# NTSB NYC08LA228: Cessna 172M, N13105, Toms River, NJ, June 25, 2008

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: June 25, 2008, 13:46 local (17:46 UTC)
- Place: Toms River, NJ
- Coordinates: 39.927223, -74.292221
- Nearby events: https://openairdocs.org/map.md?lat=39.9272&lon=-74.2922&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Minor injuries
- Injuries: 2 minor
- Status: Completed, report October 19, 2009
- Report: Approved by Office Director
- Parties: FAA/FSDO, Cessna Aircraft Company
- ADs cited in the narratives: [AD 87-20-03 R2](https://openairdocs.org/ad/87-20-03-R2) (OpenAirDocs)
- NTSB case key (mKey): 68310
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08LA228
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68310/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=68310
- Page: https://openairdocs.org/ntsb/NYC08LA228

## Probable cause

The failure of the pilot's seat to engage or remain engaged due to the improper inspection of the worn seat tracks.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Fuselage: seat/cargo attach fitting](https://openairdocs.org/ntsb-findings/01035347): Aircraft › Aircraft structures · Malfunction (probable cause); cases with it: [Cessna 172M, 1 case](https://openairdocs.org/ntsb-findings/01035347/cases.md?model=2072418), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/01035347/cases.md)
- [Fuselage: seat/cargo attach fitting](https://openairdocs.org/ntsb-findings/01035347): Aircraft › Aircraft structures · Inadequate inspection (probable cause); cases with it: [Cessna 172M, 1 case](https://openairdocs.org/ntsb-findings/01035347/cases.md?model=2072418), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/01035347/cases.md)
- [Inspection](https://openairdocs.org/ntsb-findings/02061500): Personnel issues › Task performance · Not specified (probable cause); cases with it: [Cessna 172M, 1 case](https://openairdocs.org/ntsb-findings/02061500/cases.md?model=2072418), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/02061500/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Takeoff: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330); cases with it: [Cessna 172M, 4 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=2072418), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md)
- [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 172M, 47 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072418), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172M, 100 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072418), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

During a soft-field takeoff demonstrated by the student pilot, the certificated flight instructor's(CFI's) seat rolled backward, and he instinctively reached for the control yoke. The airplane yawed to the left, the left wing struck the ground, and the airplane flipped over. The CFI stated that he adjusted the seat forward prior to taxiing the airplane to the runway and recalled "shaking the seat" to assure it was in the locked position. Examination of the seat tracks for the CFI's seat revealed that all four roller housing tangs (feet) were spread and bent, and the corresponding locations on the seat tracks were gouged. Examination of the seat tracks for both seats revealed several seat pin adjustment holes exceeded the dimensions for acceptable wear as described in the Cessna Service Manual, and "excessive wear" was noted to the seat track cap widths and the roller housing tangs. An Airworthiness Directive (AD) which required inspection of the seat tracks was completed 90 hours prior to the accident. The AD did not require inspection for excessive wear to the seat track cap widths and the tangs of the seat housings.

