You've seen the TV sound bytes, read the sensational stories in the popular press, heard the speeches by congressmen and the FAA administrator. Now read what actually happened and draw your own conclusions. Here's an in-depth report of the NTSB investigation into the April 1997 in-flight loss-of-control accident in Cheyenne, Wyoming, of a Cessna 177B Cardinal that killed seven-year-old Jessica Dubroff, her father, and pilot-in-command CFI Joe Reid.
July 7, 1997
|About NTSB Reporter ...
Reporter is a unique magazine for pilots, mechanics, or anyone who has a serious
interest in aviation safety.
Each month, this outstanding publication brings you the kind of detailed accident
investigation data exemplified by the preceding report on the Jessica Dubroff accident. No
opinions, no speculation, no advertisements...just 100% hard data from NTSB investigations
of notable air carrier, military and general aviation accidents, plus late-breaking news
briefs on aviation safety topics.
AVweb's editor-in-chief Mike Busch has been a subcriber for more than a decade, and
thinks NTSB Reporter
is a must-read for every serious
student of aviation safety.
and help support continued
continued free access to AVweb and AVflash.
Loss of Control
(The Jessica Dubroff Flight)
HISTORY OF THE FLIGHT:
On April 11, 1996, at about 0824 mountain daylight
time, a privately-owned Cessna 177B collided with terrain after a loss
of control following takeoff from runway 30 et the Cheyenne Airport, Cheyenne,
Wyoming. The pilot in command, pilot trainee, and rear seat passenger (the
pilot trainee's father) were fatally injured. The pilot trainee was a
7-year-old girl, Jessica Dubroff, who did not hold a pilot certificate.
To be eligible for a student pilot certificate, a person must be 16 years
old, and to be eligible for a private pilot certificate a person must be
at least 17 years old. Instrument meteorological conditions existed at the
time and a VFR flight plan had been filed. The flight, which was a continuation
of what was described by its promoters as a transcontinental flight "record"
attempted by the youngest "pilot" to date (the pilot trainee), was being
operated under Part 91.
On the morning of the accident, the pilot in command, the trainee and the
passenger arrived at an FBO at the Cheyenne Airport between 0715 and 0730.
A copy of a privately recorded videotape made by a bystander, displaying
a time hack generated by the camcorder's clock, showed the airplane being
loaded with personal effects at 0739. The ramp appeared to be dry and the
airplane's shadow could be clearly seen on the pavement. The video recording
then showed the pilot in command and the trainee conducting portions of a
preflight briefing and a taped television interview. During the interview,
rain could be seen streaming off the airplane's wings, and water was forming
puddles on the ramp.
The program director of a Cheyenne radio station conducted a telephone interview
with the trainee and her father at about 0745. He invited her to stay in
Cheyenne because of the weather, but the father indicated that they wanted
"to beat the storm" that was approaching.
At 0801:21, the pilot in command telephoned the Casper, Wyoming, Automated
Flight Service Station for a briefing for a VFR flight from Cheyenne to Lincoln,
Nebraska. The briefer advised of deteriorating weather moving in from the
west, an AIRMET for icing, turbulence, and flight precautions for IFR conditions
along the route of flight. The briefer described current weather conditions
at several points east of Cheyenne, and the pilot in command said, "yea,
probably looks good out there from here...lookin east looks like the sun's
shining as a matter of fact. The briefer gave the forecast for Cheyenne through
0900 local time which called for 2,000 scattered to 4,000 broken with light
rain, thunderstorms, and after 0900 local time lowering ceilings to 1,500
feet along the route of flight, and that rain, fog and thunderstorms were
forecast for several points along the intended route of flight. He stated,
"so...if you can venture out of there and go get east it looks...," to which
the pilot in command replied, "yea, it looks pretty good actually." The briefer
then made reference to the "adverse conditions" currently at Cheyenne, and
the pilot in command said, "yea, it's raining here pretty good right now[,
I] mean it's you know steady but nothin...bad and to the east it looks real
good." He then filed a VFR flight plan to Lincoln.
