NTSB Identification: SEA05FA125.
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Accident occurred Thursday, June 23, 2005 in Yamhill, OR
Probable Cause Approval Date: 08/29/2006
Aircraft: Cessna 172M, registration: N4368R
Injuries: 2 Fatal,1 Serious.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
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.
The National Transportation Safety Board determines the probable cause(s) of this accident to be: 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. Full narrative available
Index for Jun2005 | Index of months