Decisions That Matter

A rushed departure proved to be a costly mistake

May 1, 1997

Just a little over a year ago, everyone with access to newspapers or television learned the tragic results of pushing too hard into weather with a light aircraft, only it wasn't billed that way. Instead, there was a media megadose of child-pilot-at-the-controls as 7-year-old Jessica Dubroff, her father, and flight instructor crashed shortly after takeoff from Cheyenne, Wyoming, in a publicity stunt designed to show the world that anyone could fly. The trip was advertised as a cross-continent flight by the youngest "pilot" ever. Jessica, of course, was not a pilot and could not be, at her tender age. But because the national media had swallowed the hook on this fable and was following the trio's every move, the post-crash coverage could not and would not address the real issue.

The fairy tale odyssey ran afoul of a spring storm system that blustered out of the Rockies on the second day of the trip. Several other pilots, including the captain of a Beech 1900 regional airliner, delayed their departures because of weather, but Jessica's flight instructor allegedly abdicated his pilot-in-command authority to Jessica's publicity-minded father to keep the flight on time.

The NTSB has now released the final report on this accident. Although a number of mistakes were made, there was one whopper that led directly to the crash. Here are the NTSB's findings, with some comments.

On April 11, 1996, about 8:24 a.m. Mountain Daylight Time, a Cessna Cardinal struck terrain after a loss of control following takeoff from Runway 30 at Cheyenne Airport. The safety issues in the report included fatigue, the effects of media attention and itinerary pressure, and aeronautical decision making. In our day-to-day flying, most of us will not have the media as a factor. However, itinerary, fatigue, and decision making are always in play.

The pilot in command (the flight instructor�not Jessica) was properly certificated and qualified for the cross-country trip. From a purely regulatory standpoint, most pilots involved in accidents are qualified; but in this case, the weather conditions exceeded the capability of the aircraft, if not that of the pilot.

The aircraft was properly maintained and performing normally at the time of the accident. Typically, aircraft mechanical problems are a factor in fewer than 10 percent of accidents.

The Cardinal was 96 pounds over its maximum gross weight at takeoff and 84 pounds over max gross at the time of impact. While it is illegal and not very prudent, many pilots overload their aircraft successfully until an unfortunate set of circumstances proves that the manufacturer was correct in limiting the weight to the published amount. Would less weight have made a difference here? Given the magnitude of the atmospheric conditions they had to overcome, probably not.

The NTSB computed the Cardinal's best-rate-of-climb airspeed at 81 mph and the rate of climb at about 387 feet per minute, considering the density altitude of 6,670 feet. At a slower speed of 61 mph, the rate of climb was calculated to be 236 fpm. The applicable stall speeds with 10 degrees of flaps in the takeoff configuration were approximately 59 mph in level flight and 62 mph in a 20-degree bank. These numbers will soon become relevant when we discuss weather.

The 52-year-old pilot in command was a flight instructor with just under 1,500 hours total time. Although he held an instrument rating, he was not current. According to another instructor who knew the PIC, his respect for the regulations and weather was casual at best. The pilot had developed an instrument approach that went down to 500 feet into his VFR-only home field of Half Moon Bay, near San Francisco. Another pilot stated that he had observed the PIC execute several approaches into the home airport in much less than VFR conditions.

Fatigue may have been a factor in this accident, and the NTSB devoted considerable attention to it. Just prior to takeoff the pilot made numerous errors that suggest he wasn't very alert. These included starting the engine with the nosewheel still chocked, requesting taxi clearance prior to obtaining the ATIS information, reading back an incorrect frequency, accepting a radio frequency that could not be tuned on his radios, failing to acknowledge a controller's readback of weather, failing to stop at the end of the runway, and using incorrect phraseology by requesting a "Special IFR" clearance when he meant Special VFR. Most pilots have been guilty of a few of these flubs on occasion, but having them all occur in the space of a few minutes indicates that the brain was not fully engaged. It is also possible that this was the result of rushing to beat the storm, or perhaps the pilot just had poor pre-departure habits.

The pilot had averaged about 6 hours of sleep for the 3 days prior to the trip, and on the first day, he woke up at 3:30 a.m. Even copious quantities of coffee won't overcome a chronic fatigue problem. Studies have shown that most people tend to underestimate their fatigue level. When the pilot commented at a fuel stop in Rock Springs, Wyoming, that he was tired and later that night advised his wife that he "was really tired," it is safe to conclude that he probably fit the definition of being fatigued the day before the accident. The slippery slope of human factors is not to be underestimated, however; the pilot checked into the hotel at 7 p.m. local time and checked out again at 6:22 a.m., so there was opportunity for rest. The quality and quantity of his sleep the night before the accident is unknown.