At 0813:06, the pilot in command contacted the Cheyenne Air Traffic Control
Tower requesting clearance to taxi and, at 0813:24, the local controller
advised the pilot to "taxi to runway three zero, verify you have ATIS echo."
The pilot responded, "negative, what's the ATIS?" He was given the ATIS frequency
of 134.425 MHz and was requested to "advise when you have echo." The pilot
advised he would get the ATIS on frequency 134.25, and the controller corrected
him by repeating the correct frequency, 134.425.
In a segment of private videotape which did not have a time hack recorded
on it, the airplane's engine was shown running, the airplane's external lights
were on, and the nosewheel was still chocked. Rain was falling and there
was standing water on the ramp. The recording stopped, and when it resumed,
the airplane's engine was no longer running and the airplane's external lights
were off. A lineman could be seen removing the nosewheel chock, after which
the airplane's external lights came back on and the engine was restarted.
The airplane then taxied from its ramp location southeasterly along the parallel
taxiway to the approach end of runway 30.
At 0815:39, the pilot in command radioed the controller, "I don't get four
two five on this radio," in reference to his inability to receive the ATIS.
The controller responded, "Cardinal two zero seven roger, runway three zero,
wind two eight zero at two zero occasional gusts three zero altimeter two
niner seven zero." No response was received from the pilot and, at 0816:00,
the controller asked for an acknowledgement. The pilot responded "OK, two
zero seven, are we going the right way for runway 30?" The controller responded,
"you are heading the right way for runway 30, did you get the numbers?" The
pilot acknowledged, "we got em."
At 0818:12, the controller advised the pilot that a Twin Cessna just departed
reported moderate low-level wind shear plus or minus one five knots"
and the pilot responded, awe got that thank you." At 0818:53, the local
controller advised that "tower visibility Es] two and three quarters [of
a mile], field is IFR and say request." The pilot responded, OK two zero
seven would like a special IFR um ah right downwind departure." The controller
responded, "I'm not familiar with special IFR" and the pilot corrected with
"I'm sorry, special VFR."
The tower local controller then coordinated with the local radar controller
and, at 0820:19, advised the pilot that he was "cleared out of [the immediate
airport vicinity] to the east, maintain special VFR east, maintain special
VFR conditions," which was acknowledged by the pilot in command.
At 0820:51, the local controller
inquired "let me know when you're ready," and at 0820:56 the pilot responded,
"two zero seven's ready." Although the controller did not radio a takeoff
clearance until two seconds later, the airplane had already started its takeoff
Ground witnesses observed the airplane depart runway 30 heading in a
northwesterly direction, and then execute a gradual right turn to an easterly
heading. The witnesses generally described the airplane as having a low altitude,
low airspeed, high pitch attitude, and wobbly wings. As it was rolling out
of the right turn at several hundred feet AGL, the airplane was observed
to rapidly descend to the ground in a near-vertical flight path. The
impact occurred approximately 4,000 feet north of the departure end of runway
30 in a residential neighborhood.
PERSONNEL INFORMATION: Pilot In Command: The pilot in command was
52 years old and was a stockbroker by profession. He held a commercial pilot
certificate with airplane single-engine land and instrument ratings,
and a flight instructor certificate with an airplane single-engine land
rating. His flight records for the two years preceding the accident revealed
that he had given flight instruction to eight students in addition to the
pilot trainee on this flight during that time. A search of FAA records showed
no violations or enforcement actions. He instructed students through a flying
club which he helped organize at his home base of Half Moon Bay Airport,
Half Moon Bay, California.
The NTSB reported that, according to another flight instructor at the Half
Moon Bay Airport, during one instructional flight he attempted to taxi out
with the tow bar still attached to the airplane. This flight instructor also
reported that the pilot in command had developed his own instrument approach
into the Half Moon Bay Airport that went down to 500 feet.
