Pilot Debrief

CESSNA 140 near Parma, NY — 2014-07-05

Final reportERA14FA327
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Date
2014-07-05
Location
Parma, NY, USA
Airport
7NK4
Aircraft
CESSNA 140
Registration
N76850
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Landing

Probable cause

The pilot's decision to land with a quartering tailwind and his failure to maintain directional control during the landing roll. Contributing to the severity of the pilot's injuries was the failure of the aluminum center safety belt bracket.

Contributing factors

Contributing to the severity of the pilot's injuries was the failure of the aluminum center safety belt bracket.

NTSB narrative

The commercial pilot of the tailwheel-equipped airplane was performing touch-and-go landings at his private airport with a right quartering tailwind. During landing roll, the pilot lost directional control, and the airplane departed the left side of the runway into a wheat field where it nosed over. Examination of the runway revealed that a prominent row of trees was located directly adjacent to the right side of the runway, and, given the prevailing wind, there would have been associated turbulence due to the disruption of the ambient wind flow as it passed over the trees. Tire marks and ground scars indicated that, when the airplane veered off the left side of the runway, it was carrying considerable energy, as the airplane traveled 390 ft from its touchdown point to where it nosed over. Examination of the airplane revealed no evidence of any anomalies that would have precluded normal operation. The crown of the fuselage above the pilot's seat displayed an outward bulge indicating that, during the nose over, the pilot's head contacted the overhead area of the cockpit interior, which likely caused the cervical spine fracture and positional asphyxiation injuries described in the pilot's autopsy report. Examination of the pilot's 4-point restraint system revealed that the aluminum center safety belt bracket, which was likely installed when the airplane was manufactured in 1946, had failed in shearing overstress during the nose over. This resulted in the pilot being partially released from the restraint system and subsequently contacting the crown of the airplane. Examination of the airplane manufacturer's records revealed that shortly after the airplane was manufactured in 1946, the manufacturer began installing a steel center safety belt bracket in new production airplanes. Following this accident, the manufacturer issued a service bulletin that called for inspection of the center seat belt bracket on all Cessna 120 and 140 airplanes to determine if the latest type (steel) bracket was installed and replacement of any older type (aluminum) brackets found with the latest type.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot could have chosen to land into the wind instead of downwind.

NTSB coding

Evidence available

  • Photos
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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