, PB97-910402 ‘

NTSB/AAR-97/02

SEA96FA079

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

IN-FLIGHT LOSS OF CONTROL AND

SUBSEQUENT COLLISION WITH TERRAIN

CESSNA 177B, N35207

CHEYENNE, WYOMING

APRIL 11, 1996

6814
The National Transportation Safety Board is an independent Federal agency dedicated to

promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety.

Established in 1967, the agency is mandated by Congress through the Independent Safety

Board Act of 1974 to investigate transportation accidents, determine the probable causes of

the accidents, issue safety recommendations, study transportation safety issues, and evaluate

the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special

investigation reports, safety recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(202)314-6551

(800)877-6799

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Sprin~leld, Virginia 22161

(703)487-4600
NTSB/AAR-97/02 PB97-910402

NATIONAL TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

IN-FLIGHT LOSS OF CONTROL AND

SUBSEQUENT COLLISION WITH TERRAIN

CESSNA 177B, N35207

CHEYENNE, WYOMING

APRIL 11, 1996

Adopted: March 11, 1997

Notation 6814
This page intentionally left blank
iii

CONTENTS

EXECUTIVE SUMMARY .................................................................. v

1. FACTUAL INFORMATION

1.1 History of Flight ..................................................................................... 1

1.2 Injuries to Persons .................................................................................. 6

1.3 Damage to Airplane................................................................................ 6

1.4 Other Damage......................................................................................... 6

1.5 Personnel Information ............................................................................ 6

1.5.1 Pilot in Command................................................................................... 7

1.5.2 Pilot Trainee............................................................................................ 8

1.5.3 Pilot Trainee’s Father ............................................................................. 9

1.5.4 Airplane Occupants’ Sleep and Activity History Prior to the Accident 9

1.5.4.1 Pilot in Command’s Sleep and Activity History Prior to Starting Flight 9

1.5.4.2 Pilot Trainee’s Sleep and Activity History Prior to Starting Flight....... 10

1.5.4.3 Pilot Trainee Father’s Sleep and Activity History Prior to Starting

 Flight ..................................................................................................... 10

1.5.4.4 All Occupants’ Sleep and Activity History After Starting Flight.......... 10

1.6 Airplane Information .............................................................................. 12

1.6.1 Airplane Fuel Information and Guidance............................................... 12

1.6.2 Weight and Balance................................................................................ 13

1.6.3 Stall Speeds............................................................................................. 14

1.6.4 Wing Flap Settings ................................................................................. 14

1.6.5 Climb Speeds and Climb Rates .............................................................. 14

1.7 Meteorological Information ................................................................... 15

1.7.1 General Weather Information................................................................. 15

1.7.1.1 Weather Observations............................................................................. 16

1.7.1.2 Crosswinds.............................................................................................. 17

1.7.1.3 Density Altitude...................................................................................... 19

1.7.1.4 Precipitation............................................................................................ 19

1.7.1.5 Lightning Data........................................................................................ 21

1.7.2 Witness Descriptions of Weather Conditions Near the Airport ............ 21

1.7.2.1 Other Pilots ............................................................................................. 21

1.7.2.2 Air Traffic Control.................................................................................. 22

1.7.2.3 Other Eyewitness Statements ................................................................. 23

1.8 Aids to Navigation.................................................................................. 23

1.9 Communications..................................................................................... 23

1.10 Airport Information ................................................................................ 23
iv

1.11 Flight Recorders ..................................................................................... 23

1.12 Wreckage and Impact Information......................................................... 23

1.13 Medical and Pathological Information................................................... 25

1.14 Fire .......................................................................................................... 25

1.15 Survival Aspects..................................................................................... 26

1.16 Media Aspects ........................................................................................ 26

1.16.1 Itinerary Planning ................................................................................... 28

1.17 Previous Record Attempt ....................................................................... 30

1.18 Postaccident FAA Action and Legislative Changes .............................. 32

2. ANALYSIS

2.1 General.................................................................................................... 34

2.2 Analysis of the Accident Sequence........................................................ 35

2.2.1 Operation of the Airplane’s Controls..................................................... 35

2.2.2 The Accident Scenario............................................................................ 35

2.3 Human Performance Aspects ................................................................. 41

2.3.1 Fatigue .................................................................................................... 41

2.3.2 Fatigue Awareness and Education ......................................................... 42

2.3.3 Media Attention and Itinerary Pressure ................................................. 44

2.3.4 Aeronautical Decision Making............................................................... 46

2.4 Recent Legislative Changes ................................................................... 49

3. CONCLUSIONS

3.1 Findings .................................................................................................. 50

3.2 Probable Cause ....................................................................................... 53

4. RECOMMENDATIONS ..................................................................... 54

5. APPENDIXES

Appendix A--Investigation and Hearing................................................ 55

Appendix B--Transcript of AFSS Weather Briefing ............................. 56
v

EXECUTIVE SUMMARY

On April 11, 1996, about 0824 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, 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,

which was a continuation of a transcontinental flight “record” attempt by the

youngest “pilot” to date (the pilot trainee), was operated under the provisions of

14 Code of Federal Regulations Part 91.

The National Transportation Safety Board determines that the

probable cause of this 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 media commitments.

The safety issues discussed in the report include fatigue, the effects of

media attention and itinerary pressure, and aeronautical decision making. A

recommendation concerning the circumstances of this accident and the importance

of aeronautical decision making was made to the Aircraft Owners and Pilots

Association, the Experimental Aircraft Association, and the National Association

of Flight Instructors. Recommendations concerning aeronautical decision making

and the hazards of fatigue and were made to the Federal Aviation Administration.

NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

IN-FLIGHT LOSS OF CONTROL AND

SUBSEQUENT COLLISION WITH TERRAIN

CESSNA 177B, N35207

CHEYENNE, WYOMING

APRIL 11, 1996

1. FACTUAL INFORMATION

1.1 History of Flight

On April 11, 1996, about 0824 mountain daylight time (MDT),1 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,2 and rear seat

passenger (the pilot trainee’s father) were fatally injured. Instrument

meteorological conditions existed at the time, and a VFR3 flight plan had been

filed. The flight, which was a continuation of a transcontinental flight “record”4

attempt by the youngest “pilot” to date (the pilot trainee), was operated under the

provisions of 14 Code of Federal Regulations (CFR) Part 91. (See section 1.17 for

the intended route of flight.)

On the morning of April 11, the pilot in command, the pilot trainee,

and the pilot trainee’s father arrived at the Sky Harbor FBO5 at the Cheyenne

Airport between 0715 and 0730. A copy of a privately recorded videotape made

 1Unless otherwise indicated, all times are MDT, based on a 24-hour clock.

2The pilot trainee, a 7-year-old girl, did not hold a pilot certificate. To be eligible

for a student pilot certificate a person must be at least 16 years old, and to be eligible for a private

pilot certificate a person must be at least 17 years old. (14 CFR 61.103 and 61.83.)

3Visual flight rules

4In July 1995, an 8-year-old boy flew back and forth across the United States,

setting what was regarded as the “record” for the youngest “pilot,” although these flights were

not officially recognized as records. The boy’s father reported to the Safety Board that he had

contacted the Guinness Book of Records and learned that it kept no record for the youngest pilot.

5Fixed-base operator
2

by a bystander, displaying a time hack beginning at 0739 (video-recorder clock

time), showed the airplane being loaded with personal effects. 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 pilot 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 for a local Cheyenne radio station conducted a

telephone interview with the pilot trainee and her father at the airport about 0745.

He invited her to stay in Cheyenne because of the weather, but the pilot trainee’s

father indicated that they wanted “to beat the storm” that was approaching. The

pilot trainee spoke with her mother by cellular telephone as she ran to the airplane

to depart. She ended the call when she boarded the airplane.

At 0801:21, the pilot in command contacted the Casper AFSS6 via

telephone and requested a weather briefing for a VFR flight from Cheyenne to

Lincoln, Nebraska, the first scheduled fuel stop of the day’s intended flights. The

weather briefer reported:

at this time we have an AIRMET [airman’s meteorological

information] for icing moderate below...twenty four thousand in

Wyoming[; an] AIRMET for turbulence...along the route[,]

possibly severe below eighteen [thousand] otherwise moderate[;]

[IFR (instrument flight rules)] flight precautions are in effect

likewise along that route of flight[; and] there’s a cold front just to

the north of your position[,] actually they depict it through there

now.

The pilot in command replied, “yea its startin to rain here.” The

briefer continued:

with regards to the rain showers...virtually a line of it on a north

south line just west of your position an [they’re] movin from south

to north at this time so we have thunderstorms icing and

[IFR]...not looking for a lot of improvement[.] [C]heyenne[’]s

 6Automated Flight Service Station
3

currently twenty six hundred broken three thousand overcast ten

miles with light rain[.]

The briefer then 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 suns shining as a matter of fact.”

The briefer also reported that the “forecast for [C]heyenne through

[9:00 a.m. local time] calls for two thousand scattered to broken four thousand

broken and light rain[;] thunderstorms [and] after [9:00 a.m. local time] lowering

ceilings fifteen hundred feet along your 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 its raining here pretty good right now[, I] mean its

you know steady but nothin[g]...bad[,] and to the east it looks real good.” The

pilot in command then filed a VFR flight plan for the intended flight to Lincoln,

Nebraska. The telephone conversation was terminated at 0807:44. (See Appendix

B for a full transcript of the briefing.)

Following the recording of the taped television interview, there was a

break in the private video recording. At 0813:06, the pilot in command contacted

the Cheyenne ATCT7 requesting clearance to taxi, and, at 0813:24, the local

controller responded “taxi to runway three zero, verify you have ATIS8 echo?”

The pilot responded “negative, what’s the ATIS,” after which he was then given

the ATIS frequency of 134.425 MHz and was requested to “advise when you have

echo.” The pilot responded, verifying the frequency as 134.25, and this was

corrected by the local controller.

The next private video footage did not have a time hack displayed. In

that segment, the airplane’s engine was running, the airplane external lights were

visible, and the nosewheel was still chocked. Rain was falling, and the ramp

showed standing water. The recording stopped again, and when it resumed, the

engine was no longer running, and the external lights were off. A lineman was

observed removing the nosewheel chock, after which the airplane’s external lights

 7Air Traffic Control Tower

8Automated Terminal Information Service
4

were turned back on and the engine was restarted. The airplane then taxied from

its ramp location (see Figure 1) southeasterly along the parallel taxiway to the

approach end of runway 30.

