# NTSB WPR23LA337: Cessna 195B, N2192C, Los Lunas, NM, August 25, 2023 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 4 · Limited · Final report - Date: August 25, 2023, 10:15 local (16:15 UTC) - Place: Los Lunas, NM · E98 - Coordinates: 34.76, -106.74 - Nearby events: https://openairdocs.org/map.md?lat=34.7600&lon=-106.7400&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Western Pacific Region - Parties: Federal Aviation Administraton - NTSB case key (mKey): 193018 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR23LA337 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193018/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=193018 - Page: https://openairdocs.org/ntsb/WPR23LA337 ## Probable cause The pilot’s failure to secure the seat’s position in the seat rail, which resulted in a loss of directional control and nose over. ## 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 195B, 13 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2073112), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 195B, 3 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2073112), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Aircraft](https://openairdocs.org/ntsb-findings/01020000): Aircraft › Aircraft systems · Not installed/available; cases with it: [Cessna 195B, 1 case](https://openairdocs.org/ntsb-findings/01020000/cases.md?model=2073112), [All aircraft, 63 cases](https://openairdocs.org/ntsb-findings/01020000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna 195B, 12 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2073112), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis The pilot reported that during the takeoff roll, his seat slid aft on the seat rails, and he could not reach the rudder pedals. He reduced engine power and stretched to reach the brakes, however, he no longer had forward visibility. The airplane drifted to the right, and then to the left of the runway. The pilot braked hard, and the airplane nosed over. He later realized that the seat position peg had not been fully seated in the seat rail detent, and that the rear seat rail cotter pin was not installed. Both wings, the vertical stabilizer, and the rudder were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation. ## Aircraft - Registration: [N2192C](https://openairdocs.org/aircraft/N2192C), registered now, S/N 16177, built 1955 (OpenAirDocs) - Reported make and model: CESSNA 195B - Registry model: [Cessna 195B](https://openairdocs.org/model/cessna-195b) (registry code 2073112) (OpenAirDocs) - Registry engine: [Jacobs R755B series](https://openairdocs.org/engine/jacobs-r755b-series) (registry code 35007, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 16177 - Year built: 1954 - Airframe hours: 2769 - Engines: Jacobs R755B2 275 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 24, 2022 - Airport: E98, Mid Valley Airpark, runway 36, 4,332 × 37 ft, asphalt - Equipment: ADS-B, Handheld GPS, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 79; injuries: serious; airline transport; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane, helicopter; medical: basicmed, without waivers/limitations; last flight review December 11, 2021; seat: left; restraint: 3-point; flight hours: 13,000 total, 800 in this make and model, 30 in the last 90 days, 20 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 61 °F - Altimeter: 30.28 inHg - Observed at: KBRG, 8 nm away - METAR: METAR KBRG 251635Z AUTO 18009KT 10SM CLR 27/16 A3028 RMK AO2 T02690162 ## 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 20230825018289A](https://openairdocs.org/incident/20230825018289A), Aug 25, 2023: Cessna 195B, Los Lunas, NM, Substantial damage. On August 25, 2023, at approximately 1009MDT a Cessna 195B, single engine airplane, N2192C, [privacy data omitted], was involved in an accident. Upon the… ## Docket (2 files) The files NTSB released with the investigation on December 7, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=193018. 6.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16185634&FileExtension=pdf&FileName=WPR23LA337_6120_flat_Redacted-Rel.pdf - Photo (item 2, PDF, 1 page, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16185644&FileExtension=pdf&FileName=WPR23LA337_508-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.