Thursday, March 14, 2019

Loss of Control on Ground: Cessna 182D Skylane, N8905X; accident occurred March 13, 2019 near Transylvania Community Airport (3NR3), Brevard, North Carolina















Aviation Accident Final Report - National Transportation Safety Board 

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Charlotte, North Carolina

Investigation Docket - National Transportation Safety Board:


Location: Brevard, North Carolina 
Accident Number: ERA19LA131
Date & Time: March 13, 2019, 18:10 Local
Registration: N8905X
Aircraft: Cessna 182
Aircraft Damage: Substantial
Defining Event: Loss of control on ground 
Injuries: 1 None
Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The pilot performed a preflight inspection after the airplane had undergone maintenance and no anomalies were noted. He boarded the airplane, adjusted the seat, and then verified that it was locked in position. Shortly after beginning the takeoff roll, his seat slid backward. He was unable to reach the rudder pedals, and the airplane departed the left side of the runway, nosed over, and came to rest inverted. Examination revealed that the pilot seat’s left front roller housing was disengaged from the seat rail. The seat rail exhibited scoring on top of the rail, which likely occurred during the accident sequence. No scoring was noted on the sides of the rail. The roller housing was not splayed or damaged, indicating that it did not pull off the rail during the accident sequence. Although the seat rail holes were slightly worn, the pin did not exhibit any anomalies.

The mechanic stated that he did not remove the pilot's seat to perform the maintenance that he completed before the accident flight; however, given the lack of side damage to the rails and the fact that the left front seat roller housing was not splayed, it is likely that the roller housing came off the rails during the maintenance and went unnoticed by both the mechanic and the pilot, which resulted in the seat sliding backward during takeoff.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The mechanic's failure to notice that the left front seat left front roller housing disengaged from the seat rail during recent maintenance, and the pilot's failure to detect the disengaged roller housing during the preflight inspection, which resulted in the seat sliding backward during takeoff and a subsequent loss of airplane directional control.

Findings

Personnel issues Replacement - Maintenance personnel
Personnel issues Preflight inspection - Pilot
Aircraft Seat/cargo attach fitting - Incorrect service/maintenance
Aircraft Directional control - Attain/maintain not possible
Personnel issues Aircraft control - Pilot

Factual Information

On March 13, 2019, about 1810 eastern daylight time, a Cessna 182D, N8905X, was substantially damaged after it impacted terrain during takeoff from Transylvania Community Airport (3NR3), Brevard, North Carolina. The private pilot was not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was originating at the time of the accident. The
flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

According to the pilot, he completed a preflight inspection with no anomalies noted. When he boarded the airplane, the pilot seat was in its aft most position, since that was how he would typically exit the airplane. The pilot then slid the seat forward until he "could see 3 holes" in the rail, which was his typical seating position. He then "rocked the seat back and forth" to verify it was locked in position, and then proceeded to start the engine, taxi, and perform an engine runup. He then taxied onto the runway and began the takeoff roll. About 4-5 seconds into the takeoff roll, his seat slid backwards. At that point, he was unable to reach the rudder pedals, and the airplane departed the left side of the runway, nosed over, and came to rest inverted.

According to a Federal Aviation Administration (FAA) inspector who responded to the accident location, the airplane sustained substantial damage to the wings and fuselage.

According to FAA airworthiness records, the airplane was manufactured in 1961 and registered to the pilot in January 2019. The airplane's most recent annual inspection was completed on August 18, 2018, at a total time of 4,251.8 hours. In addition, the annual inspection maintenance log entry indicated that an inspection in accordance with airworthiness directive (AD) 2011-10-09, associated with a seat rail inspection, had been completed. At the time of the accident, the airplane had accumulated 4,265 total hours.

In an interview with the FAA inspector, a mechanic was working on the airplane the day before the accident to replace the transponder. He stated that sometimes he does have to remove the front seats to perform the work, however, he did not have the left front seat out of the airplane during the maintenance work, he only had the right front seat out of the airplane.

An examination of the left front seat rails revealed that the housings remained engaged on the seat rails except the left forward roller housing, which was disengaged from the seat rail. The housing tangs were not worn, distorted, or splayed. The pin that engaged into the track had no anomalies, the pin spring had positive engaging forces, and the holes were slightly worn. The seat rail was not damaged along the sides of the rail; however, the top of the rail had scoring marks.

According to the airplane owner's manual, the before engine start checklist stated, "Adjust seat to a comfortable position, check to see the seat locking mechanism is secure, and fasten safety belt."