At 0815:39, the pilot in command stated, “I don’t get four two five on

this radio.” At 0815:43, the local controller transmitted “cardinal two zero seven

roger, runway three zero, wind two eight zero at two zero occasional gusts three

zero altimeter two niner seven zero.” At 0816:00, after no response was received,

the controller asked for an acknowledgment, and the pilot responded “OK, two

zero seven, are we going the right way for three zero?” The controller responded

“you are heading the right way for runway 30, did you get the numbers?” and the

pilot acknowledged “we got em.”

At 0818:12, the local controller advised the pilot that a “twin Cessna

just departed reported moderate low-level windshear plus or minus one five knots”

and the pilot responded “we got that thank you.” At 0818:53, the local controller

advised that “tower visibility [is] two and three quarters [of a mile], field is IFR9

and say request,” to which 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 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 conditions,” which the pilot

acknowledged.

At 0820:51, the local controller inquired “let me know when you are

ready,” and the pilot responded, at 0820:56, “two zero seven’s ready.” Two

seconds later, at 0820:58, the airplane was cleared for takeoff. The controller told

investigators that the airplane was rolling at the time of this transmission.

The private videotape then showed the airplane beginning its takeoff

roll on runway 30, lifting off, and then the view of the airplane becomes

obstructed by a building.

 9Instrument flight rules
WI

Figure 1.--Map depicting airplane ground track and airport.
6

Ground witnesses observed the airplane depart the upwind end of

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, a high pitch attitude and wobbly wings. As it

was rolling out of the right turn, at several hundred feet agl,10 the airplane was

observed to rapidly descend to the ground in a near-vertical flightpath. The

impact occurred approximately 4,000 feet north of the departure (upwind) end of

runway 30 in a residential neighborhood.

1.2 Injuries to Persons

Injuries Flightcrew Passengers11 Other Total

Fatal 1 2 0 3

Serious 0 0 0 0

Minor 0 0 0 0

None 0 0 0 0

Total 1 2 0 3

1.3 Damage to Airplane

The airplane was destroyed by impact. The value of the airplane was

$45,000.

1.4 Other Damage

The airplane damaged a section of a paved, residential street.

1.5 Personnel Information

There were three occupants aboard the airplane. The pilot in

command, occupying the front right seat; the pilot trainee, occupying the front left

seat; and the father of the pilot trainee, occupying the left rear seat.

 10Above ground level

11The pilot trainee was considered a passenger because she held no pilot

certificate.
7

1.5.1 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, issued on December 11, 1990; and a flight instructor

airman certificate with airplane single-engine land rating, issued in April 1992.

His flight records for the last 2 years indicated that he gave flight instruction to

eight students, in addition to the pilot trainee, during that time.12 In March 1996,

he completed a flight instructor refresher course.13 A search of FAA14 records

showed no record of violations or enforcement actions against him. He instructed

students through a flying club he helped to organize at the Half Moon Bay Airport,

Half Moon Bay, California.

According to another flight instructor at the Half Moon Bay Airport,

the pilot in command had once attempted to taxi out with the tow bar still attached

to the airplane while providing flight instruction. He also indicated that the pilot

in command had developed his own instrument approach into the Half Moon Bay

Airport that went down to 500 feet. Another pilot based at the Half Moon Bay

Airport stated that on several occasions, he had witnessed the pilot in command

execute approaches to the airport when the weather was below minimums.

He possessed an FAA second class medical certificate issued on May

24, 1995, with the limitation that “holder shall wear lenses that correct for distant

vision and possess glasses that correct for near vision.” The private video,

recorded the morning of the accident, showed the pilot in command wearing what

appeared to be corrective lenses before he boarded the airplane.

The pilot in command’s total pilot time, as reported in his latest flight

log through April 8, 1996, was 1,484 hours. This log was opened on May 10,

1990, with 597 flight hours brought forward. He had logged no instrument time

during the 6 months preceding the accident flight, and 4.1 hours of actual and 4.0

hours of simulated instrument time during the 12 months preceding the accident

 12FAA records were obtained for seven of those students. They indicated that, as

of July, 1996, none had been issued a private pilot certificate. The eighth student could not be

uniquely identified in the FAA records.

13The curriculum, which was approved by the FAA, included a 1-hour section on

weather and a 1-hour section on human factors in aeronautical decision making, as part of a 16-

hour curriculum.

14Federal Aviation Administration
8

flight. The flight log showed that he had conducted eight flights out of airports at

elevations exceeding 4,500 feet mean sea level (msl). In addition, although not

entered in the flight log, he conducted two such takeoffs as pilot in command the

day before the accident. The details of these high-altitude takeoffs are

summarized as follows:

DATE: AIRPLANE: LOCATION: ELEVATION:

07/18/91 C-177B REXBURG, ID 4,858

07/20/91 C-177B JACKSON, WY 6,445

07/21/91 C-177B REXBURG, ID 4,858

08/02/93 C-177B BATTLE MT.,

NV

4,532

08/02/93 C-177B RAWLINS, WY 6,813

08/11/93 C-177B JACKSON, WY 6,445

08/11/93 C-177B ELKO, NV 5,135

08/06/95 C-177B S. LAKE TAHOE,

CA

6,264

04/10/96 C-177B ELKO, NV 5,135

04/10/96 C-177B ROCK SPRINGS,

WY

6,760

According to the pilot in command’s wife, he flew whenever he

could, and he liked to take long weekend trips. She said he had flown twice to

Oshkosh, Wisconsin, and once to Sedona, Arizona. He wanted everyone to learn

how to fly, and he liked to provide flying opportunities to children. According to

his wife, he took his young nephews and his sons (when they were children)

flying, and he was active in the Young Eagles program that provided flying

experiences to children.

1.5.2 Pilot Trainee

The pilot trainee, born on May 5, 1988, was 7 years old. She

possessed neither an FAA medical certificate, nor any pilot certificate. Her total

instructional time, as reported in her personal flight log through April 6, 1996, was

33.2 hours, of which 28.0 hours were conducted in a Cessna 172, 1.5 hours in a

Cessna 152, and 3.7 hours in a Cessna 177B (the accident airplane). The logbook

showed a total of 46 landings between November 3, 1995 and April 6, 1996. A

total of 29 instructional flights were logged, all with the pilot in command of the

accident flight as her instructor.
9

1.5.3 Pilot Trainee’s Father

The pilot trainee’s father was 57 years old and was a systems analyst.

He possessed neither a pilot certificate nor an FAA medical certificate.

1.5.4 Airplane Occupants’ Sleep and Activity History

Prior to the Accident

1.5.4.1 Pilot in Command’s Sleep and Activity History

Prior to Starting Flight

On Sunday, April 7, the pilot in command awoke between 0630 and

0700 Pacific daylight time (PDT) after going to bed the night before between 2230

and 2300. He participated in a news conference at the airport, spent a routine day

with his family, and went to bed about 2200. On Monday, April 8, the pilot in

command awoke about 0430 PDT15 and arrived at the airport in Half Moon Bay,

California, about 0500 PDT to participate in a live television interview on a

national news program. He then worked at his job as a stockbroker until 1300

PDT, participated in another media interview in the afternoon, and went to bed

about 2200 PDT. In addition, his flight log showed that on April 8, he piloted a 4-

hour flight conducted from Half Moon Bay to San Carlos, California, and return.

On Tuesday, April 9, he awoke about 0445 PDT and worked from

0600 to 1300. He attended a local water board meeting from 1900 to 1930, and he

went to bed about 2200 PDT.

On Wednesday, April 10, he awoke about 0330 PDT to arrive at the

airport and participate in a television interview with the pilot trainee and her father

at 0530 PDT on a national news program prior to the start of the transcontinental

flight. At 0617 PDT, the pilot in command received a weather briefing, and, at

0700, the flight departed Half Moon Bay.

 15According to the pilot’s wife, during the work week he normally went to sleep at

2200 and got up at 0445.
10

1.5.4.2 Pilot Trainee’s Sleep and Activity History

Prior to Starting Flight

According to her mother, the pilot trainee’s normal sleeping pattern

was irregular. She said that in the days before the start of the trip, the pilot trainee

had received less sleep than normal. On Wednesday, April 10, she awoke at 0300

PDT and, at 0530, participated in a television interview with her father and the

pilot in command. No further information has been made available concerning her

sleep or activities just prior to the trip.

1.5.4.3 Pilot Trainee Father’s Sleep and Activity History

Prior to Starting Flight

The Safety Board was unable to obtain any information regarding the

pilot trainee father’s sleep and activity history prior to the flight.16

1.5.4.4 All Occupants’ Sleep and Activity History

After Starting Flight

On Wednesday April 10, the airplane departed Half Moon Bay at

0700 PDT, and landed at Elko, Nevada, approximately 1020 PDT and was

refueled. At Elko, the pilot in command closed the flight plan from Half Moon

Bay, filed a new one to Rock Springs, Wyoming, and received a weather briefing

for the Rock Springs flight.

The airplane then departed Elko approximately 1115 PDT, arriving in

Rock Springs, approximately 3 hours later. The pilot in command commented that

he looked forward to resting at the hotel in Cheyenne. The airport manager said

that the pilot was “noticeably exhausted.” The pilot in command then telephoned

the Casper AFSS and closed the flight plan from Elko, filed a new one to

Cheyenne, and received a weather briefing for the Cheyenne flight. The pilot

trainee spoke with the airport manager and several other airport staff members.

The airplane then departed Rock Springs approximately 1540.

The airplane landed at Cheyenne Airport at 1726. The pilot in

command telephoned his wife from the airport and said that he was elated at the

 16His current wife did not respond to the Safety Board’s requests for information.
11

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,

according to the program director, 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. He stated that all three occupants 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 a separate room.

According to the hotel clerk, they all seemed happy and the pilot

trainee’s father spoke of the need for an early departure. They dined in the hotel

restaurant.17 Hotel records indicate that four long distance telephone calls were

made from the father’s room the evening of April 10, the last one beginning at

2114. The pilot trainee’s mother received a telephone call during this period.

According to the mother, the pilot trainee’s father related to her that the pilot

trainee had gone to sleep with her head resting against the window on one of the

flight segments, and that she had received assistance from the pilot in command on

one of the landings because of winds.

