slipping aft if the primary seat locking mechanism fails.

According to Cessna Aircraft Company, the approved seat stop uses a U-shaped piece of metal that fits over the seat track and is held using a pin through the side hole. This is secured using a cotter pin. The design does not allow the seat lock pin to engage in the hole through which it is secured.

Aircraft

Registration
N180LG
Reported as
Cessna 180A
Category
Airplane
Serial number
32693
Airframe hours
3,112
Engine
Teledyne Continental O-470-K, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 1, 2005 · 47 hours before
Departed
OAR · Marina, CA
Destination
1C9 · Hollister, CA
Airport
OAR · Marina, runway 29, 3,000 × 75 ft, asphalt

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
69
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
June 1, 2004
Seat
Left
Flight hours
2,206 total · 1,512 in this make and model · 31 in the last 90 days · 18 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 9 knots
Visibility
10 statute miles
Lowest ceiling
1,200 ft broken
Temperature
64 °F, dew point 55 °F
Altimeter
30.02 inHg
Observed at
MRY, 7 nm away

Docket · 7

The files NTSB released with the investigation on December 18, 2006, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.5 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.