The pilot in command had a current second class medical certificate with
the limitation that "holder shall wear lenses that correct for distant vision
and possess glasses that correct for near vision."
According to the pilot's logs, as of April 8, 1996, he had a total time of
1,484 hours. He had not logged any instrument time during the six months
preceding the accident. Records indicated that he had conducted 10 flights
from airports located above 4,500 feet MSL.
Pilot Trainee: The pilot trainee did not hold any FAA certificates.
Her total instructional time as reported in her personal flight log through
April 6, 1996, was 33.2 hours. All of the flights occurred in Cessna aircraft,
including 3.7 hours in the accident 177B. A total of 29 flights were logged,
all with the pilot in command as her instructor.
SLEEP AND ACTIVITY HISTORY: On Wednesday, April 10, 1996, the airplane
departed Half Moon Bay, California, at 0700 p.d.t., and landed at Elko, Nevada,
at approximately 1020 p.d.t., and was refueled. The airplane departed Elko
at 1115 p.d.t, and arrived in Rock Springs, Wyoming, approximately three
hours later. The airport manager at Rock Springs said the pilot in command
was "noticeably exhausted." The pilot in command telephoned the Casper, Wyoming,
Automated Flight Service Station and received a weather briefing for the
flight to Cheyenne, Wyoming. The airplane departed Rock Springs at approximately
1540 and landed at Cheyenne at approximately 1726. The pilot in command
telephoned his wife from the airport and said that he was elated at the
receptions they had received. According to his wife, he sounded tired, and
he stated that he was very tired.
The program director for a local Cheyenne radio station provided transportation
for all three occupants from the airport to the hotel. During the ride, they
discussed a storm front that was predicted to arrive in Cheyenne the next
morning. According to the program director, the pilot in command was "very
adamant" that the flight should depart by 0615, and the pilot trainee's father
agreed. The program director stated that all three looked tired and discussed
being very tired. Upon arrival at the hotel at approximately 1900, the pilot
trainee and her father checked into one room and the pilot in command checked
into another room.
On the morning of the accident, the pilot in command checked out of his hotel
room at 0622. The desk clerk said he looked fairly rested and seemed happy.
The trainee and her father checked out of their hotel room at 0714 and, with
the pilot in command, returned to the Cheyenne Airport by hotel shuttle.
AIRPLANE INFORMATION: The airplane, a four-place Cessna 177B,
was manufactured in 1975 and registered to the pilot in command in 1987.
Prior to the accident flight, both the airframe and engine had accumulated
3,582.3 flight hours. The airplane received its last annual inspection on
July 8, 1995, at 3,508.4 flight hours.
The airplane was equipped with dual 3-inch aluminum rudder pedal extensions
on the left side rudder pedal assembly, which were installed a few weeks
before the accident flight. Cushions on the front left seat (to raise up
and extend the left seat occupant's forward view) were visible on the video
recording made immediately prior to the airplane's departure from Cheyenne.
The airplane was equipped with two 25-gallon wing tanks, providing a
total of 49 gallons of usable fuel. It had been topped up with 26.3 gallons
of 100LL fuel shortly after its arrival in Cheyenne.
The 1975 Cessna 177B Owner's Manual states in Section II that prior to takeoff
from short fields above 3,000 feet elevation, the mixture should be leaned
to give maximum power. According to FAA Advisory Circular 61-23B,
"Carburetors are normally calibrated at sea level pressure to meter the correct
amount of fuel with the mixture control in the 'FULL RICH' position. As altitude
increases, air density decreases...If the fuel/air mixture is too rich, i.e.,
too much fuel in terms of the weight of the air [high density altitude],
excessive fuel consumption, rough engine operation, and appreciable loss
of power will occur."
WEIGHT AND BALANCE: The airplane's maximum gross takeoff weight was
2,500 pounds. The takeoff weight on the morning of the accident was calculated
by Safety Board investigators to be 2,596 pounds. The center of gravity was
calculated to have been at 110.4 inches. The aft center of gravity limit
for the Cessna 177B at its maximum 2,500 pounds gross weight is 114.5 inches.