On Thursday, April 11, the pilot in command checked out of his hotel

room at 0622. The desk clerk said that he looked fairly rested and seemed happy.

The pilot trainee’s father called the hotel front desk about 0625 to cancel a

scheduled 0630 wake-up call. The pilot trainee’s father later indicated that the

pilot trainee had been awake and ready to leave before 0600, but he asked her to

sleep longer because he felt that it was important for her to receive 9 hours of

sleep to make up for the lost sleep before the trip. He and the pilot trainee checked

out of their hotel room at 0714 and, with the pilot in command, returned to the

Cheyenne Airport by hotel shuttle.

 17The morning of the accident, the pilot trainee’s father indicated to the radio

station program director that “they” had dined at the hotel restaurant the night before. It is

unknown whether “they” referred to all three of the flight participants (himself, the pilot in

command, and the pilot trainee) or to only two of those participants.
12

1.6 Airplane Information

The airplane, a four-place Cessna 177B, serial No. 17702266, was

manufactured in 1975 and was registered to the pilot in command on May 27,

1987. The airplane was equipped with a Lycoming O-360-A1F6D engine, serial

No. L-20022-36A. Prior to the accident flight, both the airframe and engine had

accumulated 3,582.3 flight hours. The airplane received an 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 seat rudder pedal assembly, which were installed a few

weeks before the record-attempting flight. Cushions on the front left seat (to raise

up and extend the occupant forward) were visible on the video recording made

immediately prior to the airplane’s departure from Cheyenne.

1.6.1 Airplane Fuel Information and Guidance

The airplane was equipped with two integral 25-gallon fuel tanks

providing a total of 49 gallons of usable fuel. The airplane was topped off with

26.3 gallons of 100 low lead aviation fuel by Sky Harbor Air Service, Inc., shortly

after its arrival in Cheyenne on April 10.

The 1975 Cessna 177B Owner’s Manual states in Section II that,

“[p]rior to take-off from short fields above 3,000 feet elevation, the mixture should

be leaned to give maximum power.” According to FAA Advisory Circular (AC)

61-23B, Pilot’s Handbook of Aeronautical Knowledge:

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.
13

1.6.2 Weight and Balance

The airplane’s maximum gross takeoff weight was 2,500 pounds.

The takeoff weight of the airplane on the morning of the accident was calculated

by Safety Board investigators to be 2,596 pounds, using the following data derived

from available weight and balance records, known fuel load, occupant weight

provided by the Wyoming State Crime Laboratory, and weighed miscellaneous

items:

ITEM: WEIGHT: ARM: MOMENT:

 (pounds) (inches) (pound-inches)

Empty weight18 1,589 103.95 165,177

Engine oil 17 47 799

Fuel (49 gallons) 294 112 32,928

Left-front pax19 60 90 5,400

Right-front pilot20 170 93 15,810

Left-rear pax21 205 134 27,470

Equipment/baggage22 154 162 24,948

Food, film, miscellaneous23 83 140 11,620

Lost fluids24 14 100 1,400

Lost food25 10 100 1,000

Estimated total at takeoff: 2,596 110.4 286,552

less 2 gallons fuel burned -12 112 -1,344

Estimated total at site: 2,584 110.4 285,208

Center of gravity limits for the Cessna 177B at the maximum 2,500

pound gross weight limit are: 105.7 inches (forward) and 114.5 inches (aft).

 18Includes 1 gallon unusable fuel

19Includes clothing worn

20Includes clothing worn

21Includes clothing worn

22Includes packed suitcases, video camera, tapes, and cell phone

23Includes food and intact fluids on board and promotional hats

24Includes bottles of drinkables and airplane oil

25Includes packaged and nonpackaged food
14

1.6.3 Stall Speeds

The power off, aft center of gravity stall speeds, in miles per hour

calibrated airspeed (CAS), published in the airplane owner’s manual as a function

of flap setting and angle of bank (AoB) for 2,500 pounds gross weight, were:

STALL SPEEDS - MPH CAS

 0o

 AoB 20o AoB 40o AoB 60o AoB

FLAPS UP 63 65 72 89

FLAPS 15o 58 60 67 83

FLAPS 30o 53 55 60 75

1.6.4 Wing Flap Settings

The 1975 Cessna 177-B Owner’s Manual states that:

Take-offs are accomplished with the wing flaps set in the 0o

 to 15o

position. The preferred flap setting for normal take-off is 10o.

This flap setting (in comparison to flaps up) produces a shorter

ground run, easier lift-off, shorter total distance over the obstacle,

and increased visibility over the nose in the initial climb-out.

Examination of the airplane wreckage indicated a 10o flap extension

at the time of impact. (See section 1.12)

1.6.5 Climb Speeds and Climb Rates

Interpolation of flight test data provided by Cessna for the weight,

flap configuration, and approximate density altitude of the accident flight (6,670

feet) showed the following climb speeds and climb rates:
15

Climb Speed,

CAS, mph

Climb Rate

fpm

Best rate of climb

speed, Vy

81 387

Best Angle of climb

speed, Vx

71 359

Slow Speed climb 61 232

For comparison purposes, the following climb rates are for the

accident aircraft’s weight and flap configuration at sea level:

Climb Speed,

CAS, mph

Climb Rate

fpm

Best rate of climb

speed, Vy

87 685

Best Angle of

climb speed, Vx

72 634

1.7 Meteorological Information

1.7.1 General Weather Information

The NWS26 0900 surface analysis chart showed a weak, quasistationary front extending from western Montana southeastward through

southeastern Wyoming becoming a moderate cold front over extreme northeastern

Colorado. The chart indicated that the cold front curved northeastward through

central Nebraska to a low pressure center located near Sioux Falls, South Dakota,

and continued northeastward through northern Michigan.

The NWS 0600 850 millibar (about 5,000 feet) analysis chart

indicated a center of low pressure over the Nebraska panhandle. The chart

indicated southwesterly winds of 25 knots and 45 knots over Nebraska east of the

low.

 26National Weather Service
16

The NWS 0600 700 millibar (about 10,000 feet) analysis chart

showed a center of low pressure over western South Dakota. Also, the chart

showed a trough of low pressure extending south of the low over eastern

Wyoming and Colorado. The chart indicated southwesterly winds of 25 knots and

30 knots over Nebraska east of the trough.

1.7.1.1 Weather Observations27

Weather observations at Cheyenne were accomplished by an ASOS28

located approximately 3,300 feet north/northeast of the arrival (threshold) end of

runway 30. Pertinent official weather observations for Cheyenne, in part, follow:

Cheyenne Airport, Wyoming

Field elevation 6,156 feet msl, ASOS-augmented

Time—0656; type—record; sky condition—measured ceiling

6,500 feet overcast; visibility—10+ miles; temperature—49

degrees F; dew point—32 degrees F; wind—320 degrees at 9

knots; altimeter setting—29.65 inches Hg.

Time—0739; type—special; sky condition—measured ceiling

2,800 feet broken 4,200 feet overcast; visibility—10+ miles;

weather—light rain; temperature—44 degrees F; dew point—31

degrees F; wind—300 degrees at 11 knots; altimeter setting—

29.67 inches Hg; remarks—rain began 0736 precipitation, trace

precipitation fell since previous record observation.

Time—0756; type—record; sky condition—measured ceiling

2,600 feet broken 3,100 feet overcast; visibility—10+ miles;

weather—light rain; temperature—44 degrees F; dew point—31

degrees F; wind—310 degrees at 15 knots; altimeter setting—

29.67 inches Hg; remarks—rain began 0736 precipitation, trace

precipitation fell since previous record observation.

 27Heights in surface weather observations are above ground level. All directions

are true north unless noted. All distances are statute miles unless noted.

28Automated Surface Observation System
17

Time—0815; type—special; sky condition—2,400 feet scattered

measured ceiling 3,100 feet overcast; visibility—5 miles;

weather—moderate rain; temperature—43 degrees F; dew point—

32 degrees F; wind—260 degrees at 15 knots; altimeter setting—

29.69 inches Hg; remarks—0.03 inch rain fell since previous

record observation, wind shift began 0800.

Time—0823; type—special; 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

degrees at 20 knots gusting 28 knots; altimeter setting—29.71

inches Hg; remarks—broken variable scattered, thunderstorm

began 0823, 0.04 inch rain fell since previous record observation,

wind shift began 0800, peak wind 260 degrees at 28 knots/0817.

Time—0830; type—special; sky condition—1,400 feet scattered

measured ceiling 2,000 feet broken 3,100 feet overcast;

visibility—2 1⁄2 miles; weather—thunderstorm light rain;

temperature—38 degrees F; dew point—32 degrees F; wind—260

degrees at 25 knots gusting 30 knots; altimeter setting—29.71

inches Hg; remarks—surface visibility 5 miles, thunderstorm

began 0823, 0.06 inch rain fell since previous record observation,

wind shift began 0800, peak wind 260 degrees at 30 knots/0830,

pressure rising rapidly.

Part B of the Cheyenne Surface Weather Observation form showed

that light rain began at 0740 and moderate rain occurred from 0815 to 0820. Also,

the form showed light rain from 0820 to 0835.

1.7.1.2 Crosswinds

The nearest Doppler Weather Surveillance Radar-1988 (WSR-88D)

was located at the Cheyenne NWS office on the Southern boundary of the airport.

Velocity data derived 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.
18

The Cheyenne ASOS calculated the 2-minute average wind and the

maximum 5-second wind once each minute. The following are along track and

cross track wind components along the runway heading (304 degrees magnetic)

calculated from the two sets of wind data from 0815 to 0824, inclusive:

2-Minute Average Wind

Time

MDT

Wind Dir

Magnetic

Wind Spd

Knots

Along Trk

Knots

Cross Trk

Knots

0815 251 15 9 12

0816 247 18 10 15

0817 245 22 11 19

0818 243 23 11 20

0819 240 23 10 21

0820 238 23 9 21

0821 240 22 10 20

0822 241 20 9 18

0823 238 20 8 18

0824 237 20 8 18

Maximum 5-Second Average Wind

Time

MDT

Wind Dir

Magnetic

Wind Spd

Knots

Along Trk

Knots

Cross Trk

Knots

0815 251 17 10 14

0816 242 24 11 21

0817 247 28 15 23

0818 240 25 11 22

0819 256 26 17 19

0820 234 25 9 23

0821 241 24 11 21

0822 241 23 10 20

0823 235 22 8 21

0824 250 23 14 19
19

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 anemometer,29 indicated that the wind direction was variable but

did not seem to favor either runway (30 or 26). He also said that the accident

airplane was parked near runway 30 and that the airplane would be able to depart

faster using that runway.