The key players in this scenario — and in many other accidents last year — were inclement weather and a pressing desire to get someplace. It is a lethal combination, one that all pilots would do well to understand.

The flight was to depart from Cheyenne early in the morning before the storm system arrived, but Jessica's father decided that she needed the sleep after a very long first day and delayed her wake-up call by about half an hour. There were further delays as local media interviews took precious time. The program director of a Cheyenne radio station conducted a telephone interview with Jessica and her father at the airport around 7:45. He invited them to stay because of the weather, but the father was anxious to beat the storm.

At 8:01 the pilot in command contacted the Casper Automated Flight Service Station and requested a weather briefing for a VFR flight from Cheyenne to Lincoln, Nebraska. The weather briefer reported: "At this time we have an airmet for icing, moderate below 24,000 in Wyoming; an airmet for turbulence along the route, possibly severe below 18,000, otherwise moderate; IFR flight precautions are in effect likewise along that route, and there's a cold front just to the north of your position; actually, they depict it through there now."

The pilot replied, "Yeah, it's starting to rain here."

The briefer continued: "With regards to rain showers...virtually a line of it on a north-south line just west of your position, and they're moving from the south to the north at this time, so we have thunderstorms, icing, and IFR...not looking for a lot of improvement. Cheyenne is currently 2,600 broken, 3,000 overcast, 10 miles with light rain."

The briefer then described current conditions at several points east of Cheyenne, and the pilot replied, "Yeah, probably looks good out there from here...looking east, looks like the sun's shining, as a matter of fact."

The forecast contained thunderstorms, rain, and fog for Cheyenne and points east. The briefer then stated, "So if you can venture out of there and go east it looks...," to which the pilot replied, "Yeah, it looks pretty good, actually." The briefer then referenced "adverse conditions currently in Cheyenne," and the pilot said, "Yeah, it's raining pretty good right here now.... It's steady but nothing bad...and to the east it looks real good." The pilot then filed a VFR flight plan for Lincoln.

At 8:13 the engine was started and the pilot began to make the series of minor mistakes mentioned earlier. After the engine restart following removal of the nosewheel chock, a home videotape showed steady rain and standing water on the ramp.

A Cessna 414 departed, and at 8:18 the tower relayed to the Cardinal, "A twin Cessna just departed reported moderate low-level wind shear plus or minus 15 knots," and the pilot acknowledged. A few seconds later the tower advised that "tower visibility is two-and-three-quarters, field is IFR and say request," to which the pilot responded, "OK, Two-Zero-Seven would like a Special IFR [sic] with a right downwind departure." The controller clarified that the pilot meant Special VFR and cleared the flight out of the airport vicinity. The flight was cleared for takeoff at 8:20, although the pilot had dispensed with the runup and had just rolled out onto the runway.

The home video showed the aircraft lifting off Runway 30, and ground witnesses observed the Cardinal execute a gradual right turn to the east. The aircraft was described as having a low altitude, low airspeed, a high pitch attitude, and wobbly wings. As it was rolling out of the right turn at several hundred feet agl, the aircraft descended rapidly to the ground in a near-vertical attitude approximately 4,000 feet from the departure end of Runway 30.

The automated surface observation system (ASOS) located 3,300 feet from the northeast arrival end of Runway 30 reported the following conditions just a few minutes prior to the accident: 0815, special — sky condition 2,400 scattered, measured ceiling 3,100 overcast, visibility 5 miles in moderate rain, temperature 43, dew point 32, wind 260 at 15 knots. This was augmented by the tower's observation that the field had gone IFR just a few minutes later.

The winds were gusty and appeared to be more aligned with Runway 26, which generated some crosswind components in excess of the aircraft's demonstrated capability of approximately 15 knots. This demonstrated velocity is not limiting, and a competent pilot may be able to handle more, but only with caution. The tower controller indicated that the wind direction was quite variable (according to his wind source, which was different from ASOS) and did not favor either runways 26 or 30 — and that 30 was a shorter taxi for the Cardinal.

The data from the nearby Doppler weather surveillance radar showed rainfall at departure time to be moderate and becoming heavy to intense where the aircraft began its right turn and was observed to stall.