WING FLAP SETTING: Examination of the wreckage indicated a 10 degree
flap extension at the time of impact. The airplane's Owner's Manual states
that takeoffs can be accomplished with the flaps set in the zero to 15 degrees
positions. The preferred flap setting for a normal takeoff is 10 degrees.
WEATHER OBSERVATION: Weather observations at Cheyenne are taken by
an Automated Surface Observation System (ASOS). The 0823 special observation
was: sky condition - 1,600 feet scattered; measured ceiling - 2,400
feet broken, 3,100 feet overcast; visibility - 5 miles; weather
thunderstorm, light rain; temperature - 40 degrees F.; dew point -
32 degrees F.; wind - 250 at 20 knots, gusting to 28 knots; altimeter
- 29.71; remarks broken variable scattered, thunderstorm began 0823,
0.04 inch rain feel since previous record observation, wind shift began 0800,
peak wind 260 degrees at 28 knots recorded at 0817.
The nearest Doppler Weather Surveillance Radar was located at the Cheyenne
National Weather Service office located on the southern boundary of the airport.
Velocity data from the Doppler radar indicated that the wind direction in
the airport area around the time of the accident was from about 260 degrees
true near the surface and did not shift substantially through approximately
350 feet AGL. The winds were 15 to 30 knots.
Investigators asked the tower controller why runway 30 was in use at the
time. He reported that at his console, the wind readings, which did not come
from the ASOS, indicated that the winds were variable and did not favor either
runway 30 or runway 26. He also said that the accident airplane was parked
closer to runway 30 and would be able to depart faster using that runway.
The controller's wind readings came from a National Weather Service anemometer
which was located near the threshold of runway 30. No record was kept of
the wind directions recorded by that anemometer.
OTHER PILOTS: A pilot with the State of Wyoming, who is based at Cheyenne,
holds an ATP rating and has more than 13,800 flight hours, departed from
runway 30 in a Cessna 414 at 0816. He told investigators that his radar painted
a steep gradient of green/yellow/red echoes beginning about four to five
miles from his position on the runway. He requested a 60 degree turn to the
right (heading 360 degrees) immediately after takeoff. While on the runway,
he observed cloud to ground lightning to the west. The strongest part of
the storm appeared to be at about 230 to 240 degrees with echoes extending
to about 330 degrees. The pilot recalled strong crosswinds during his takeoff,
requiring significant aileron input. He said he experienced control difficulties
all the way down the runway, more than he would normally expect under those
wind conditions. After rotation, the airplane did not accelerate rapidly
at first. He said he experienced moderate turbulence and the airspeed fluctuated
+/-15 knots. He said that the airplane began to climb satisfactorily
after leaving the airport boundary. At 200 to 300 feet AGL, the turbulence
and airspeed fluctuations subsided.
The pilot of the Cessna 414 reported that he was aware that the accident
airplane was planning to take off soon after his departure and that he was
concerned and gave a pilot report to the tower hoping that the pilot of the
Cessna 177B would hear it. He said that he never talked to anyone in the
The captain of United Express flight 7502 (a Beech 1900) landed at Cheyenne
Airport at about 0820. He remembered that as the airplane taxied to the gate,
the rain showers became heavier. He remembered hearing the pilot report from
the Cessna 414. The captain said he decided to delay his planned takeoff
until the weather improved. He said that he observed lightning within one
or two miles of the airport as his airplane arrived at the gate, and that
the rain changed to what appeared to be small hail.
AIR TRAFFIC CONTROL: The Cheyenne ATCT local controller who was on
duty at the time of the accident reported that the weather began deteriorating
shortly after he took his position shortly before the accident. He recalled
that visibility was lowest from the southwest through the north and was better
to the east and southeast. He said that the worst weather was in the northwest,
and that the weather seemed stationary. At 0818:12, he advised the accident
airplane that "twin Cessna just departed reported moderate low level windshear
plus or minus one five knots."