## Factual narrative

On June 25, 2008, at 1346 eastern daylight time, a Cessna 172M, N13105, was substantially damaged during takeoff from Robert J. Miller Airpark (MJX), Toms River, New Jersey. The certificated flight instructor (CFI) and student pilot received minor injuries. Visual meteorological conditions prevailed, and no flight plan was filed for the instructional flight destined for Lakehurst Naval Air Station/Maxwell Field (NEL), Lakehurst, New Jersey, and conducted under Title 14 Code of Federal Regulations Part 91. The airplane was operated by a Flying Club for the purpose of flight training. According to the CFI, the student pilot was at the controls during the takeoff, as he was demonstrating a soft-field takeoff. As the airplane's nose lifted off the runway, the CFI's seat rolled backward, and he instinctively reached for the control yoke. The airplane then yawed to the left, and the left wing struck the ground. Upon impact, the airplane spun around, the nose wheel impacted a rut in the grass, and the airplane flipped over. The CFI stated he "distinctly remembered adjusting the seat forward," prior to taxiing the airplane to the runway, "as it had been moved backwards to exit the airplane [after landing]." The CFI reported "shaking the seat" to assure it was in the locked position. The student pilot stated he observed the CFI "rocking his seat to ensure it was secure" during the preflight. During the takeoff, the student pilot heard a noise which he thought was the tail of the airplane scraping the runway, followed by the CFI stating that his "seat was rolling back." After the airplane came to rest inverted, the student pilot remained strapped into his seat by the seatbelt and shoulder harness; however, his seat was separated from the floor of the airplane during the accident sequence. The student pilot noted that the CFI was secured in his seat by his seatbelt and shoulder harness, and that the CFI's seat remained attached to the floor of the airplane. The student pilot removed his seat from the airplane during the egress. Examination of the airplane by a Federal Aviation Administration (FAA) inspector and a representative of Cessna Aircraft revealed that the forward portion of the seat tracks for seat No. 1 (student pilot's seat) were cracked and slightly deformed upwards at the fifth adjustment hole. The aft portion of both tracks for seat No. 1 displayed impact damage consistent with the shape of the aft roller housings. The cap on the outboard track had wear grooves. The guide holes for the adjustment pin displayed oblong wear, and the bottom of the track holes exhibited wear spots, where the adjustment pins made contact. The adjustment pins were not bent, the roll pins were installed, and the spring was intact. The forward portion of the seat tracks for seat No. 2 (CFI's seat) were also cracked and slightly deformed upwards at the fifth adjustment hole. All four roller housing tangs (feet) were spread and bent. The front feet were off the track,while the two rear feet remained partially attached to the track. The tracks were gouged where they were in contact with the rear seat legs. The guide holes for the adjustment pins displayed oblong wear, and the bottom of the track holes had wear spots, where the adjustment pins made contact. The adjustment pins were not bent, the spring was intact and the tension was strong. Examination of the seat tracks for both seats revealed several seat pin adjustment holes exceeded the dimensions for acceptable wear as described in the Cessna Service Manual, and "excessive wear" was noted to the seat track cap widths and the roller housing tangs. The airplane sustained substantial damage to the vertical stabilizer, rudder, and left wing. Examination of the airplane's maintenance records revealed the airplane had accumulated 8,631 hours of total time. The seat tracks were replaced on July 23, 1993 at 6,019 hours total time. The Seat Track Inspection Airworthiness Directive (AD) 87-20-03R2 was complied with during the most recent annual inspection on June 16, 2007 at 8,541 hours total flight time. The AD required the inspection of the seat tracks; specifically the holes in each track for excessive wear, dirt or debris, and limited vertical play. The AD did not require inspection for excessive wear to the seat track cap widths and the tangs of the seat housings. Inspection time and date criteria outlined in the AD required that aircraft operated under Part 91 regulations (not for hire) only required the inspection after accumulation of 1,000 hours, at the next annual inspection, and each subsequent annual inspection. The CFI held a commercial pilot certificate with ratings for single-engine and multiengine land and instrument airplane. He also held a flight instructor certificate with a rating for airplane single-engine land. The CFI reported approximately 6,153 hours of total flight experience, 1,018 of which were in the Cessna 172. The CFI's most recent second-class medical certificate was issued on June 29, 2007. At that time, he reported a weight of 235 pounds. The student pilot reported 92 hours of total flight experience, 91 of which were in the Cessna 172. His most recent third-class medical certificate was issued on July 15, 2006. At that time, he reported a weight of 250 pounds. The winds reported at the airport at 1335, were from 280 degrees at 9 knots, gusting to 14 knots.

## Aircraft

- Registration: [N13105](https://openairdocs.org/deregistered/N13105-2013-11-12), registration cancelled 2013-11-12, S/N 17262499, built 1973 (OpenAirDocs)
- Reported make and model: CESSNA 172M
- Registry model: [Cessna 172M](https://openairdocs.org/model/cessna-172m) (registry code 2072418) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 17262499
- Airframe hours: 8631
- Engines: Lycoming O-320 150 horsepower reciprocating
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Operator: Lakehurst Navy Flying Club
- Registered owner: Lakehurst Navy Flying Club
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, June 16, 2007, 90 hours before
- Departed: MJX, Toms River, NJ
- Destination: NEL, Lakehurst, NJ
- Airport: MJX, Robert Miller Air Park, runway 24, 5,949 × 100 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Flight instructor; age 62; injuries: minor; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review July 11, 2006; seat: right; flight hours: 6,153 total, 1,018 in this make and model, 5,933 as pilot in command, 149 in the last 90 days, 65 in the last 30 days, 3 in the last 24 hours
- Student pilot; age 55; injuries: minor; medical: class 3, with waivers/limitations; last flight review June 18, 2008; seat: left; flight hours: 92 total, 91 in this make and model, 32 as pilot in command, 14 in the last 90 days, 3 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 280° at 9 knots, gusting 14
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 84 °F, dew point 52 °F
- Altimeter: 30.15 inHg
- Observed at: MJX

