# NTSB SEA05FA125: Cessna 172M, N4368R, Yamhill, OR, June 24, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 23, 2005, 20:30 local (Jun 24, 2005, 03:30 UTC) - Place: Yamhill, OR - Coordinates: 45.361946, -123.355552 - Nearby events: https://openairdocs.org/map.md?lat=45.3619&lon=-123.3556&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed, report August 29, 2006 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, Federal Aviation Administration, Textron Lycoming - NTSB case key (mKey): 61799 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA05FA125 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/61799/pdf - Page: https://openairdocs.org/ntsb/SEA05FA125 ## Probable cause The flight instructor's excessive climb and failure to maintain adequate airspeed during an attempted go-around, which resulted in an inadvertent stall and subsequent collision with the ground. Contributing factors were the flight instructor's improper decision making. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, go-around (vfr) - in-flight planning/decision - improper, pilot in command(cfi) (contributing factor) - psychological condition, pilot in command(cfi) (contributing factor) - inadequate certification/approval,airman, faa(organization) (contributing factor) - climb - excessive, pilot in command(cfi) (cause) - airspeed - not maintained, pilot in command(cfi) (cause) - stall - encountered, pilot in command(cfi) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis Aboard the airplane for the instructional flight were the flight instructor, the student pilot, and a passenger. After making several landings at another airport, the airplane made an approach to the west end of a 2,125-foot-long grass airstrip. Due to rising terrain to the west, landings at this airstrip are made to the west, takeoffs are made to the east and go-arounds are potentially dangerous. Two witnesses observed the airplane descend on final approach to a point from which both believed a normal landing could have been made. With the airplane at an altitude of 6 to 10 feet agl, engine power was added for a go-around. However, the airplane did not climb out straight ahead. It turned left about 90 degrees and entered a steep climb, ascending to about 100 feet agl before stalling and descending vertically to ground impact. Examination of the airframe and engine revealed no evidence of any discrepancies that would have prevented normal operation of the airplane. The instructor's toxicology test results were positive for fluoxetine, a prescription anti-depressant. On his most recent application for a second class airman medical certificate in October 2003, the instructor noted a history of an unspecified injury from an F-16 ejection, and continued pain with three years of antidepressant use (but none for the prior two years). The instructor was issued a medical certificate, and the FAA did not request or receive any additional medical information from the instructor. Review of U.S. Air Force and Veteran's Affairs (VA) medical records revealed that the instructor had severe and ongoing symptoms of obsessive-compulsive disorder and post-traumatic stress disorder that started following his crash of an F-16 in 1992, in which he sustained a significant head injury. The VA records noted panic attacks and checking behaviors as recently as August 2004, in spite of the use of multiple psychiatric medications. The circumstances of this accident are such that a typical instructor would have been expected to avoid the scenario that resulted in the crash, either by continuing the landing or by properly executing a timely go around. OCD patients can experience delayed decision-making. The handling of the airplane afterward suggested that the instructor was unable to take the actions necessary to avoid the accident. ## Factual narrative HISTORY OF FLIGHT On June 23, 2005, about 2030 Pacific daylight time, a Cessna 172M, N4368R, sustained substantial damage when it impacted the ground in an uncontrolled descent following a loss of control during a go-around from the Flying M Airport near Yamhill, Oregon. The flight instructor and the student pilot received fatal injuries, and the passenger received serious injuries. The airplane was registered to and operated by Hillsboro Flying Club of Portland, Oregon. Visual meteorological conditions prevailed and no flight plan was filed for the instructional flight that was conducted under 14 CFR Part 91. The flight departed from the Portland-Hillsboro Airport about 1945. In an interview conducted by the NTSB investigator-in-charge (IIC), the passenger stated that she wanted to go flying with her boyfriend, the student pilot, to see how he was doing. She knew she could only fly with him when he was flying with his flight instructor. The arrangements for the flight were made about a week before it took place. The day of the flight was a beautiful day, so she knew they would be going. When asked what they had planned for the flight, the passenger said "all we were supposed to do is go on a flight so I could see how [the student pilot] was doing." The plan was to land at Twin Oaks Airport, Hillsboro, Oregon. While at Twin Oaks, the flight instructor would sign off the student pilot to make solo flights there in the future. The plan "did not happen." The student pilot was seated in the left front seat, the flight instructor was seated in the right front seat, and she was seated in the left rear seat. She was wearing a headset and could talk and listen to both pilots. She had a lap belt only. She thinks both pilots had shoulder harnesses and lap belts. Once they got airborne, the flight instructor started having the student pilot practice stalls. After three stalls, the passenger asked them to stop as it was making her nervous. Then they flew to an airport that had a grass airstrip and a paved airstrip. She did not recognize the airport. She had been to Twin Oaks before, and this airport did not look like Twin Oaks. They landed a few times on the grass airstrip. The flight instructor told the student pilot that he wanted him to practice landing at a grass airstrip because this would help him to land if he ever had an engine problem. The flight instructor made the first landing and takeoff from the grass airstrip to demonstrate for the student pilot. Then the student pilot made "a couple of takeoffs and landings." The passenger said that this was the pattern the instructor followed when training the student - he landed first, then the student would land. She knew this because the student pilot had told her about it when they talked about his flying. The passenger recalled that a few times during the flight, the flight instructor said "my airplane." This made her mad