1.7.1.3 Density Altitude

At the time of the accident, the Cheyenne Airport density altitude

determined from the ASOS was approximately 6,670 feet.

1.7.1.4 Precipitation

The accident site was located approximately 1.5 nautical miles

northwest of the radar antenna. (See Figure 1.) Data recorded at around 0820

indicated reflectivity of about 35 dBZ30 (indicating moderate precipitation) at the

departure end of runway 30 to about 45 dBZ (indicating very heavy precipitation)

in the area where the airplane began its right turn. Based on these data, the rate of

precipitation at the time of the right turn (assuming it was all liquid precipitation)31

was calculated to be a maximum of 3.146 inches per hour. Test data for high lift

configuration airfoils from the National Aeronautics and Space Administration

(NASA) Langley Research Center, Aircraft Landing Dynamics Facility (ALDF),

show a maximum loss in lift of 2 to 3 percent for this rate of rainfall.

The PPI32 composite radar image from 0823 indicated reflectivities in

the vicinity of Cheyenne from around 40 dBZ (indicating strong precipitation) to

50 dBZ (indicating intense precipitation). (See Figure 2.)

 29The controller’s wind readings came from the original (pre-ASOS) NWS

anemometer, which was located midfield, about 1,300 feet southwest of the ASOS, near the

threshold of runway 30. No record of the direction of winds recorded by that anemometer is

kept.

30The measure of strength of weather echoes.

31The melting of snow and ice as it falls through the freezing level just above the

surface results in an increased reflectivity. Therefore, to the extent that the precipitation was

frozen, the precipitation rate would be less.

32plan-position indicator

21

1.7.1.5 Lightning Data

Cloud-to-ground lightning strike information from the National

Lightning Detection Network for the 20-mile radius centered on Cheyenne was

obtained from Global Atmospherics, Inc., for the period from 0805 to 0830,

inclusive. According to a company representative, the median accuracy of the data

was 1⁄2 mile.

The data indicate that prior to the accident airplane’s takeoff, there

were lightning strikes at 08:15:53, and at 08:18:38, and two strikes at 08:20:02.

The strikes ranged from 0.5 mile to 1.2 miles to the west of the airport. The

strikes at 0820 were about 1 to 2 miles south of the accident site.

1.7.2 Witness Descriptions of Weather Conditions Near the Airport

1.7.2.1 Other Pilots

A pilot with the State of Wyoming, who holds an airline transport

pilot rating with more than 13,800 flight hours and has been based in Cheyenne

since January 1987, departed from runway 30 in a Cessna 414 at 0816.

He recalled that once on the runway, the tower gave him westerly

winds of 25 knots gusting to 30 knots. He tilted his weather radar up to avoid

ground clutter and set it to the lowest scale of 10 miles. He remembered his radar

painting a steep gradient of green/yellow/red echoes beginning about 4 to 5 miles

from his position on the runway. He requested a 60-degree turn to the right

(heading of 360 degrees) immediately after takeoff. While on the runway he

observed cloud to ground lightning to the west (2 or 3 strokes spaced 10 to 15

seconds apart). The strongest part of the storm appeared to him to be 230 to 240

degrees off the departure end of runway 26, but echoes extended to about 330

degrees. The pilot recalled strong crosswinds during his takeoff, requiring

significant aileron input. He said that he experienced control difficulties all the

way down the runway, more so than he would normally expect under those wind

conditions. After rotation the airplane did not initially accelerate very rapidly. He

said that he experienced moderate turbulence, and his airspeed fluctuated +/- 15

knots. He said that the airplane began to climb adequately after leaving the airport

boundary. At 200 to 300 feet above the ground, the turbulence and airspeed

fluctuations subsided. He said he started his turn to the north about 1⁄2 mile after

takeoff because of the approaching leading edge of the heavier rain.
22

He further stated he was aware that a Cessna 177 (the accident

airplane) was planning on taking off soon after his departure because he had heard

the accident airplane’s pilot on the tower frequency. He said that he was

concerned and immediately gave a pilot report to the tower, hoping that the Cessna

177 would hear it. He remembered reporting light-to-moderate turbulence, low

level windshear, and airspeed fluctuations of +/- 15 knots. He said that he never

talked to anyone in the accident airplane.

The pilot in command of United Express Flight 7502 (a Beech 1900)

that landed at the Cheyenne Airport about 0820, just prior to the departure of the

accident airplane, reported that as the airplane taxied to the gate, the rain showers

became heavier. He remembered hearing on the radio the pilot of the Cessna 414

who had just departed reporting to air traffic control a 30-knot windshear. Upon

hearing the report, the captain said that he decided to delay his planned takeoff

until the weather improved. He said that he observed lightning within 1 or 2 miles

of the airport as his airplane arrived at the gate.

He stated that the rain changed to what he believed to be small hail.

The flight departed Cheyenne at 1020.

1.7.2.2 Air Traffic Control

The Cheyenne ATCT local controller, who was on duty at the time of

the accident, reported that the weather began deteriorating after he took his

position shortly before the accident. He recalled that the 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, “[a] twin Cessna

[that] just departed reported moderate low level windshear plus or minus one five

knots.”

He said that the 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

and lower than expected.
23

1.7.2.3 Other Eyewitness Statements

Eyewitnesses who observed all or part of the accident sequence

reported that the weather conditions at that time were windy, with moderate to

heavy mixed precipitation (rain, snow, and sleet), thunder and lightning.

(Locations of eyewitnesses are noted on Figure 1.)

1.8 Aids to Navigation

Navigational aids did not pertain to this investigation and were not

examined.

1.9 Communications

There were no known communications equipment difficulties.

1.10 Airport Information

The Cheyenne Airport is owned and operated by the Cheyenne

Airport Board and is located in Laramie County, 1 mile north of the city of

Cheyenne. The airport has a field elevation of 6,156 feet above sea level.

The airport has two 150-foot-wide runways, identified as 30-12,

which is 6,691 feet long, and 26-08, which is 9,200 feet long. Runway 30 has a

0.5 percent uphill slope, and the centerline of the runway has a heading of 304

degrees magnetic.

1.11 Flight Recorders

The airplane was not equipped, nor was it required to be equipped,

with either a cockpit voice recorder or a flight data recorder.

1.12 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 initial ground impact

point of the engine was coincident with its final resting place, and the engine was

still attached to the airplane. The crash site was located bearing 321 degrees and

9,600 feet from the threshold of runway 30 at the Cheyenne Airport. (See Figure
24

1.) 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 residential yard.

The airplane was found upright and was oriented along a

southeasterly bearing. The nose section and forward cabin area were crushed and

displaced rearward along the airplane’s longitudinal axis. Both cabin doors

exhibited crush lines indicative of a 67-degree nose down pitch attitude of the

airplane upon impact with the ground. The vertical and horizontal stabilizers were

relatively free of damage, as were their associated control surfaces and the

stabilator trim tab.

The cockpit/cabin area was observed to be heavily compressed along

its longitudinal axis. The right cabin door, which was separated from the airplane,

was folded over. The axis of the fold line was measured relative to the lower edge

of the door and was found to be approximately 113 degrees from the airplane’s

longitudinal axis.

The 2-bladed 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 from tip to tip

but had separated from the airframe. The wing had been rotated to an inverted

attitude during recovery of the occupants. The leading edges displayed extensive

compressive deformation oriented along the chord line of the wing with the

deformation more pronounced toward the wing tips. The flap jackscrew extension

was measured at 2.1 inches, corresponding to a 10-degree flap extension. Control

cable continuity for both elevator and rudder, as well as the ailerons, was

confirmed.

The mixture control knob was found in the full rich position in the

cockpit, and cable continuity was established between the mixture control knob

and the carburetor.

The carburetor air box was crushed with the carburetor heat valve

observed in the “cold” (off) position.
25

A damaged video recorder and two blank video tapes were found at

the wreckage site. No video tape was found within the recorder unit at the crash

site.

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 caption “Sea to Shining Sea” and “April 1996.”

1.13 Medical and Pathological Information

Autopsies were performed on all three occupants by a forensic

pathologist at the Wyoming State Crime Laboratory, Cheyenne, Wyoming, on the

evening of April 11, 1996. The autopsy reports concluded that traumatic injuries

were the cause of death for all three victims. For the pilot in command, autopsy

evidence noted bilateral fractured wrists, bilateral fractured ankles, and bilateral

fractured feet (multiple bones). The autopsy showed no wrist or ankle fractures

for the pilot trainee but numerous fractures in the bones of the right foot. The

autopsy report on the pilot trainee’s father noted that the left breast shirt pocket

contained “numerous slips of paper with appointment times and dates of TV

interviews,” including one scheduled for the evening of the accident in Ft. Wayne,

Indiana, and another for the next evening in Massachusetts. The pocket also

contained numerous business cards from various radio, TV stations, and networks.

The stomach of the pilot in command contained approximately 150

milliliters of partially digested food particles. Neither of the stomachs of the pilot

trainee or the father contained partially digested food.

Toxicological tests of specimens taken from the pilot in command

and the pilot trainee were negative, with the exception of a finding of 2.3

micrograms per milliliter of Acetaminophen33 detected in blood for the pilot in

command. No specimens were analyzed for the pilot trainee’s father.

1.14 Fire

There was no fire.

 33A nonprescription pain killer (commonly sold under the trade name Tylenol).
26

1.15 Survival Aspects

The impact was not survivable for the three occupants.

1.16 Media Aspects

According to the pilot in command’s wife, he mentioned the

upcoming record-attempting flight to a reporter from the Half Moon Bay Review,

and the newspaper printed a short article several weeks before the flight.

According to the reporter, the newspaper received calls about the article from

larger newspapers in the San Francisco area. These larger newspapers

subsequently published stories about the record attempt, and, in that reporter’s

opinion, these stories might have sparked the tremendous national media attention

that the story subsequently received. According to the pilot in command’s wife,

media interest started to be heavy about 1 week before the flight. The pilot in

command participated in several airport interviews with the pilot trainee and her

father, and media representatives often telephoned his house at late hours. On

Saturday, April 6, the pilot in command participated in an afternoon news

conference. On Sunday, April 7, he participated in another news conference at the

Half Moon Bay Airport.