He said that the accident airplane did not come to a complete stop at the
beginning of the runway, and that it was rolling when he gave the takeoff
clearance. He stated that after becoming airborne, the airplane appeared
slower than expected.
WRECKAGE AND IMPACT INFORMATION: The airplane came to rest on the
south edge of a level, residential street at the entrance to a private
residential driveway. The final resting spot was nearly the same as the initial
point of impact. The crash site was on a bearing of 321 degrees and 9,600
feet from the departure threshold of runway 30. The wreckage distribution
was largely confined to the immediate ground impact site, but a distribution
of small fragments extended from the ground impact site southeast into a
The airplane was upright and was oriented along a southeast heading. The
nose section and forward cabin area were crushed. Both cabin doors evidenced
crush lines which indicated that the airplane impacted at a 67 degree nose
The two-blade propeller was separated from the engine. One blade was
beneath the left wing. The other blade was embedded in the ground impact
crater. Both blades exhibited tip curl and blade twist, along with extensive
chordwise scratching and small leading edge nicks.
The entire wing structure remained essentially intact, but had separated
from the airframe.
The mixture control knob was found in the full rich position. A damaged video
recorder and two blank videotapes were found at the wreckage site. No videotape
was found inside of the recorder.
Approximately 15 pounds of navy blue baseball caps were recovered at the
site. The baseball caps displayed the pilot trainee's name in gold lettering
along with the slogan, "Sea to Shining Sea" and "April 1996."
MEDICAL AND PATHOLOGICAL INFORMATION: The Wyoming State Crime Laboratory
conducted autopsies on the accident victims. The reports concluded that all
three victims died from traumatic injuries. Injuries sustained by the pilot
in command, including fractured wrists, fractured ankles and fractured
feet, and the lack of comparable injuries to the pilot trainee, indicated
that the pilot in command was operating the controls of the aircraft at impact.
The autopsy report on the trainee's father noted that his left shirt pocket
contained "numerous slips of paper with appointment times and dates of TV
interviews," including one scheduled for that evening in Ft. Wayne, Indiana,
and another for the next evening in Massachusetts. There also were numerous
business cards from radio stations, TV stations and networks.
MEDIA ASPECTS: The pilot in command's wife reported that her husband
was "flabbergasted" by the media coverage. ABC News had provided a video
recorder to the trainee's father along with three blank video cassettes to
record the first day's flight activities. The first three tapes were to be
turned in to ABC News at Cheyenne, and were to be replaced with blank tape
cassettes for additional recording.
Numerous media representatives were present when the flight departed Half
Moon Bay, California, and the occupants of the aircraft were interviewed
on live national television at 0530 that morning. Upon arrival at Cheyenne,
a large number of spectators, including news media, were present at the airport.
There was a welcome presentation by Cheyenne's Mayor. On the morning of the
accident, the airplane occupants participated in at least three media interviews.
...he considered the flight a
"non-event for aviation" and
simply "flying cross country with
a 7-year-old sitting next to you
and the parents paying for it."