because she wanted to see her boyfriend fly. The passenger said that the flight "turned into instruction instead of just a flight." She was starting to get drowsy. She usually fell asleep when she went flying. The last thing she remembers about the accident flight is that they were flying away from the airport where they had made the landings. The next thing she remembers is waking up in the hospital. According to one witness, who was a pilot and resided at the airport, the airplane made a left traffic pattern for landing on runway 25. The airplane was high on final approach, and the pilot slipped first one way and then the other to lose altitude. The slips were "picture perfect" and the pilot then executed a "perfect flare" at a point where about 1,800 feet of the 2,125-foot-long grass airstrip was available for landing. The witness stated that the airplane was in no danger of overshooting the runway and could "have easily landed and stopped on the runway." With the airplane at an altitude of about 10 feet agl, the pilot added power. The witness expected the airplane to climb out straight ahead; however, the airplane turned left until it was "sideways" to the runway, the nose pitched up, and the airplane climbed steeply to about 80 to 100 feet agl before stalling. The airplane pivoted about its left wing, descended in a near vertical attitude and impacted the ground. When asked about engine power, the witness stated that the power was "on full", but the engine was "running rough, like the carburetor heat might have been on." Another witness, who was not a pilot, but had observed many airplanes land at the airport, reported that he first saw the airplane when it was on final approach. The motion of the airplane seemed odd to him as it slipped to the right and then to the left. The airplane then "swung into a normal descent," and it looked to the witness to be in the correct position to touch down about a third of the way from the runway threshold, at the "normal" touchdown location. When the airplane was at an altitude of 6 to 8 feet agl, he heard the engine throttle up. The airplane's nose started to come up and it rolled to the left. The airplane ascended in a nose high attitude, and at the top of its climb, it "whipped over," pivoting around the left wing to a nose down vertical attitude. The airplane descended and hit the ground right wing first. When asked about engine power, the witness stated that the airplane's engine was running at "full throttle" until it hit the ground. PERSONNEL INFORMATION The flight instructor held a commercial pilot certificate with airplane single engine land and instrument airplane ratings and a flight instructor certificate with an airplane single engine land rating. His most recent second class medical certificate was issued on October 10, 2003, with the limitation, must wear corrective lenses. Review of the flight instructor's FAA airman records indicated that he received his private pilot certificate on October 5, 1985, by completion of the required test. He received his commercial pilot certificate on February 10, 1993, on the basis of military competence obtained in the United States Air Force. On November 18, 2003, he received his flight instructor certificate by completion of the required test. On May 29, 2004, the flight instructor was involved in an accident while providing flight instruction to a student in a Cessna 172M at Vernonia Municipal Airport, Vernonia, Oregon. According to the NTSB Factual Report on the accident, the flight instructor was performing a simulated engine out forced landing as a demonstration for his student. During the landing on the 2,940-foot-long grass runway, the airplane touched down long, overran the runway end, and struck a fence. The flight instructor and the student were not injured, and the airplane sustained substantial damage. The NTSB determined that the probable cause of the accident was "the instructor pilot's misjudgment of speed and distance and his failure to execute a go-around resulting in an overrun of the runway." The flight instructor's FAA airman records indicated that on July 9, 2004, he completed a reexamination given by an FAA inspector. A pilot logbook belonging to the flight instructor was found in the airplane. The entries in this logbook began on October 13, 2003, and continued to an entry on June 22, 2005. The entries totaled 624.8 hours flight time, all in single engine land airplanes, of which 565.4 hours were acting as a flight instructor. The logbook showed total time carried forward of 4,000 hours of which 2,000 hours were in single engine land airplanes and 2,000 hours were in multiengine land airplanes. There were no entries found in the flight instructor's logbook showing a flight into the Flying M Airport. However, another flight instructor submitted a written statement indicating he had flown into the Flying M Airport with the accident flight instructor on March 10, 2005. He stated t ## Aircraft - Registration: [N4368R](https://openairdocs.org/deregistered/N4368R-2007-09-18), registration cancelled 2007-09-18, S/N 17263119, built 1974 (OpenAirDocs) - Reported make and model: Cessna 172M - Registry model: [Cessna 172M](https://openairdocs.org/model/cessna-172m) (registry code 2072418) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17263119 - Airframe hours: 7651 - Engines: Textron Lycoming O-320-E2D 150 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: Hillsboro Flying Club - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2005, 109 hours before - Departed: HIO, Hillsboro, OR - Destination: OR05, Yamhill, OR - Airport: OR05, Flying M, runway 25, 2,125 × 40 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 39; injuries: fatal; commercial, flight instructor; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review November 1, 2003; seat: right; toxicology performed; flight hours: 4,625 total, 4,096 as pilot in command, 53 in the last 90 days, 31 in the last 30 days - Student pilot; age 19; injuries: fatal; student; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 12 total, 12 in this make and model, 2 as pilot in command, 12 in the last 90 days, 12 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 20° at 8 knots - Visibility: 10 statute miles - Temperature: 70 °F, dew point 50 °F - Altimeter: 29.98 inHg - Observed at: MMV, 14 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20050623013179A](https://openairdocs.org/incident/20050623013179A), Jun 23, 2005: Cessna 172M, Yamhill, OR, Substantial damage, 2 fatal. (-23) N4368R was observed executing a go-around from a height of approximately ten feet above the surface with approximately 1800 feet of the 2125 foot long… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.