Undetermined · NTSB ERA22FA009

CESSNA P210 — Atlanta, GA

4 fatal High-time pilot
DateOctober 8, 2021
LocationAtlanta, GA
AircraftCESSNA P210
Purpose of flightPersonal
ConditionsDay · Visual Meteorological Cond
Phase / occurrencePrior to flight Aircraft loading event
Pilot age47
Pilot total time1,000 hrs · Experienced
Time in typeUnknown
Fatalities4

Probable cause

The pilot’s failure to ensure that his seat was properly secured before initiating the takeoff, which resulted in a loss of control during the initial climb. Contributing to the accident was the lack of an installed secondary seat stop, and the airplane’s aft center of gravity condition.

NTSB findings

  • Personnel issues-Task performance-Planning/preparation-Weight/balance calculations-Pilot
  • Personnel issues-Task performance-Use of equip/info-Use of equip/system-Pilot
  • Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot
  • Aircraft-Aircraft structures-Fuselage-Seat/cargo attach fitting-Not specified

What happened

The pilot and three passengers were taking off when the airplane became airborne about 1,000 ft down the runway, pitched nose up, and rolled left to an inverted attitude before impacting terrain next to the runway in a nose-down attitude. Postaccident examination of the flight controls revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Review of weight and balance information indicated that the airplane was more than 500 lbs over its maximum gross weight and that the center of gravity was aft of limits.

Examination of the wreckage revealed witness marks along the pilot’s seat tracks that corresponded with the seat being in the aft position at the time of impact. Given the pilot's stature, it is unlikely that this position would have allowed him to fully actuate the flight controls, and it is therefore unlikely that he intentionally initiated the takeoff with his seat in this position. Examination of the wreckage and maintenance logs revealed that the airplane was not equipped with manufacturer-recommended secondary seat stop mechanisms for either of the two front seats.

Review of operational and maintenance documents published by the airframe manufacturer showed the critical importance of ensuring that the pilot seats were secured before initiating a flight, since accelerations such as those encountered during takeoff could dislodge an unsecured seat. It is likely that the pilot did not properly secure his seat before takeoff, which resulted in the seat sliding aft, and his subsequent inadvertent application of aft inputs to the control yoke during the rotation and initial climb, which resulted in the airplane’s steep climb and a loss of control. The airplane’s aft center of gravity likely contributed to the loss of control.

Although toxicology testing of the pilot identified the presence of several medications, whether any medical factors contributed to the accident could not be determined from the available evidence. Some or all of the ethanol detected in the pilot’s toxicology may have been from sources other than consumption.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

View the official NTSB docket →