History of Flight

Takeoff Miscellaneous/other
Takeoff Loss of control on ground (Defining event)

Pilot Information

Certificate: Private 
Age: 60, Male
Airplane Rating(s): Single-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With waivers/limitations 
Last FAA Medical Exam: July 6, 2017
Occupational Pilot: No
Last Flight Review or Equivalent: April 18, 2018
Flight Time: 294 hours (Total, all aircraft), 294 hours (Total, this make and model), 240 hours (Pilot In Command, all aircraft), 14 hours (Last 90 days, all aircraft), 1 hours (Last 30 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N8905X
Model/Series: 182 D 
Aircraft Category: Airplane
Year of Manufacture: 1961
Amateur Built: No
Airworthiness Certificate: Normal 
Serial Number: 18253305
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: August 18, 2018 Annual
Certified Max Gross Wt.: 2348 lbs
Time Since Last Inspection: 13 Hrs
Engines: 1 Reciprocating
Airframe Total Time: 4265 Hrs at time of accident
Engine Manufacturer: Continental
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: O-470 SERIES
Registered Owner:
Rated Power: 230 Horsepower
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: AVL,2162 ft msl 
Distance from Accident Site: 11 Nautical Miles
Observation Time: 17:54 Local 
Direction from Accident Site: 45°
Lowest Cloud Condition: Clear 
Visibility: 10 miles
Lowest Ceiling: None 
Visibility (RVR): 
Wind Speed/Gusts: 8 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 140° 
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.21 inches Hg 
Temperature/Dew Point: 14°C / 0°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Brevard, NC (3NR3) 
Type of Flight Plan Filed: None
Destination: Asheville, NC (AVL) 
Type of Clearance: None
Departure Time: 18:10 Local
Type of Airspace: Class G

Airport Information

Airport: Transylvania Community 3NR3 
Runway Surface Type: Asphalt
Airport Elevation: 2110 ft msl
Runway Surface Condition: Dry
Runway Used: 27 IFR 
Approach: None
Runway Length/Width: 2903 ft / 50 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 None 
Aircraft Damage: Substantial
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None 
Latitude, Longitude: 35.269721,-82.643608(est)

Location: Brevard, NC
Accident Number: ERA19LA131
Date & Time: 03/13/2019, 1810 EDT
Registration: N8905X
Aircraft: Cessna 182
Injuries: 1 Minor
Flight Conducted Under: Part 91: General Aviation - Personal 

On March 13, 2019, about 1810 eastern daylight time, a Cessna 182D, N8905X, was substantially damaged after it impacted terrain during takeoff from Transylvania Community Airport (3NR3), Brevard, North Carolina. The private pilot incurred minor injuries. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was originating at the time of the accident. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

According to the pilot, he completed a preflight inspection with no anomalies noted. When he boarded the airplane, the pilot seat was in its aft most position, since that was how he would typically exit the airplane. The pilot then slid the seat forward until he "could see 3 holes" in the rail, which was his typical seating position. He then "rocked the seat back and forth" to verify it was locked in position, and then proceeded to start the engine, taxi, and perform an engine runup. He then taxied onto the runway and began the takeoff roll. About 4-5 seconds into the takeoff roll, his seat slid backwards. At that point, he was unable to reach the rudder pedals, and the airplane departed the left side of the runway, nosed over, and came to rest inverted.

According to a Federal Aviation Administration (FAA) inspector who responded to the accident location, the airplane sustained substantial damage to the wings and fuselage.

According to FAA records, the airplane was manufactured in 1961 and registered to the pilot in January 2019. The airplane's most recent annual inspection was completed on August 18, 2018. In addition, the annual inspection maintenance log entry indicated that the inspection an inspection in accordance with airworthiness directive (AD) 2011-10-09 had been completed.

The airplane was retained for further examination.

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N8905X
Model/Series: 182 D
Aircraft Category: Airplane
Amateur Built: No
Operator: Paul B Greene
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: AVL
Observation Time: 1754 EDT
Distance from Accident Site: 11 Nautical Miles
Temperature/Dew Point: 14°C / 0°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 8 knots / , 140°
Lowest Ceiling: None
Visibility:  10 Miles
Altimeter Setting: 30.22 inches Hg
Type of Flight Plan Filed: Unknown
Departure Point: Brevard, NC (3NR3)
Destination:

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor
Latitude, Longitude:  35.269722, -82.643611 (est)

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