During a television interview of the pilot trainee conducted at Half

Moon Bay by ABC News shortly before the start of the flight, she stated that “I

wanted to break the record and be the youngest pilot to go cross-country.” The

previous record holder, an 8-year-old pilot trainee, established his record the

previous year. (See section 1.17.)

According to the pilot trainee’s mother, 1 week before the flight, the

pilot in command and the pilot trainee took several reporters flying. She said that

on that flight they forgot the runup, and that the pilot trainee noticed in flight that

the airplane door was open.

In another ABC News interview of both the pilot trainee and her

father at Half Moon Bay, her father inquired, “who told you you wanted to fly

across country?” and the pilot trainee responded, “you.” Her father responded

“oh, I did,” at which time the ABC News correspondent conducting the video

interview inquired “oh, did you come up with the idea dad, is that where it was?”

The pilot trainee’s father responded “I did originally, and I asked [the pilot

trainee’s] mom if it would be OK with her, if [the pilot trainee] flew across
27

country, and she said yes. And I asked [the pilot trainee] and said ‘hey, honey,

you don’t have to answer me right away. You could think about this a little, but

[the pilot trainee] said ‘No, that’s something I’d like to do’.”

An entry made by the pilot in command in the pilot trainee’s flight

log, dated April 2, indicated that they had made a “low pass for photos.” An entry

dated April 4 included a reference to “photo & news interviews.”

The pilot in command’s wife reported that by Monday, April 8, when

he participated in an early morning television interview on a national news

program, her husband was “flabbergasted” by the media coverage. The mother of

the trainee said that no one expected the media attention to get so big.

ABC News provided a leased video recorder to the pilot trainee’s

father along with three 120-minute blank video cassettes that were to be used to

record the first day’s flight activities. The dates of receipt and projected return of

the video recorder, under the lease agreement, were April 8 and 15, respectively.

The first three tapes were to be returned to ABC News upon arrival at Cheyenne

and were to be replaced with blank tape cassettes for recording the following day’s

trip. The contract did not provide any monetary compensation for recording the

videotapes.

Numerous media representatives were present at the airport on the

morning of April 10, when the first flight of the trip departed Half Moon Bay, and

a news helicopter flew overhead, according to several witnesses. The pilot trainee,

her father, and the pilot in command were interviewed live on national television

at 0530 that morning.

The airplane was met by several spectators and one newspaper

reporter at its first stop in Elko. No media were present during the next stopover

at Rock Springs. However, the airport manager at Rock Springs reported that the

pilot trainee’s father placed a telephone call from a pay telephone in the airport

lobby and remained on the telephone at least 30 minutes, even after the pilot was

ready to go. According to the assistant airport manager, the pilot trainee’s father

talked with a national media organization. When he got off the telephone, he

made a comment that the pilot in command would not get to bed as early as he had

hoped because they would have to wait at Cheyenne for the delayed arrival of a

media crew.
28

Upon arrival at Cheyenne, the first overnight stop of the trip, a large

number of spectators, including media persons, were present. There was a

welcome presentation by the mayor, and media interviews that, according to the

program manager for a local radio station, lasted over an hour. The program

director for a Cheyenne radio station provided a ride to the hotel for the pilot, the

trainee, and the pilot trainee’s father following the media interviews.

On the morning of the accident, the airplane occupants participated in

at least three media interviews. The pilot trainee was interviewed during a brief

telephone call with the program director, and she also spoke with a television

reporter. In addition, the pilot in command participated in a 2-minute interview

with a television reporter outside on the ramp shortly before taking off.

1.16.1 Itinerary Planning

The idea for the “record”-attempting, cross-country flight was

proposed by the pilot trainee’s father in February, according to the pilot trainee’s

mother. The original plan was for the pilot trainee and the pilot in command to fly

from California to Massachusetts and to complete the trip before the pilot trainee

reached her 8th birthday on May 5. It was agreed that the pilot in command would

be paid at his normal hourly rate for flight instruction, with additional

compensation for the non-flight time. According to his wife, when the trip was

first conceived, the pilot in command 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 at

that time, he planned to return from the East Coast with a business partner after the

trip was over.

According to the pilot trainee’s mother, about 1 month before the trip,

the pilot trainee asked her father to accompany her on the trip and he agreed. Two

or three weeks before the trip, the itinerary was expanded to include a return from

Massachusetts to Half Moon Bay via 13 intermediate stops. On Sunday, March

31, the pilot in command met with the pilot trainee at her home, sat next to a large

map of the United States, and planned the itinerary for the trip. It involved

approximately 51 hours of flying over 8 days, with no days off, and included
29

planned visits to relatives34 and other specific destinations and events. (See Figure

3.)

Documentation recovered from the accident site revealed that the

intended transcontinental trip was to commence on the morning of April 10 from

Half Moon Bay, California. The flight was projected to make intermediate fuel

stops at Elko, Nevada, and Rock Springs, Wyoming, before making its first

overnight stopover at Cheyenne, Wyoming.

The following chart displays the intended route of flight and

projected daily flight times, as contained in an itinerary sheet found in the aircraft

wreckage:

ORIGINATION FINAL DESTINATION INTERMEDIATE

FUEL STOPS

DATE: FLT TIME

Half Moon Bay,

CA

Cheyenne, WY Elko, NV;

Rock Springs, WY

04/10/96 08.00 hours

Cheyenne, WY Ft. Wayne, IN Lincoln, NB;

Peoria, IL

04/11/96 07.50 hours

Ft. Wayne, IN Falmouth, MA Cleveland, OH;

Williamsport, PA

04/12/96 06.00 hours

Falmouth, MA Clinton, MD Frederick, MD 04/13/96 03.00 hours

Clinton, MD Lakeland, FL Raleigh, NC;

Charleston, SC;

Jacksonville, FL

04/14/96 06.75 hours

Lakeland, FL Houston, TX Marianna, FL;

Mobile, AL

04/15/96 07.00 hours

Houston, TX Sedona, AZ San Angelo, TX;

Albuquerque, NM

04/16/96 08.00 hours

Sedona, AZ Half Moon Bay, CA Lancaster, CA 04/17/96 05.00 hours

Documents recovered from the accident site also included a handwritten letter dated March 3, 1996, from the pilot trainee to the President of the

United States, which stated, in part, “May I visit you at the White House and even

more so will you fly with me for simply 15-20 minutes...? I am scheduled to

arrive in D.C., on Saturday April 13, 1996.”35 Also recovered from the accident

 34According to the pilot trainee’s mother, the pilot trainee wanted to visit her

grandfather in Falmouth, Massachusetts, and an uncle in Houston, Texas.

35The itinerary indicated that on April 13, the airplane was scheduled to land at

Clinton, Maryland, which is approximately 8 miles from Washington, D.C.
30

site was a letter dated March 21, 1996, from the U. S. Congresswoman from the

14th District of California to the pilot trainee that stated, in part, “[u]nfortunately,

I will not be in Washington, D.C., when you are here and therefore unable to meet

you on your arrival. Please call...my office...prior to your departure to arrange a

tour of our nation’s Capitol.” Also, the itinerary indicated that they planned to

arrive at Lakeland, Florida, on the afternoon of April 14.36 This coincided with the

opening of the annual “Sun ’n Fun” Experimental Aircraft Association’s fly-in at

Linder Regional Airport.

A local pilot, who encountered the pilot in command on Sunday,

April 7, at the Half Moon Bay Airport, reported that he inquired as to why the

flight was to be conducted via a northerly routing. The pilot in command replied

that “it was planned around scheduled ‘events,’ visits of friends and relatives” and

“the Sun ’n Fun fly-in.” According to the local pilot, when he expressed concern

about the weather along the northern route at that time of year, the pilot in

command assured him that he would stop and wait out any adverse weather.

When the local pilot inquired as to why the flight was scheduled for this time of

the year, the pilot in command responded that the pilot trainee “would turn 8 years

old in early May.” According to the pilot in command’s wife and a friend (the coowner of the accident airplane), the pilot in command indicated to them that the

trip might take longer than planned.

1.17 Previous Record Attempt

In an attempt to understand the effects of the itinerary and media

attention on similar flights, Safety Board staff interviewed the father of an 8 year

old who flew with his father back and forth across the United States in July 1995

and set the youngest “pilot”37 flight “record,”38 which the accident flight was

attempting to beat.

He reported that the local newspaper published a short article about

the flight 1 day before it began. According to the father, within 1 hour, the family

was contacted by two radio stations, and by the time of the trip’s first takeoff,

 36No arrivals were to be accepted at Lakeland, Florida, after 1300 local time on

that day.

37The 8-year-old boy did not hold a pilot certificate. (See footnote 2.)

38In fact, no official record is kept for the youngest pilot. (See footnote 4.)

32

there was a media “frenzy” at the airport inspired by the newspaper article. He

said one reporter explained that “we’re looking for a happy story on kids.”

According to the father, the parents were besieged by media requests

on the first day of the flight. He stated that the flight did not have a fixed itinerary

and that their route was determined largely by weather, with many deviations. He

said that there were several days on which they stopped flying early because of

weather problems. He said that flight legs were limited to 2 hours or less because

of his 8-year-old son’s bladder needs. He stated that the trip took 10 days, and

involved 49.5 hours of flight time.

The father said that media requests to the family for information

about the intended route of flight were difficult to answer because of the lack of an

itinerary, and they eventually advised the media to contact FAA Flight Service for

updates on the airplane’s position. He said that they did not seek out media

attention, but that there were media people waiting for the flight at nearly every

stop. He said that they were distracting, irritating, asked the same questions all the

time, and became a major distraction from flying duties.

1.18 Postaccident FAA Action and Legislative Changes

On April 24, 1996, the Administrator of the FAA issued a letter to all

certified flight instructors (CFIs) reiterating their responsibilities, especially with

regard to unusual training requests and student pilots. The letter stated, in part:

One key concept which you must demonstrate to all your students

is set forth in Title 14 of the Code of Federal Regulations, Section

91.3, Responsibility and authority of the pilot in command. That

regulation states, in part, that the pilot in command of an aircraft is

directly responsible for, and is the final authority as to, the

operation of that aircraft. It is one regulation that leaves little to

interpretation; it means everything you do as pilot in command

affects the safe conduct of the flight—your preparation, your

judgements, your decision making affects not only your life but

that of your student, your passengers, and, in many cases, the

public. It is a responsibility and authority not to be taken

lightly....
33

You know how to make the decision to take the controls from a

student pilot so that the safety of the flight is not compromised.

