# NTSB SEA91FA059: Cessna 172, N7119T, Oregon City, OR, February 28, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: February 27, 1991, 17:35 local (Feb 28, 1991, 01:35 UTC)
- Place: Oregon City, OR
- Coordinates: 45.320743, -122.519081 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=45.3207&lon=-122.5191&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal, 2 serious
- Status: Completed, report May 7, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 41305
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA91FA059
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/41305/pdf
- Page: https://openairdocs.org/ntsb/SEA91FA059

## Probable cause

THE PILOT'S FAILURE TO ATTAIN PROPER AIRSPEED BEFORE TAKEOFF.  FACTORS RELATING TO THE ACCIDENT WERE THE BINDING BRAKE, THE UPHILL GRASS AIRSTRIP, THE TAIL WIND WEATHER CONDITIONS, AND THE IMPROPER ANNUAL INSPECTION THAT WAS JUST COMPLETED ON THE AIRCRAFT.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of control - in flight, takeoff - initial climb
  - landing gear,normal brake system - binding(mechanical) (contributing factor)
  - airspeed(vlof) - not attained, pilot in command (cause)
  - terrain condition - uphill (contributing factor)
  - weather condition - tailwind (contributing factor)
  - maintenance,annual inspection - improper, other maintenance personnel (contributing factor)
- In flight collision with object, takeoff
- In flight collision with terrain/water, descent - uncontrolled
  - terrain condition - ground

## Analysis

THE PILOT INITIATED A TAKEOFF UPHILL ON A GRASS AIRSTRIP IN TAILWIND WEATHER CONDITIONS.  THE ACFT LIFTED OFF NEAR MID-FIELD, SETTLED BACK TO THE GROUND, AND TOOK OFF AGAIN 150 FEET FROM THE END OF THE STRIP.  THE ACFT IMPACTED BERRY VINES AT THE END OF THE STRIP, ROLLED 90 DEGREES TO THE RIGHT AND IMPACTED A TREE OFF THE END OF THE AIRSTRIP.  EXAM OF THE WRECKAGE REVEALED THE RIGHT BRAKE CYLINDER WAS CORRODED AND THE BRAKE WAS BINDING.  THE A & P MECHANIC WHO SIGNED OFF AN ANNUAL INSPECTION OF THE ACFT JUST BEFORE THE ACCIDENT DID NOT HAVE ACFT INSP AUTH.

## Aircraft

- Registration: [N7119T](https://openairdocs.org/deregistered/N7119T-1991-07-09), registration cancelled 1991-07-09, S/N 46719 (OpenAirDocs)
- Reported make and model: CESSNA 172
- Registry model: [Cessna 172](https://openairdocs.org/model/cessna-172) (registry code 2072402) (OpenAirDocs)
- Category: Airplane
- Serial number: 17246719
- Airframe hours: 1533
- Engines: CONTINENTAL O-300-A 145 horsepower reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Operator: Merle D. Kirchem
- Registered owner: Merle D. Kirchem
- Last inspection: Annual, February 27, 1991, 1 hours before
- Airport: 19S, Aero Acres, runway 21, 1,835 × 300 ft, grass/turf

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 41; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; flight hours: 308 total, 225 in this make and model, 284 as pilot in command, 21 in the last 90 days, 8 in the last 30 days, 4 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 360° at 6 knots
- Visibility: 45 statute miles
- Lowest ceiling: none
- Temperature: 57 °F, dew point 39 °F
- Altimeter: 29.00 inHg
- Observed at: SLE, 27 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 19910227003599A](https://openairdocs.org/incident/19910227003599A), Feb 27, 1991: Cessna 172, Oregon City, OR, Destroyed, 1 fatal. Attempted uphill takeoff with dragging brake. Lifted last 150 feet. Hit 8 foot high vines. Stalled into trees.

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.

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