Yamhill, OR, USA
N4368R
Cessna 172M
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.
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 that they "performed two approaches, two full-stop landings, and two takeoffs" in a Cessna 182. He further stated that the accident flight instructor "was advised of the special considerations necessary for flight operations at the Flying-M Ranch" and "performed the second approach, landing, and takeoff as pilot in command." The student pilot was issued a third class medical certificate on June 6, 2005, with the limitation, must wear corrective lenses. Review of the student pilot's flight logbook, which was found in the airplane, revealed that as of June 20, 2005, he had accumulated a total of 12.1 hours flight time of which 10.2 hours were dual flight instruction and 1.9 hours were solo. The logbook indicated the student received all of the flight instruction from the flight instructor, and the flight instructor endorsed the logbook for solo flight on June 10, 2005. AIRCRAFT INFORMATION Examination of the airplane's maintenance records indicated that the 1974 model Cessna Skyhawk received its most recent annual inspection on February 17, 2005, at a total time of 7,542.1 hours. As of that date, the engine, a Lycoming O-320-E2D, S/N RL-49952-27A, had accumulated 1,190.2 hours since factory remanufacture. Review of the maintenance records revealed no evidence of any uncorrected maintenance discrepancies. A "Cry Log" found in the airplane listed no uncorrected cries or discrepancies. The most recent cry stated "stall warning horn very light at 70 mph, not grounding." This cry was written up by the student pilot. The resolution to the problem stated that the stall warning system was inspected from the wing to the horn and no visible signs of a problem were found. Additionally, the resolution stated that the airplane was test flown and no defects in the stall warning system were noted. The test flight was made on June 14, 2005. METEOROLOGICAL INFORMATION At 2053, the reported weather conditions at McMinnville Municipal Airport, McMinnville, Oregon, located approximately 14 nautical miles southeast of the accident site, were wind from 020 degrees at 8 knots, visibility 10 statute miles, sky clear, temperature 21 degrees C, dew point 10 degrees C, and altimeter 29.99 inches Hg. AIRPORT INFORMATION According to information on the website, airnav.com, the Flying M Airport is privately owned and has a single turf/gravel runway, oriented 7/25 degrees, which is 2,125 feet long and 40 feet wide. Landings are made to the west (runway 25) and takeoffs are made to the east (runway 7). The obstructions listed for runway 7 are "70 ft. trees mtn, 55 ft. from runway, MOUNTAIN TO SOUTHWEST, TREES SURROUND PRIMARY AND APCH SFC." The obstructions listed for runway 25 are "45 ft. trees, 250 ft. from runway, 90 ft. right of centerline, 5:1 slope to clear, 100' TREES 150R AND 50' TREES ON CNTRLN AT 1000'. ABRUPT 5' RISE IN TERRAIN TO THRS: 30' TREES 50' R AT 400' BYD THR." WRECKAGE AND IMPACT INFORMATION Examination of the accident site by NTSB and FAA representatives revealed that the airplane impacted the ground about 128 feet south of the runway centerline and 267 feet east of the fence at the end of runway 25. The airplane remained substantially intact and came to rest upright on a measured magnetic heading of 320 degrees with the rear of the fuselage resting on a split rail fence and the nose and outboard section of the right wing resting on the gravel road running parallel to the south side of the runway. The airplane was resting below a power line that ran alongside the road, and the power line was not damaged during the accident. The leading edge of the right wing outboard of the lift strut attach point was crushed aft to the forward spar. The leading edge of the left wing was undamaged. The outboard rear section of the left wing was bent upward and displayed transfers of brown woody material that matched the color and texture of the power pole located a few feet behind the wreckage. The empennage was undamaged. The forward section of the cabin was crushed aft, the firewall was pushed aft about 1 foot, and the nose of the propeller spinner was crushed flat against the propeller. The wreckage was recovered from the accident site on June 24, 2005, and examined on August 2, 2005, at the facilities of Specialty Aircraft in Redmond, Oregon, by the NTSB IIC and representatives of Cessna Aircraft Company, Textron Lycoming and the FAA. All flight controls were accounted for and remained attached to their respective surfaces. Flight control cable continuity was confirmed from the tailcone to the aft baggage area and from the wing roots to the flaps and ailerons. The flaps were determined to be retracted, and the elevator trim tab was found to be set approximately 3 degrees up. The left front seat base was broken and its seat rails were bent. A gouge was noted on the ninth hole aft on the outboard left front seat rail. The left front outboard lap belt had been cut. The buckle was latched and the inboard lap belt remained intact. The right front seat was out of the aircraft and its base was deformed to the right. The right seat rails were bent, separated from the floor and curled upwards at the forward ends. The outboard right seat rail's first hole aft was broken. The left front seat lap belts were unlatched and intact. Both the left and right shoulder harnesses had been cut. The left rear lap belt had been cut. The rear bench seat base was buckled downward in the middle, but remained attached to the floor. The rear bench seat back remained intact. The engine remained attached to the airframe by the engine mount. The propeller remained attached to the engine crankshaft flange. The propeller blades displayed leading edge gouging, tip damage and chord wise scratching. One of the blades exhibited torsional twisting and "S" bending. The propeller, top spark plugs and the vacuum pump were removed. Using a drive tool, the crankshaft was rotated by hand through the vacuum pump drive pad and engine continuity was confirmed. "Thumb" compression was obtained on all four cylinders. The cylinder combustion chambers were examined through the spark plug holes using a lighted bore scope. There was no visible evidence of foreign object ingestion or detonation, and the valves appeared to be intact and undamaged. Both magnetos produced spark at all four leads during hand rotation. No evidence of pre-impact mechanical malfunctions was observed during examination of the engine. MEDICAL AND PATHOLOGICAL INFORMATION Autopsies of the flight instructor and the student pilot were conducted by the Medical Examiner Division of the Oregon State Police in Clackamas, Oregon. Toxicology tests on both individuals were conducted by the FAA's Toxicology and Accident Research Laboratory. The student pilot's test results were negative for carbon monoxide, cyanide, ethanol and drugs. The flight instructor's test results were negative for carbon monoxide, cyanide, and ethanol. The flight instructor's test results were positive for 71.24 ug/ml acetaminophen in urine, 2.228 ug/ml fluoxetine in urine, 54.374 ug/ml fluoxetine in liver, 2.691 ug/ml norfluoxetine in urine, and 79.836 ug/ml norfluoxetine in liver. The NTSB Medical Officer reviewed the flight instructor's FAA medical records. These records indicated that the flight instructor's most recent application for a 2nd Class Airman Medical Certificate was on October 10, 2003. The application indicated "no" for "Do you currently use any medication" and "yes" for "Mental disorders of any sort," "Military medical discharge," "Admission to hospital" and "Other illness, disability, or surgery." Under "Explanations" is noted "Depression" and "Injury from Class A Mishap (Ejection)." Under "Visits to Health Professional Within Last 3 Years" is noted only a "General Check Up" in 2002. Under "Comments on History and Findings" is noted "Ejected from F16 in 1992. Discharged from Air Force 1997 with continued pain. Took depression meds 1997-2000. No meds for 2 years now." The record of application indicated that the pilot "has been issued" a medical certificate. There is no indication that any additional records were requested or received by the FAA in regard to this application. Electronic records do not indicate any other applications for
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.
Source: NTSB Aviation Accident Database
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