Pilot Debrief

Cessna 182 near Brevard, NC — 2019-03-13

Final reportERA19LA131
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Date
2019-03-13
Location
Brevard, NC, USA
Airport
3NR3
Aircraft
Cessna 182
Registration
N8905X
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Takeoff roll

Probable cause

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.

NTSB narrative

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.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not ensure seat was properly locked before takeoff.

NTSB coding

Evidence available

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

Docket documents5

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