Accident Cessna 172M N4368R,
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ASN Wikibase Occurrence # 44457
 
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Date:Thursday 23 June 2005
Time:20:30
Type:Silhouette image of generic C172 model; specific model in this crash may look slightly different    
Cessna 172M
Owner/operator:Hillsboro Flying Club
Registration: N4368R
MSN: 17263119
Year of manufacture:1974
Total airframe hrs:7651 hours
Engine model:Textron Lycoming O-320-E2D
Fatalities:Fatalities: 2 / Occupants: 3
Aircraft damage: Substantial
Category:Accident
Location:Yamhill, OR -   United States of America
Phase: Approach
Nature:Training
Departure airport:Hillsboro, OR (HIO)
Destination airport:Yamhill, OR (OR05)
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
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.
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.

Accident investigation:
cover
  
Investigating agency: NTSB
Report number: SEA05FA125
Status: Investigation completed
Duration:
Download report: Final report

Sources:

NTSB: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20050628X00881&key=1

Location

Revision history:

Date/timeContributorUpdates
28-Oct-2008 00:45 ASN archive Added
21-Dec-2016 19:24 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
06-Dec-2017 10:15 ASN Update Bot Updated [Source, Narrative]

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