Flying M Airport
Aircraft Accident/Incident Report

Yamhill, Oregon 97148
Thursday, June 23, 2005 20:30 PDT

NTSB Narrative Summary Released at Completion of Accident

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.

NTSB Probable Cause Narrative

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.

Event Information

Type of Event Accident
Event Date 6/23/2005
Event Day of the Week Thursday
Time of Event 2030
Event Time Zone Pacific Daylight Time
Event City Yamhill
Event State OREGON
Event Country --
Zipcode of the event site 97148
Event Date Year 2005
Event Date Month 6
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 452143N
Event Location Longitude 1232120W
Event Location Airport Flying M
Event Location Nearest Airport ID OR05
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation 448
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 2053 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 135
Weather Observation Facility ID MMV
Elevation of weather observation facility 163
Distance of event from weather observation facility (units?) 14
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling --
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 21
Dew Point at event time (in degress fahrenheit) 10
Wind Direction (degrees magnetic) 20
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 8
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.99
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 2
Injury Total Minor --
Injury Total None --
Injury Total Serious 1
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 20271
NTSB Notification Source FAA ROC
NTSB Notification Date Jun 23 2005 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Aug 29 2006 3:49PM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office Portland, OR

Aircraft Involved

Aircraft #1

Aircraft Registration Number N4368R
NTSB Number SEA05FA125
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Cessna
Aircraft Model 172M
Aircraft Series Identifier --
Aircraft Serial Number 17263119
Certified Max Gross Weight 2300
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 4
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Feb 1 2005 12:00AM
Airframe hours since last inspection 109
Airframe Hours 7651
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Hillsboro Flying Club
Aircraft Owner Street Address 4609 SW Pendleton St.
Aircraft Owner City Portland
Aircraft Owner State OR
Aircraft Owner Country USA
Aircraft Owner Zipcode 97221
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Instructional
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code HIO
Departure City Hillsboro
Departure State OR
Departure Country USA
Departure Time 1945
Departure Time Zone PDT
Destination Same as Local Flt crash at destination city
Destination Airport Code OR05
Destination City Yamhill
Destination State OR
Destination Country USA
Specific Phase of Flight Go-around (VFR)
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jun 15 2006 12:52PM
User who most recently changed record STAM
Since inspection or accident Time of Accident
Event Location Runway Number and Location 25
Runway Length 2125
Runway Width 40
Sight Seeing flight No
Air Medical Flight No
Medical Flight --