ITINERARY PLANNING: The idea for the "record"-attempting cross
country flight was proposed by the trainee's father in February, 1996, according
to the trainee's mother. The original plan was for the trainee and the pilot
in command to fly from California to Massachusetts and to complete the trip
by May 5, 1996, which was the trainee's eighth birthday. It was agreed that
the pilot in command would be paid his normal hourly rate for flight instruction,
with additional compensation for the non-flight time. According to the
pilot in command's wife, when the flight was first conceived, he did not
expect publicity. She said that he considered the flight a "non-event
for aviation" and simply Flying cross country with a 7-year-old
sitting next to you and the parents paying for it." She said that he originally
planned to return from the East Coast with a business partner after the trip
According to the trainee's mother, about one month before the trip the trainee
asked her father to go with her and he agreed. Two to three weeks before
the trip, the itinerary was expanded to involve approximately 51 hours of
flying over eight days, with no days off, and included planned visits to
relatives and other events. The outbound trip was to originate at Half Moon
Bay, California. The first day's stops were: Elko, Nevada; Rock Springs,
Wyoming; overnight in Cheyenne, Wyoming. The second day's stops would be:
Lincoln, Nebraska; Peoria, Illinois; overnight in Fort Wayne, Indiana. The
third day's stops would be: Cleveland, Ohio; Williamsport, Pennsylvania;
overnight in Falmouth, Massachusetts. The fourth day's flight would stop
at: Frederick, Maryland; overnight in Clinton, Maryland. The fifth day's
flight would stop at: Raleigh, North Carolina; Charleston, South Carolina;
Jacksonville, Florida; overnight at Lakeland, Florida. The sixth day's flight
would stop at: Marianna, Florida; Mobile, Alabama; overnight in Houston,
Texas. The seventh day's flight would stop at: San Angelo, Texas; Albuquerque,
New Mexico; overnight at Sedona, Arizona. The schedule for the eighth day
was a stop at Lancaster, California, and a final destination of Half Moon
PREVIOUS RECORD ATTEMPT: Investigators could find no organization
which keeps an official record for "the youngest pilots The father of an
8-year-old boy who flew with his father across the United States
in July, 1995, to set a self-proclaimed "youngest pilot flight record"
was interviewed by Safety Board investigators. The 8-year-old boy
did not hold any FAA certificates. The father reported that a local newspaper
published a short item about the flight the day before it began, and that
within an hour of the newspaper's publication he was contacted by two radio
stations. He said that by the time of departure, there was a media "frenzy"
at the airport. He said one reporter explained that "we're looking for a
happy story on kids."
ANALYSIS: The pilot in command was properly certificated and qualified
for the intended trip. Additionally, evidence indicated that he was wearing
the corrective lenses required by his medical certificate at the time of
There was no evidence that airplane maintenance was a factor in the accident.
Because the ground temperature was above freezing up to the time of the takeoff,
and because of the short duration of the flight, airframe icing was not likely
a factor in this accident.
THE ACCIDENT SCENARIO: The statements provided by witnesses indicated
that the airplane's climb rate and speed were slow and that after the airplane
transitioned to an easterly heading, it rapidly rolled off on a wing and
descended steeply to the ground in a near vertical flight path, consistent
with a stall.
Based on performance data provided by NASA, the Safety Board determined that
the rainfall present at the time of takeoff could reduce the airplane's lift
by as much as three percent, increasing the airplane's stall speed by about
The Safety Board found that the pilot in command decided to turn right
immediately after takeoff to avoid the nearby thunderstorm and heavy
precipitation that would have been encountered on a straight-out departure.
Witness statements indicated a gradual turn, consistent with a bank angle
of about 20 degrees. With the flaps set at 10 degrees, this turn would increase
the stall speed about three miles per hour, from about 59 mph for steady
level flight to about 62 mph.
Because the airplane was about 96 pounds overweight at takeoff, the Safety
Board found that this would have increased the stall speed another two percent.
The Cheyenne Airport has a field elevation of 6,156 feet MSL. Density altitude
at the time of takeoff was calculated to have been 6,670 feet MSL. According
to airplane performance data from Cessna, the high density altitude and the
airplane's overweight condition would have decreased the airplane's best
rate of climb speed from 84 mph to 81 mph, with a climb rate of 387 feet
per minute. Thus, the airplane had decreased performance with an increased
stall speed. However, it should have been able to climb and turn safely.
The Safety Board analyzed possible reasons why this did not occur.
Investigators believe the evidence shows that the pilot did not lean the
fuel/air mixture for maximum power for the high density altitude takeoff.
The mixture knob was found in the full rich position at the accident scene.
Although it is possible that impact forces moved the knob forward to full
rich, investigators noted that the linkage rod was not bent. Investigators
also noted that the pilot did not stop at the end of the runway before the
takeoff roll, which would have been the most common and appropriate time
to adjust the fuel/air mixture.