## 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 20080625839919A](https://openairdocs.org/incident/20080625839919A), Jun 25, 2008: Cessna 172, Toms River, NJ, Substantial damage. (-23) The purpose of the dual instructional flight was to prepare the student for the private pilot checkride. A simulated soft field takeoff was commenced…

## Docket (15 files)

The files NTSB released with the investigation on August 28, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=68310. 11.5 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 832 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316559&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Student Pilot Statement (item 2, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316560&FileExtension=.PDF&FileName=Student%20Pilot%20Statement-Redacted.PDF
- MJX Recorded Weather Observations (item 3, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316561&FileExtension=.PDF&FileName=MJX%20Recorded%20Weather%20Observations-Master.PDF
- CFI Interview (item 4, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316637&FileExtension=.PDF&FileName=CFI%20Interview-Redacted.PDF
- FAA Interview (item 5, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317004&FileExtension=.PDF&FileName=FAA%20Interview-Redacted.PDF
- Photo 1 (Courtesy of Cessna Aircraft) - Seat #2 tracks (item 6, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316991&FileExtension=.PDF&FileName=Photo%201%20(Courtesy%20of%20Cessna%20Aircraft)%20-%20Seat%20%232%20tracks-Master.PDF
- Photo 2 (Courtesy of Cessna Aircraft) - Seat #2 aft seat foot (inboard) (item 7, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316994&FileExtension=.PDF&FileName=Photo%202%20(Courtesy%20of%20Cessna%20Aircraft)%20-%20Seat%20%232%20aft%20seat%20foot%20(inboard)-Master.PDF
- Photo 3 (Courtesy of Cessna Aircraft) - Seat #2 aft seat foot (outboard) (item 8, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316995&FileExtension=.PDF&FileName=Photo%203%20(Courtesy%20of%20Cessna%20Aircraft)%20-%20Seat%20%232%20aft%20seat%20foot%20(outboard)-Master.PDF
- Photo 4 (Courtesy of Cessna Aircraft) - Seat #2 forward seat foot (outboard) worn pin guide (item 9, .PDF, 501 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316996&FileExtension=.PDF&FileName=Photo%204%20(Courtesy%20of%20Cessna%20Aircraft)%20-%20Seat%20%232%20forward%20seat%20foot%20(outboard)%20worn%20pin%20guide-Master.PDF
- Photo 5 (Courtesy of Cessna Aircraft) - Seat #2 forward seat foot (inboard) worn pin guide (item 10, .PDF, 523 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316997&FileExtension=.PDF&FileName=Photo%205%20(Courtesy%20of%20Cessna%20Aircraft)%20-%20Seat%20%232%20forward%20seat%20foot%20(inboard)%20worn%20pin%20guide-Master.PDF
- Photo 6 (Courtesy of Cessna Aircraft) - Seat #2 inboard seat feet (item 11, .PDF, 992 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316998&FileExtension=.PDF&FileName=Photo%206%20(Courtesy%20of%20Cessna%20Aircraft)%20-%20Seat%20%232%20inboard%20seat%20feet-Master.PDF
- Photo 7 (Courtesy of Cesnna Aircraft) - Seat #2 outboard seat rail with damage from forward foot (item 12, .PDF, 498 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316999&FileExtension=.PDF&FileName=Photo%207%20(Courtesy%20of%20Cesnna%20Aircraft)%20-%20Seat%20%232%20outboard%20seat%20rail%20with%20damage%20from%20forward%20foot-Master.PDF
- Photo 8 (Courtesy of Cessna Aircraft) - Seat #2 feet/nylon rollers/spacers (item 13, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317000&FileExtension=.PDF&FileName=Photo%208%20(Courtesy%20of%20Cessna%20Aircraft)%20-%20Seat%20%232%20feet%2Fnylon%20rollers%2Fspacers-Master.PDF
- Aircraft Logbooks (excerpt) (item 14, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317134&FileExtension=.PDF&FileName=Aircraft%20Logbooks%20(excerpt)-Redacted.PDF
- Cessna Report (excerpt) (item 15, .PDF, 247 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317305&FileExtension=.PDF&FileName=Cessna%20Report%20(excerpt)-Redacted.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.

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