# NTSB WPR18LA259: Cessna 172, N24ME, Roche Harbor, WA, September 12, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: September 12, 2018, 08:10 local (15:10 UTC) - Place: Roche Harbor, WA · on airport - Coordinates: 48.61222, -123.13861 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=48.6122&lon=-123.1386&mi=10 - Phase of flight: [Prior to flight](https://openairdocs.org/ntsb-phases/100) (OpenAirDocs' grouping) - Defining event: [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 98285 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR18LA259 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98285/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98285 - Page: https://openairdocs.org/ntsb/WPR18LA259 ## Probable cause The pilot’s failure to secure his seat position prior to takeoff, which resulted in a loss of airplane control and subsequent hard landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incomplete action](https://openairdocs.org/ntsb-findings/02041040): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 172S, 2 cases](https://openairdocs.org/ntsb-findings/02041040/cases.md?model=2072439), [All aircraft, 105 cases](https://openairdocs.org/ntsb-findings/02041040/cases.md) - [Misc hardware: fasteners](https://openairdocs.org/ntsb-findings/01071430): Aircraft › Fluids/misc hardware · Incorrect use/operation (probable cause); cases with it: [Cessna 172S, 1 case](https://openairdocs.org/ntsb-findings/01071430/cases.md?model=2072439), [All aircraft, 58 cases](https://openairdocs.org/ntsb-findings/01071430/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 172S, 206 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072439), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030) (defining event); cases with it: [Cessna 172S, 6 cases](https://openairdocs.org/ntsb-events/030/sequence.md?model=2072439), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Cessna 172S, 77 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2072439), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis The pilot reported that he adjusted his seat and “wiggled it” prior to takeoff to ensure it was locked in place. However, during the takeoff roll, the seat moved all the way aft, and the pilot was not able to reach the throttle or the rudder pedals. The airplane veered to the left and lifted off the ground. Shortly after, the tail struck the ground, followed by the left wing, and the airplane came to rest on its nose. A postaccident examination of the seat rail and latching mechanism revealed no anomalies. There was proper hole engagement with the seat pin and holes in the seat rail; the seat did not move once the stop was engaged with the hole. Therefore, it is likely that although the pilot attempted to secure his seat before takeoff, the seat pin was likely not engaged in the corresponding hole in the seat rail, which resulted in its aft movement when the airplane gained speed during the takeoff roll. ## Factual narrative On September 12, 2018, at 0810 Pacific daylight time, a Cessna 172 airplane, N24ME, was substantially damaged when it was involved in an accident near Roche Harbor, Washington. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. According to the pilot, just prior to takeoff, he adjusted his seat and “wiggled it” to ensure it was locked. During the takeoff roll, the seat moved all the way aft, and the pilot was not able to reach the throttle or the rudder pedals. The airplane veered to the left and lifted off the ground. Shortly after, the tail struck the ground, followed by the left wing, and the airplane came to rest on its nose. A Federal Aviation Administration (FAA) inspector responded to the accident site. The FAA inspector observed the pilot’s seat in the farthest aft position with the stops engaged in the aft holes. He further reported that the seat moved freely in both directions, to each stop, with no binding encountered. Additionally, there was proper hole engagement with the seat pin and holes in the seat rail; the seat did not move once the stop was engaged with the hole. ## Aircraft - Registration: [N24ME](https://openairdocs.org/deregistered/N24ME-2019-11-08), registration cancelled 2019-11-08, S/N 172S8463, built 2000 (OpenAirDocs) - Reported make and model: Cessna 172 (S) - Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172S8463 - Year built: 2000 - Engines: Lycoming IO-540 SER 300 horsepower reciprocating - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: Island Air - Registered owner: Cannery Leasing Ltd - Airworthiness certificate: Standard, Normal - Destination: BLI, Bellingham, WA - Airport: WA09, Roche Harbor, runway 25, 3,593 × 30 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: none; commercial, airline transport; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: class 1, with waivers/limitations; seat: left; flight hours: 5,030 total, 0 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 0.5 statute miles - Lowest ceiling: 400 ft overcast - Temperature: 55 °F, dew point 54 °F - Altimeter: 29.92 inHg - Observed at: KFHR, 7 nm away - METAR: METAR KFHR 121453Z AUTO 00000KT 2 1/2SM BR OVC004 13/12 A2992 ## 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 20180912013449A](https://openairdocs.org/incident/20180912013449A), Sep 12, 2018: Cessna 172S, Roche Harbor, WA, Substantial damage. The pilot seat rail adjustment was not in the lock position. On departure roll, the pilot seat slid all the way back to the most aft limit keeping the pilot… ## Docket (2 files) The files NTSB released with the investigation on March 24, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98285. 3.6 MB in all. - Summary of findings FAA (item 1, PDF, 1 page, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13425344&FileExtension=pdf&FileName=Summary%20of%20Findings%20FAA_Redacted-Rel.pdf - Photos (item 2, PDF, 4 pages, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13425548&FileExtension=pdf&FileName=Photos-Rel.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.