The Cessna 414 that departed just a few minutes prior to the Cardinal shows the difference that experience and equipment make. That pilot held an ATP certificate with nearly 14,000 hours flight time and almost 10 years of local experience. Just prior to departure he tilted the Cessna's weather radar up to avoid ground clutter and to scan the departure area for heavy rain. Extending in a line from southwest through northwest there was a steep precipitation gradient beginning 4 to 5 miles from the end of the runway. Under these conditions the pilot recognized the signature of an approaching thunderstorm. Like the pilot of the Cardinal, he requested an immediate right turn after takeoff. During the takeoff roll the 414 pilot encountered strong crosswinds and had some control difficulties all the way down the runway. After becoming airborne, the aircraft accelerated much more slowly than usual and the flight encountered the plus-and-minus-15-knot airspeed fluctuations. After the aircraft passed 300 feet agl, the turbulence subsided and the flight control became easier. Lightning strikes were noted 1 to 2 miles west of the airport, and the NTSB concluded that the accident occurred at the edge of a thunderstorm.

Several items are noteworthy here. The 414 had on-board weather radar that allowed the pilot to know with more precision where the weather was — however, with lightning, strong winds, and heavy rain visible from the taxiway, no storm avoidance gear was needed to recognize the threat. The wind shift of 30 knots that the 414 pilot reported is not something to explore in a heavily loaded aircraft during takeoff. The risk definitely outweighs the reward. Recall that the Cessna 177B Cardinal's VY of 81 mph and stall speed of 62 in a 20-degree bank affords only a 20-mph cushion. Given the witnesses' statements regarding the slow climb, nose-high attitude, and wobbly wings, it's a safe bet that the Cardinal was probably climbing more slowly than V Y in a futile attempt to eke out some more performance. A 30-knot shear (35 mph) simply overcame the Cardinal, and the outcome was inevitable.

Several significant differences in aircraft may help to explain why one flight made it. First, the 414 is turbocharged, so the engines were developing full, sea-level power and not the altitude-degraded output of the 177. Secondly, the climb performance of a twin is typically much greater than that of a single, and — finally — with its higher wing loading, the 414 would have been more controllable in turbulence. Also, the twin departed a few minutes earlier and may have had more time to gain airspeed before encountering the shear.

Now we come to the psychology and the motivation that prompted the Cardinal pilot to push beyond the limits of safety. From the outset, this flight appeared to be a media event, and the itinerary was built on meeting a specific schedule. Jessica's father had spent hours arranging interviews with radio and TV stations all across the country. The flight itinerary called for 51 hours of flying in only 8 days, with no time off and no contingency for weather — an ambitious schedule at best.

According to the NTSB report, the pilot explained the weather situation to the father. Instead of providing him with the options, however, he succumbed to the very human tendency to attempt completion of "the mission." One choice was to depart well before Cheyenne came under the storm's influence. This would have meant giving up several media interviews — something the father was apparently loathe to do. The second choice was to delay the flight until the front had passed, which would probably have delayed the trip at least a day or more because the weather would be preceding them across the country. Since the pilot had allowed his instrument currency to lapse, he would not have been able to legally file an IFR flight plan to deal with low clouds and visibilities — even without thunderstorms.

The pilot may also have been influenced by the successful departure of the 414 pilot. The "herd" mentality is very tough to overcome because it implies that someone is less of a pilot when he or she declines a decision that another pilot has just successfully executed. Here, the Cardinal pilot failed to heed the warning that the 414 almost didn't make it. With thunderstorm-related accidents, only a few minutes can make the difference.

Perhaps the pilot did not understand the performance differences between aircraft or the significance of a 30-knot shear close to the ground. It is also conceivable, given the area of the country where the pilot was based (San Francisco) and his relatively low flight time, that he didn't have much familiarity with thunderstorms. This is an ongoing problem for general aviation where pilots do not have the opportunity to learn under controlled circumstances about the dangers of severe weather, particularly in another region of the country.

The pilot succumbed to wishful thinking when he kept making comments during the weather briefing about how good the weather looked to the east. When you are persuading yourself that it is OK to go despite strong evidence otherwise, look at the risk-reward equation.

Ultimately, all of us will face circumstances like this. None of the choices will be totally satisfying, and they may not be nearly as clear-cut during the process. Hindsight clarifies the view. This is where contingency plans are essential — either have substitute transportation or pick up the phone and let your party know that you won't be arriving as planned. The point is that you will eventually arrive — and that sure beats the other alternative.


See also the index of "Safety Pilot" articles, organized by subject. Bruce Landsberg is executive director of the AOPA Air Safety Foundation.