But a more subtle and difficult responsibility for you is to

withstand the pressure exerted by parents, the media, or the child

to initiate or complete something that you know is questionable.

You must not let your enthusiasm for teaching people to fly cloud

your judgement....

In October 1996, the U. S. Congress enacted Title VI of the Federal

Aviation Authorization Act of 1996, which amended Title 49 of the United States

Code to include the Child Pilot Safety Act. This Act provides, in part, as follows:

Sec. 44724. Manipulation of Flight Controls

(a) PROHIBITION. - No pilot in command of an airplane may

allow an individual who does not hold -

(1) a valid private pilots certificate issued by the Administrator

of the Federal Aviation Administration under Part 61 of

title 14, Code of Federal Regulations; and

(2) the appropriate medical certificate issued by the

Administrator under part 67 of such title, to manipulate the

controls of an airplane if the pilot knows or should have

known that the individual is attempting to set a record or

engage in an aeronautical competition or aeronautical feat,

as defined by the Administrator.

Another part of the Act requires that the Administrator of the FAA

conduct a study of the impacts of children flying aircraft and issue a report within

6 months of enactment. The Act also requires the Administrator to issue a report

on the results of the study and to issue recommendations on whether the statutory

restrictions should be modified.

These statutory restrictions were developed, in part, in response to the

present accident.
34

2. ANALYSIS

2.1 General

The pilot in command was properly certificated and qualified for the

intended cross-country trip. Additionally, the evidence indicates that 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.

Postaccident examination of the wreckage revealed that the airplane’s

engine was developing power at the time of the accident, and that the flaps had

been set at the preferred takeoff setting of 10 degrees. Additionally, there was no

evidence of any airframe or control malfunction during the takeoff and subsequent

crash.

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.

There were no air traffic control factors that contributed to the cause

of the accident.

Casper Automated Flight Service Station (AFSS) provided a weather

briefing to the pilot in command. A review of the briefing transcript revealed that

the briefer adhered to agency guidelines and provided a comprehensive weather

briefing to the pilot in command. As a result, the Safety Board concludes that the

pilot in command was provided with a satisfactory weather briefing prior to

departing Cheyenne.

Although the pilot in command stated that he was unable to access the

most recent ATIS broadcast on his radio, this was not a factor in the accident

because he received all significant weather information from the tower controller

and the AFSS weather briefer.
35

2.2 Analysis of the Accident Sequence

2.2.1 Operation of the Airplane’s Controls

Autopsy findings of multiple wrist, ankle and feet fractures to the

pilot in command indicate that he was handling the flight controls at the time of

impact, and the absence of such injuries to the pilot trainee suggests that she was

not handling the flight controls at the time of impact.

It is unknown whether the pilot in command assumed control of the

airplane just prior to the impact, or whether he was flying during the entire takeoff

and accident sequence. The portrayal of the trip as an attempt to break the

transcontinental trip record by the youngest “pilot” suggests that the pilot trainee

would be doing the flying herself. Consistent with this portrayal, she was seated

in the left seat in front of the flight and navigation instruments, which is the seat

generally occupied by the person who is operating the controls. However, it is

known that the pilot trainee had not, in fact, done all of the flying herself on the

first day of the flight.39 Further, strong crosswinds, moderate turbulence, and

gusty winds existed at the time of the takeoff. As indicated by the control

difficulties experienced by the Cessna 414 pilot, who took off just before the

accident flight, the weather conditions at the time the airplane took off were

challenging even for experienced pilots, and it is unlikely that the pilot trainee

could have handled them without some assistance.

Therefore, the Safety Board concludes that 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.

2.2.2 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 flightpath, consistent with a stall. The Safety Board

 39The pilot trainee’s father told her mother at the end of the first day that the pilot

trainee had slept for part of the trip, and that the pilot in command had assisted her in one of the

landings because of strong winds.
36

analyzed the factors that may have increased the airplane’s stall speed and reduced

its climb speed to the point at which it stalled. These factors include the weather,

the airplane’s attitude and weight, and the high density altitude.

Eyewitnesses described moderate to heavy rain and a mixture of ice

and snow pellets occurring at the accident site. Doppler reflectivity returns

indicate heavy to very heavy precipitation in the same area.

Analysis of radar and ASOS data and eyewitness reports show that

the accident airplane was most likely encountering light to moderate rain as it

began its takeoff roll. As the plane proceeded down the runway, rotated, and

exited the runway environment, the Doppler reflectivity patterns show that the

airplane encountered increasing amounts of precipitation until the time of the

accident. In addition, the reflectivity returns in the accident area shown at 0823

indicate that the airplane was experiencing a maximum precipitation rate of 3.146

inches per hour just prior to the accident. Based on airplane performance data

provided by NASA, such rainfall could reduce the airplane’s lift by as much as 3

percent.40 This would increase the airplane’s stall speed by about 1.5 percent.

Lightning was observed west of the airport by pilots prior to the

accident. In addition, witnesses saw occasional lightning west of the airport

around the time of the accident. Archived information indicated cloud-to-ground

lightning strikes at 0820, 1 to 2 miles south of the accident site. There is no

evidence of lightning strikes affecting the airplane. However, from the evidence

of lightning, along with the Doppler radar data indicating composite reflectivity in

the area (see section 1.7.1.4), the Safety Board concludes that the accident

sequence took place near the edge of a thunderstorm.

The Cessna 414 pilot who departed just prior to the accident flight

indicated that he turned about 1⁄2 mile after takeoff because of the approaching

storm. The pilot in command of the accident flight also turned shortly after

takeoff. The Safety Board concludes 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. The

 40As noted in section 1.7.1.4, the melting of frozen precipitation results in a

greater reflectivity return than the same volume of liquid precipitation. It is known that the

precipitation at the time of the accident was at least partly, if not totally, frozen. Therefore, to the

extent that the precipitation at the time of the accident sequence was frozen, the precipitation

rate, and therefore the loss of lift, would be less.
37

witness statements indicate that the turn to the east was gradual; this is consistent

with a bank angle of about 20 degrees. With the flaps at 10 degrees, a 20-degree

bank angle would increase the stall speed about 3 mph, from about 59 mph for

steady level flight to about 62 mph.

Using the total weights of the clothed occupants, a full load of fuel,

personal baggage and miscellaneous items (food and fluids) plus the airplane’s

basic empty weight, the Safety Board concludes that the airplane was 96 pounds

over the maximum gross takeoff weight at takeoff, and 84 pounds over the

maximum gross takeoff weight at the time of the impact. The additional weight

would have increased the airplane’s stall speed about 2 percent.

The combined effect of the rain, the excess weight and the bank angle

of the airplane could have increased the airplane’s stall speed to about 64 mph.

The airplane’s best rate of climb speed at sea level is 87 mph (with a climb rate of

685 feet per minute). However, the high density altitude at the airport and the

overweight condition of the airplane would have affected the airplane’s climb

performance.

The Cheyenne Airport has a field elevation of 6,156 feet msl. Taking

into account the temperature, the density altitude at the time of the takeoff and

accident was 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 to 81 mph; with a climb rate

of 387 feet per minute.

Thus, the combination of the effects of the rain, the overweight

condition, and the gradual bank angle of the airplane would have increased the

airplane’s stall speed from about 59 mph to about 64 mph, and, along with the

high density altitude, decreased its best rate-of-climb speed from 84 mph to about

81 mph. However, the airplane should have been able to climb and turn safely.

Thus, the Safety Board analyzed the possible reasons why this did not occur.

These include a possible reduction in engine power from carburetor icing or an

over-rich fuel/air mixture, and the effects of fluctuating winds, poor visibility and

the lack of sufficient experience in takeoffs from high density altitudes on the pilot

in command’s ability to operate the airplane.

As noted in section 1.6.1, it is necessary to lean the fuel mixture at

higher altitudes to allow maximum engine performance; an over-rich mixture can
38

result in an appreciable loss of power and reduced climb performance capability.

The mixture control knob was found in the full rich (forward) position at the

accident site, thus suggesting that it was in that position prior to impact, although

it is possible that the knob was out and impact forces moved the knob forward

without bending the rod. The pilot’s failure to stop at the end of the runway

before his takeoff roll, which would have been the most common and appropriate

time to adjust the fuel/air mixture, further suggests that he did not properly lean

the mixture.

Further, carburetor icing conditions existed at the time of takeoff (the

temperature was 40 degrees, the dew point was 32 degrees, and there was moisture

in the air). Thus, without the application of carburetor heat during taxi and runup,

ice may have formed in the carburetor and reduced the available power at takeoff.

The carburetor heat valve was found in the “off” position at the accident site. The

pilot’s failure to stop at the end of the runway before his takeoff roll suggests that

he did not perform a pretakeoff checklist, which would have included a magneto

and carburetor heat check (turning on the carburetor heat.) However the Safety

Board could not conclusively determine its position during the takeoff sequence.

Either or both of these conditions could have reduced the engine

power sufficiently to cause a loss of climb capability. However, because the

settings of the mixture control knob and the carburetor heat valve during the

takeoff could not be determined positively, the Safety Board cannot conclusively

determine whether a power reduction from an over-rich mixture and/or carburetor

icing existed at the time of the accident.

ASOS ceilometer data and eyewitness reports indicate that the cloud

bases in the accident area were probably around 1,500 feet agl. Additionally,

numerous eyewitnesses stated that the airplane was visible until the accident.

Personnel in the tower, about 1.2 nautical miles from the accident location,

observed the accident sequence.

The Safety Board concludes that 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 because of the need to scan to his left

to see flight instruments in front of the pilot trainee and to his right to see the

ground, as he attempted to operate the airplane at low speed, with a lower-than-
39

normal climb rate, with the distraction of rain and ice impacting the airplane, and

in instrument meteorological conditions.

Analysis of weather data indicate that the winds were generally

westerly at the surface and near-surface at speeds that varied between 15 and 30

knots. In addition, there is evidence of significant crosswinds of 21 to 23 knots on

runway 30 at the time of the accident flight’s takeoff. (See sections 1.7.1.2 and

1.7.2.1.)

