Investigation Finds Seat Slides Back, Pilot Loses Control On Go-Around

An Australian coroner Wedneday released findings that concur with an Australian Transport Safety Bureau report blaming an illegally-modified sliding seat for the death of a student pilot. The pilot, 46-year old Ramasamy Ayathurai was killed September 28th, 2001 when he lost control of a Cessna 172 while attempting a go-around at the Latrobe Valley Airport southeast of Melbourne, Australia.

The pilot stated his intention to make a full stop landing on runway 03. Witnesses heard the engine power increase and saw the aircraft begin a go-around from about 100 ft on short final, according to the ATSB report. The aircraft entered a steep left climbing turn with flaps fully extended. At about 300 feet, the wings were seen to roll level, and the aircraft "fishtailed". The aircraft then pitched down and impacted the ground, destroying the aircraft and killing the pilot. Weather at the time of the accident was clear sky with unlimited visibility and a light breeze.

Examination of the wreckage found no evidence to suggest that the aircraft was not capable of normal operation. However, the investigation revealed that the pilot's seat stops did not match factory specifications and allowed the pilot to adjust the seat forward of the seat rail. In other words, he apparently ran the seat off its tracks. The ATSB report found the rear seat latch was engaged 410mm fwd of the door rear pillar.

Tests conducted on a pilot of the same basic size revealed that the subject could not properly manipulate the controls of the aircraft with the seat in that position. The pilot could not apply much forward elevator control and could only reach the throttle by pulling back on the control wheel. Testing of a similar aircraft showed significant forward pressure was required to control the aircraft in a full throttle and full flap go-around.

The ATSB concluded that aircraft mishandling and loss of control could not be ruled out, but the event as described was consistent with the seat sliding back and denying the pilot adequate control input to avoid the accident. As a result, the ATSB issued three Safety Advisory Notices alerting pilots, aircraft owners, and mechanics to use the proper parts, install them correctly, and to insure the proper engagement of the seat locks before flight.

FMI: www.atsb.gov.au/aviation/occurs/occurs_detail.cfm?ID=281