Carburetor icing conditions existed at the time of takeoff. Investigators
noted that without the application of carburetor heat during taxi and runup,
ice may have formed the carburetor and reduced the available power at takeoff.
The carburetor heat control was found in the "off" position. The pilot's
failure to stop at the end of the runway also suggested to investigators
that he did not perform a pretakeoff checklist, which would have included
a magneto check and check of the carburetor heat.
The Safety Board found that although the horizontal in-flight visibility
at the time of the stall was most likely substantially degraded due to
precipitation, eliminating a visible horizon, the pilot in command could
have maintained ground reference by looking out the side window. However,
this could have been disorienting to the pilot because of the need to scan
to his left to see the flight instruments in front of the trainee and to
his right to see the ground as he attempted to operate the airplane at a
low speed, with a lower than normal climb rate.
The Safety Board found that the wind conditions would have made it more difficult
for the pilot in command to maintain a constant airspeed and rate of climb
and could have resulted in an unintended reduction in airspeed to below the
airplane's stall speed. The wind conditions also may have affected the pilot's
perception of the airplane's speed. What was initially a crosswind during
the takeoff roll and initial climb, became a tailwind after the airplane
began its right turn. Because the pilot was most likely looking outside during
the special VFR departure, he may have not been adequately monitoring the
airspeed indicator, or may have had difficulty monitoring it because of airspeed
fluctuations, and may have mistaken the increase in ground speed as an increase
in airspeed. This may have led him to misjudge the margin of safety above
the airplane's stall speed.
The Safety Board noted that the pilot in command's limited experience in
operating out of high density altitude airports should have prompted him
to be cautious, in addition to his knowledge of the storm that was moving
in and the report of wind shear from the Cessna 414 pilot who had just departed.
Accordingly, the Safety Board concluded that the pilot in command inappropriately
decided to take off under conditions that were too challenging for the pilot
trainee, and, apparently, even for him to handle safely.
FATIGUE: Although the Safety Board noted that the pilot in command
had the opportunity to receive a full night's sleep the night before the
accident, the quantity and quality of the sleep he received is unknown.
Immediately before the accident, he committed several errors that are consistent
with a lack of alertness. However, the errors also could have been caused
by rushing, distractions, or bad habits. Therefore, the Safety Board was
unable to conclude that fatigue was a factor in the accident.
The errors included:
started the engine while the nosewheel was still chocked;
requested a taxi clearance without first obtaining the ATIS;
read back a radio frequency incorrectly;
accepted a radio frequency he could not dial up on his radios;
failed to acknowledge, as requested, weather information from the controller;
asked "are we going the right way?";
failed to stop at the end of the runway;
requested a "special IFR" clearance.
MEDIA ATTENTION AND ITINERARY PRESSURE: The Safety Board noted that
self-induced pressures from media attention can degrade decision making,
increasing the perceived importance of maintaining a schedule compared with
other factors. The Safety Board concluded that the airplane's occupants'
participation in media events the night before and the morning of the accident
flight resulted in a later-than-planned takeoff from Cheyenne under
deteriorating weather conditions. However, media presence at the airport
and interviews scheduled on subsequent stops probably also added pressure
to attempt the takeoff and maintain the schedule. The Safety Board found
that the itinerary was overly ambitious, and that a desire to adhere to it
may have contributed to the pilot in command's decision to take off under
the questionable conditions at Cheyenne.
PROBABLE CAUSE: The National Transportation Safety Board determined
the probable cause of the accident was the pilot in command's improper decision
to take off into deteriorating weather conditions (including turbulence,
gusty winds, and an advancing thunderstorm and associated precipitation)
when the airplane was overweight and when the density altitude was higher
than he was accustomed to, resulting in a stall caused by failure to maintain
airspeed. Contributing to the pilot in command's decision to take off was
a desire to adhere to an overly ambitious itinerary, in part, because of