Wind data from ASOS showed that wind speeds were most likely

about 5 knots higher around the takeoff time of the accident flight than when the

Cessna 414 departed, reporting to the tower controller moderate low level

windshear and airspeed fluctuations of +/- 15 knots. This report was

acknowledged by the pilot in command of the accident flight. The Safety Board

concludes that the airplane experienced strong crosswinds, moderate turbulence

and gusty winds during its takeoff and attempted climb, and that the pilot in

command was aware of these adverse wind conditions prior to executing the

takeoff.

Although airplane control problems associated with crosswinds

would exist during the initial takeoff roll, control problems associated with

turbulence and gusty winds would have affected the airborne portion of the flight

as well. Specifically, these wind conditions would make it more difficult to

maintain a constant airspeed and rate of climb and could result in an unintended

reduction in airspeed to below the airplane’s stall speed.

The wind conditions may also have affected the pilot’s perception of

his airspeed after the right turn. What was initially a crosswind during the takeoff

roll and initial airborne phase became a tailwind after the airplane began its right

turn. Because the pilot was most likely looking outside the airplane during the

VFR departure, he may not have been adequately monitoring the airspeed

indicator or he may have had difficulty monitoring it because of airspeed

fluctuations, and he may have misperceived the increased ground speed as an

increase in airspeed. Accordingly, the Safety Board concludes that 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.
40

The pilot in command had only performed a total of ten known

takeoffs out of airports at elevations exceeding 4,500 feet msl, and only five of

those flights were performed from airports over 6,000 feet msl. Higher density

altitudes result in a reduction of aerodynamic (wing and propeller) and powerplant

performance during takeoff and initial climb, and in a longer takeoff run and

slower rate of climb. This reduced rate of climb might well prompt a person who

was inexperienced with high density altitude takeoffs to raise the nose of the

airplane in an attempt to increase the rate of climb, thereby further decreasing the

airspeed. Therefore, the Safety Board concludes that 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 Safety Board has been unable to determine which of the above

factors, or a combination of factors, resulted in the reduction in the climb speed to

below the stall speed. However, the Safety Board concludes that 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 Safety Board notes that the pilot in command had limited

experience operating out of high density altitude airports, such as Cheyenne, and

that this should have prompted him to be cautious. He had expressed concern

about the predicted storm that was to move in from the west, and he had wanted to

leave early enough to avoid the storm. Further, just prior to departure, the pilot

knew the wind conditions reported by a pilot who had just departed.

Accordingly, the Safety Board concludes 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. Therefore, the

Safety Board attempted to analyze the human performance factors that might have

caused the pilot in command to depart under those conditions. These factors

include the possible effects of fatigue, the emphasis placed on media events, and

the desire to adhere to the programmed itinerary.
41

2.3 Human Performance Aspects

2.3.1 Fatigue

The pilot in command’s sleeping schedule in the days before the

accident flight may have led to fatigue. He received 6 1⁄2, 6 3⁄4, and 5 1⁄2 hours of

sleep, respectively, in the 3 days prior to the start of the trip on April 10, compared

to the 8 1⁄2 to 9 hours of sleep that he typically received per night on weekends.41

On April 10, he awoke at 0330, earlier than his normal wake-up time. By midafternoon on April 10, during the fueling stop at Rock Springs, he told a witness

of being tired. After arriving at Cheyenne, he telephoned his wife and said that he

“was really tired.”

There is evidence that people tend to underestimate their level of

tiredness,42 so that when the pilot reported being “really tired” it probably reflected

a high level of fatigue. Accordingly, based on his early wake-up time (0330 PDT),

his long and demanding flight regime the first day of the transcontinental flight,

his comments about being tired, and his potential sleep loss in the days before the

trip, the Safety Board concludes that the pilot in command suffered from fatigue

on the day before the accident.

The pilot in command had the opportunity to receive a full night’s

sleep the night before the accident between the time he checked into his hotel

room at about 1900 and the time he checked out the next morning at 0622.

However, the quantity and quality of his sleep during that time is unknown.

Immediately before the accident, the pilot in command committed several errors

that are consistent with a lack of alertness.43 The number and variety of these

 41Extra sleep on weekends is often a sign that the individual is building a sleep

deficit during the week. The pilot in command routinely received less than 7 hours of sleep per

night during the work week and compensated by sleeping longer on weekends. Before the

accident, his sleep was less than usual during the work week, and he had no opportunity to

compensate.

42See Aircraft Accident Report, “Uncontrolled Collision with Terrain, American

International Airways Flight 808, Douglas DC-8-61, N814CK, U. S. Naval Air Station,

Guantanamo Bay, Cuba, August 18, 1993” (NTSB/AAR-94/04)

43Specifically, he started the airplane engine while the nosewheel was still

chocked; requested a taxi clearance without having obtained the ATIS; read back a radio

frequency incorrectly; accepted a radio frequency that he could not dial on his radio; failed to

acknowledge, as requested, the weather information provided by the controller; asked “are we

going the right way”; failed to stop at the end of the runway; and used incorrect phraseology

when he requested a “special IFR” clearance.
42

errors are consistent with a general degradation in performance of the sort

produced by fatigue. Fatigue can degrade all aspects of performance, especially

decision making, and could have resulted in the pilot in command being less than

fully alert as he made the final determination to take off. However, there are other

possible explanations for these errors, such as the effects of rushing, distraction

from tasks, or the influence of habitual bad flying practices.44 In addition, as noted

above, the pilot in command had the opportunity to receive ample rest the night

before. Therefore, there is insufficient evidence to conclude that fatigue was a

factor in the accident.

2.3.2 Fatigue Awareness and Education

The Safety Board is concerned that the pilot in command continued

flying the day before the accident even though he knew that he was fatigued.

Recent literature45 indicates that fatigue is a pervasive factor, often difficult for an

individual to recognize, that can degrade decision making and most other aspects

of human performance.

Educating operators in all modes of transportation on fatigue has been

of special concern to the Safety Board. In 1989, the Safety Board recommended

that the Department of Transportation (DOT) encourage education as part of an

aggressive Federal program to address the problems of fatigue and sleep issues in

transportation safety:

I-89-3

Develop and disseminate educational material for transportation

industry personnel and management regarding shift work; work

and rest schedules; and proper regimens of health, diet, and rest.

On April 20, 1996, the DOT provided the Safety Board with copies of

a publication, two video films, and brochures developed for DOT use in fatigue

education. One video and brochure, entitled “Fatigue Busters - How to Survive

 44It was reported by pilots at Half Moon Bay that the pilot in command had

executed unpublished approaches when the weather was below VFR minimums. It is also

known that the pilot in command once attempted to taxi with a tow bar still attached to the

airplane, and that a week before the accident flight, he forgot to do a runup and close the airplane

door before making a flight with several reporters.

45See Fatigue Symposium Proceedings, November 1-2, 1995, National

Transportation Safety Board and NASA Ames Research Center. Washington, D.C.: National

Transportation Safety Board.
43

Fatigue in the 90’s,” was prepared by the FAA and has been sent to its regional

safety offices. The Safety Board was impressed at the level of detail in this

material and encouraged the DOT to continue to develop and disseminate similar

materials as research progressed and to develop similar information in modes other

than aviation and highway. As a result of these actions, on July 19, 1996, the

Safety Board classified Safety Recommendation I-89-3 “Open--Acceptable

Response.”

In 1994, following a study of major air carrier accidents in which

flightcrew performance was a factor,46 the Safety Board recommended that the

FAA:

A-94-005

Require U.S. air carriers operating under 14 CFR Part 121 to

include, as part of pilot training, a program to educate pilots about

the detrimental effects of fatigue, and strategies for avoiding

fatigue and countering its effects.

In 1994, as a result of its investigation of an accident involving a

Continental Express Embraer-120 RT on April 29, 1993, at Pine Bluff, Arkansas,47

the Safety Board recommended that the FAA:

A-93-073

Require that 14 CFR Part 135 air carriers provide aircrews, as part

of their initial and recurrent training, information on fatigue

countermeasures relevant to the duty/rest schedules being flown

by the company.

On September 8, 1995, the FAA issued Change 1 to AC 120-51B,

Crew Resource Management (CRM) Training. Appendix 3, Paragraph 2H, of the

revised AC recommends CRM training on a number of topics, including factual

information about the detrimental effects of fatigue and strategies for avoiding and

countering its effects. As a result of this action, on January 16, 1996, the Safety

 46See Safety Study, “A Review of Flightcrew-Involved, Major Accidents of U.S.

Air Carriers, 1978 Through 1990” (NTSB/SS-94/01)

47See Aircraft Accident/Incident Summary Report, “In-flight Loss of Control,

Leading to Forced Landing and Runway Overrun, Continental Express, Inc., N24706, Embraer

EMB-120 RT, Pine Bluff, Arkansas, April 29, 1993” (NTSB/AAR-94/02/SUM)
44

Board classified Safety Recommendations A-94-005 and A-93-073 “Closed--

Acceptable Action.”

The Safety Board is encouraged by these actions and continues to

encourage the transportation community to expand understanding and education

on fatigue and countermeasures to it. However, the pilot in command’s decision

to continue flying the day before the accident when he knew that he was fatigued

indicates that he did not adequately appreciate the potentially hazardous effects of

fatigue on flight safety. The Safety Board concludes that 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. Therefore, the Safety Board believes that the FAA

should expand the development and increase the dissemination of educational

materials on the hazards of fatigue to the general aviation piloting community.

2.3.3 Media Attention and Itinerary Pressure

When the trip was proposed, the pilot in command told his wife that

the flight would be a “non-event for aviation” and simply “flying cross country

with a 7 year old next to you and the parents paying for it.” The evidence indicates

that he was surprised and awed by the media attention that developed. However,

according to his wife, he was pleased by the media attention.

The media interest apparently began from an article in a local paper.

Media interviews began several days before the trip, and included numerous

telephone calls at home and early morning live television interviews on national

news programs. Media representatives were present at nearly every stop on the

trip, and the time spent participating in media events interfered with other

activities that could have affected flight safety.48 For example, the media events at

Cheyenne the night before the accident resulted in a delayed arrival at the hotel,

thus delaying the opportunity for the participants to obtain much needed rest.

