# NTSB WPR09CA059: Cessna 210, N9619T, Sheridan, WY, December 17, 2008

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Data collection · Final report
- Date: December 17, 2008, 12:20 local (19:20 UTC)
- Place: Sheridan, WY
- Coordinates: 44.769165, -106.980278
- Nearby events: https://openairdocs.org/map.md?lat=44.7692&lon=-106.9803&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed, report January 22, 2009
- Report: Approved by Office Director
- NTSB office: Western Pacific Region
- Parties: Federal Aviation Administration
- NTSB case key (mKey): 69597
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09CA059
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/69597/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=69597
- Page: https://openairdocs.org/ntsb/WPR09CA059

## Probable cause

Maintenance personnel's failure to reinstall the left front pilot's seat correctly, which resulted in the pilot's loss of control and subsequent impact with a taxiway sign.

## 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 · Incorrect service/maintenance (probable cause); cases with it: [Cessna 210, 1 case](https://openairdocs.org/ntsb-findings/01035347/cases.md?model=2073402), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/01035347/cases.md)
- [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 210, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2073402), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md)

## Sequence of events

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

- [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna 210, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=2073402), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md)
- [Takeoff: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Cessna 210, 6 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=2073402), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md)
- [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Cessna 210, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=2073402), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md)

## Analysis

During the preflight inspection the pilot noticed a small amount of hydraulic oil pooled by the trim wheel. In order to troubleshoot the problem, maintenance personnel removed the left front pilot's seat and then reinstalled it when the problem was resolved. After adding full power and during the takeoff roll the pilot's seat abruptly slid to the full back position, resulting in the airplane veering sharply to the left as the pilot's feet left the rudder pedals. In order to avoid taxi signs on the left side of the runway, the pilot rotated, but then heard something strike the airplane. Airborne, the pilot managed to get the seat forward, climb to pattern altitude, and land uneventfully. After securing the airplane the pilot noticed that the left front seat had not been reinstalled in the seat rail, but was resting on top of it. Damage to the airplane consisted of a propeller strike, a hole in the undercarriage, and damage to both horizontal stabilizers.

## Factual narrative

During the preflight inspection the pilot noticed a small amount of hydraulic oil pooled by the trim wheel. In order to trouble shoot the problem maintenance personnel removed the left front pilot's seat and then reinstalled it when the problem was resolved. After adding full power and during the takeoff roll the pilot's seat abruptly slid to the full back position, resulting in the airplane veering sharply to the left as the pilot's feet left the rudder pedals. In order to avoid taxi signs on the left side of the runway the pilot rotated, but then he heard something strike the airplane. Airborne, the pilot managed to get the seat forward, climb to pattern altitude, and land uneventfully. After securing the airplane the pilot noticed that the left front seat had not been reinstalled in the seat rail, but was resting on top of it. Damage to the airplane consisted of a propeller strike, a hole in the undercarriage, and damage to both horizontal stabilizers.

## Aircraft

- Registration: [N9619T](https://openairdocs.org/deregistered/N9619T-2014-11-24), registration cancelled 2014-11-24, S/N 57419, built 1961 (OpenAirDocs)
- Reported make and model: CESSNA 210
- Registry model: [Cessna 210](https://openairdocs.org/model/cessna-210) (registry code 2073402) (OpenAirDocs)
- Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 57419
- Airframe hours: 3244
- Engines: Teledyne Continental IO-470 260 horsepower reciprocating
- Damage: Substantial damage
- Flight: Business, Part 91
- Operator: Daleray Madewell
- Registered owner: Madewell Inc.
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, December 11, 2008
- Departed: SHR, Sheridan, WY
- Destination: DGW, Douglas, WY
- Airport: SHR, Sheridan County Airport, runway 23, 5,039 × 75 ft, gravel

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 44; injuries: none; private; airplane ratings: single-engine land; medical: class 3; last flight review June 3, 2008; seat: left; flight hours: 206 total, 192 in this make and model, 149 as pilot in command, 38 in the last 90 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 340° at 4 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 23 °F, dew point 9 °F
- Observed at: SHR

## Other investigations on N9619T (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 WPR12FA098](https://openairdocs.org/ntsb/WPR12FA098), Feb 9, 2012: Cessna 210 (N9619T), Morgan, UT, substantial damage, 2 fatal. Probable cause: The non-instrument-rated pilot’s poor planning and continued visual flight rules flight into instrument meteorological conditions and failure to maintain clearance from mountainous terrain.

## Docket (1 files)

The files NTSB released with the investigation on January 6, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=69597. 825 KB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 825 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305850&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-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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