NTSB Executive Summary, Dubroff accident report

On April 11, 1996, about 8:24 a.m. mountain daylight time, a privately owned Cessna 177B, registration N35207, collided with terrain after a loss of control following takeoff from runway 30 at the Cheyenne Airport, Cheyenne, Wyoming. The pilot in command, pilot trainee Jessica Dubroff, and rear seat passenger (the pilot trainee's father) were fatally injured. Instrument meteorological conditions existed at the time, and a visual flight rules flight plan had been filed. The flight was a continuation of a transcontinental flight and was operated under the provisions of 14 Code of Federal Regulations Part 91.

The safety issues discussed in the report include fatigue, the effects of media attention and itinerary pressure, and aeronautical decision making.

CONCLUSIONS:

• The pilot in command was properly certificated and qualified for the intended cross-country trip.
• The pilot in command was wearing corrective lenses at the time of takeoff as required by the limitation on his current medical certificate.
• There was no evidence that airplane maintenance was a factor in the accident.
• The airplane's engine was developing power at the time of the accident, and the flaps had been set at the preferred takeoff setting.
• There was no evidence of airframe or control malfunction during the takeoff and subsequent crash.
• Airframe icing was not likely a factor in this accident.
• There were no air traffic control factors that contributed to the cause of the accident.
• The pilot in command was provided with a satisfactory weather briefing prior to departing Cheyenne.
• The pilot in command was at least assisting the pilot trainee (if he was not the sole manipulator of the controls) during the takeoff and climb-out sequence, and, at the time of impact, the pilot in command was the sole manipulator of the airplane's controls.
• The accident sequence took place near the edge of a thunderstorm.
• 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.
• The airplane was 96 pounds over maximum gross takeoff weight at takeoff, and 84 pounds over the maximum gross takeoff weight at the time of the impact.
• Although 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 visual ground reference by looking out the side window. However, this could have been disorienting to the pilot.
• The airplane experienced strong crosswinds, moderate turbulence and gusty winds during its takeoff and attempted climb, and the pilot in command was aware of these adverse wind conditions prior to executing the takeoff.
• The right turn into a tailwind may have caused the pilot in command to misjudge the margin of safety above the airplane's stall speed. In addition, the pilot may have increased the airplane's pitch angle to compensate for the perceived decreased climb rate, especially if the pilot misperceived the apparent ground speed for airspeed, or if the pilot became disoriented.
• The high density altitude and possibly the pilot in command's limited experience with this type of takeoff contributed to the loss of airspeed that led to the stall.
• The pilot in command failed to ensure that the airplane maintained sufficient airspeed during the initial climb and subsequent downwind turn to ensure an adequate margin above the airplane's stall speed, resulting in a stall and collision with the terrain.
• 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.
• The pilot in command suffered from fatigue during the day before the accident.
• Information on fatigue and its effects, and methods to counteract it, might have assisted the pilot in command to recognize his own fatigue on the first day of the flight, and possibly enhanced the safety of the trip.
• The airplane 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.
• The presence of media at the Cheyenne Airport and media interviews scheduled for the next two overnight stops probably also added pressure to attempt the takeoff and maintain the itinerary.
• The itinerary was overly ambitious, and 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 determines that the probable cause of this accident was the pilot in command's improper decision to takeoff 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 an a stall caused by failure to maintain airspeed.

Contributing to the pilot in command's decision to takeoff was a desire to adhere to an overly ambitious itinerary, in part, because of media commitments.

RECOMMENDATIONS:

As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations:

--to the Aircraft Owners and Pilots Association, the Experimental Aircraft Association, and the National Association of Flight Instructors:

Disseminate information about the circumstances of this accident and continue to emphasize to your memberships the importance of aeronautical decision making.

--to the Federal Aviation Administration:

Expand the development and increase the dissemination of educational materials on the hazards of fatigue to the general aviation piloting community.

Incorporate the lessons learned from this accident into educational materials on aeronautical decision making.

Posted Wednesday, March 05, 1997 11:49:34 AM