Also, on the morning of the accident, the pilot in command’s preflight inspection

and preparation of the airplane was interrupted by a television reporter’s

 48In addition, the father videorecorded parts of the first day’s flight from the back

seat of the airplane for use by a national news service, providing a regular reminder of the news

value of the flight.
45

interview, possibly degrading the thoroughness of the preflight preparations.49

The airplane occupants also participated in two other media interviews, further

delaying the departure. Further, slips of paper found in the shirt pocket of the

pilot trainee’s father indicated that they had media interviews scheduled for that

evening in Ft. Wayne, Indiana, and the following evening in Massachusetts.

On the morning of the accident, the weather was changing. There

was a cold front approaching Cheyenne, but the weather to the east was good. If

the airplane had departed ahead of the storm, it would have encountered good

weather along its intended route. If the airplane had waited until after the storm

passed, its intended route would have been blocked by the storm. The pilot had

made it clear the night before that he wanted to depart ahead of the cold front, but

their departure was delayed by a later-than-planned checkout from the hotel and

by the media interviews. By the time the airplane was ready for takeoff, the only

way to avoid being held up by the storm, and therefore to maintain the tightly

scheduled itinerary, was to fly for several minutes in the deteriorating and

potentially unsafe weather conditions associated with the storm.

Self-induced pressures from media attention can degrade decision

making, increasing the perceived importance of maintaining the schedule

compared to other factors. It would have been a normal human response for the

pilot in command to have been affected by the media attention.

The Safety Board concludes that 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 Safety Board further concludes that 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 planned itinerary for the trip involved approximately 51 hours of

flying time (with 3 to 8 hours of flight time scheduled per day), more than 8 days,

and no days off. In contrast, the father of the 8-year-old child, who had set the

previous youngest “pilot” flight “record,” indicated that they followed no fixed

 49For example, if he had been fully attentive to the preflight preparations, he might

have questioned whether the numerous bags and other items being loaded on the airplane would

result in an overweight condition.
46

itinerary, and that their route was flexible. He said that their flight legs were

limited to 2 hours or less to accommodate the child’s physiological needs.

It is not clear why the pilot in command agreed to an itinerary that

was so demanding and had so little flexibility. He had flown long trips before and

must have known that weather can be difficult to predict. When another pilot

expressed concern about the itinerary, especially about weather through the

mountains at that time of the year,50 the pilot assured him that he would stop and

wait out any adverse weather. The pilot also acknowledged to his wife and

another friend that the trip might take longer than planned. But he did not build

any reserve time into the itinerary that would allow for such delays.

The Safety Board concludes 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.

2.3.4 Aeronautical Decision Making

Since 1988, the Safety Board has made three recommendations urging

the FAA to enhance pilot training in decision making for commercial operations.

Following its Special Study of Emergency Medical Service Helicopter

Operations,51 the Board recommended that the FAA:

A-88-002

Require that the material being developed for the Emergency

Medical Service (EMS) pilot supplement to the aeronautical

decision making manual for helicopter pilots be incorporated into

EMS pilot initial and recurrent training.

On October 20, 1988, the FAA issued AC 135-14, “Emergency

Medical Services/Helicopter.” This AC provided information on overall training

requirements that should be satisfied by Part 135 operators for FAA program

approval, including guidance regarding aeronautical decision making for EMS

helicopter pilots. On January 25, 1989, the Safety Board classified Safety

Recommendation A-88-002 “Closed--Acceptable Alternate Action.”

 50The trip was planned for April because the pilot trainee would turn 8 years old

in May, and she would break the previous “record” only if the flight were completed before then.

51See Safety Study, “Commercial Emergency Medical Service Helicopter

Operations” (NTSB/SS-88/01)
47

Following its investigation of a midair collision involving a Piper

Aerostar PA-60 airplane and a Bell 412 helicopter that occurred on April 4, 1991,

52

the Safety Board further expressed its concern about aeronautical decision making.

The Safety Board issued the following recommendation to the FAA on October

11, 1991:

A-91-93

Disseminate more aggressively available information and

materials pertaining to Aeronautical Decision Making training and

actively promote its implementation among all categories of pilots

in the civil aviation community.

On December 1, 1989, the FAA published AC 120-51, “Cockpit

Resource Management Training (CRM),” and on December 13, 1991, the FAA

published AC 60-22, “Aeronautical Decision Making.” Both publications

addressed the importance of including decision making in pilot training programs.

Based on the latter action, the Safety Board classified A-91-93 “Closed--

Acceptable Action.”

In 1993, following its investigation of an accident involving a Scenic

Air Tours Beech Model E18S near Maui, Hawaii, on April 22, 1992,53 the Safety

Board again expressed its concern about the adequacy of aeronautical decision

making training and issued the following recommendation to the FAA:

A-93-013

Issue an air carrier operations bulletin instructing all principal

operations inspectors to aggressively encourage all commercial

operators to incorporate comprehensive aeronautical decision

making (ADM) training in their pilot training programs.

On February 22, 1994, the Safety Board classified Safety

Recommendation A-93-013 “Closed--Acceptable Action,” based on the FAA’s

proposal to issue Change 1 to AC-120-51B to emphasize to field office inspectors

 52See Aircraft Accident/Incident Summary Report, “Midair Collision Involving

Lycoming Air Services Piper Aerostar PA-60 and Sun Company Aviation Department Bell 412,

Merion, Pennsylvania, April 4, 1991” (NTSB/AAR-91/01/SUM)

53See Aircraft Accident Report, “Tomy International, Inc. d/b/a Scenic Air Tours,

Flight 22, Beech Model E18S, N342E, In-Flight Collision with Terrain, Mount Kaleakala, Maui,

Hawaii, April 22, 1992” (NTSB/AAR-93-01)
48

the importance of encouraging operators to incorporate decision making in their

company training programs. The change was subsequently issued on September 8,

1995.

Although these actions with regard to AC-120-51 (CRM) have

improved and enhanced decision making training for commercial pilots, general

aviation pilots are not exposed to this training. AC 60-22 (Aeronautical Decision

Making), issued by the FAA in 1991, was aimed at general aviation pilots and

flight instructors. This AC provides a basis for explaining decision making to

pilots and a framework for teaching judgment issues to pilots. The AC describes

common dangerous tendencies, dangerous attitudes, fitness for duty, and decision

making models.

Recent developments in the area of aeronautical decision making54

have focused on decision making involving real life situations, in which decisions

must often be made rapidly in response to changing and ambiguous circumstances.

This work has emphasized the importance of experience for rapidly assessing

situations and choosing workable alternatives.

The Safety Board is aware of several recent initiatives to upgrade the

teaching of decision making to general aviation pilots. For example, the Air

Safety Foundation of the Aircraft Owners and Pilots Association (AOPA) has

recently developed a pilot training seminar entitled “Never Again” that is being

presented to pilot groups and that focuses on actual weather-related incidents. By

using videotape reconstruction and regular audience discussion, the seminar

presents decision making issues in a manner that is compelling and closely related

to actual pilot experiences. The Safety Board is also aware that the National

Association of Flight Instructors (NAFI) is developing a new program in decision

making skills aimed at flight instructor recertification training. It will emphasize

judgment in concrete situations facing pilots. The Safety Board commends these

efforts.

This accident demonstrates the need for continued efforts in the area

of aeronautical decision making for general aviation pilots. The circumstances of

this accident could be instructive to other general aviation pilots in raising their

 54See Judith Orasanu and Terry Connolly, “The Reinvention of Decision Making”

in Gary A. Klein, Judith Orasanu, Roberta Calderwood, and Caroline E. Zsambok (Eds.),

Decision Making in Action: Models and Methods. Norwood, N. J.: Ablex Publishing

Corporation.
49

awareness of potential decision making errors. Therefore, the Safety Board

believes that AOPA, the Experimental Aircraft Association (EAA), and NAFI

should disseminate information about the circumstances of this accident and

continue to emphasize to their members the importance of aeronautical decision

making.

The Safety Board recognizes that the FAA’s letter of April 24, 1996,

to flight instructors generally addressed CFI responsibilities and the importance of

making appropriate decisions. However, it did not specifically refer to the

circumstances of this accident. Therefore, the Safety Board believes that the FAA

should incorporate the lessons learned from this accident into educational

materials on aeronautical decision making.

2.4 Recent Legislative Changes

As noted in section 1.18, in October 1996, Congress passed the Child

Pilot Safety Act, which limits “record”-attempting flights and has ordered the FAA

to conduct a study of the impacts of children flying aircraft. As shown in this

accident, the record-setting aspect and associated media and itinerary pressure of

such flights can distort a pilot’s decision making and lead to an unsafe situation.
50

3. CONCLUSIONS

3.1 Findings

1. The pilot in command was properly certificated and qualified

for the intended cross-country trip.

2. The pilot in command was wearing corrective lenses at the

time of takeoff, as required by the limitation on his current

medical certificate.

3. There was no evidence that airplane maintenance was a factor

in the accident.

4. The airplane’s engine was developing power at the time of

the accident, and the flaps had been set at the preferred

takeoff setting.

5. There was no evidence of airframe or control malfunction

during the takeoff and subsequent crash.

6. Airframe icing was not likely a factor in this accident.

7. There were no air traffic control factors that contributed to

the cause of the accident.

8. The pilot in command was provided with a satisfactory

weather briefing prior to departing Cheyenne.

9. 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.

10. The accident sequence took place near the edge of a

thunderstorm.
51

11. 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 straightout departure.

12. The airplane was 96 pounds over the maximum gross takeoff

weight at takeoff, and 84 pounds over the maximum gross

takeoff weight at the time of the impact.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.
52

18. 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.

19. The pilot in command suffered from fatigue on the day before

the accident.

20. 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.

21. 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.

22. 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.

23. 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.
53

3.2 Probable Cause

The National Transportation Safety Board determines that the

probable cause of this 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 media commitments.
54

4. 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 members the importance of

aeronautical decision making. (A-97-19)

--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. (A-97-20)

Incorporate the lessons learned from this accident into educational

materials on aeronautical decision making. (A-97-21)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

James E. Hall

Chairman

Robert T. Francis II

Vice Chairman

John Hammerschmidt

Member

John J. Goglia

Member

George W. Black, Jr.

Member

March 11, 1997
55

5. APPENDIXES

APPENDIX A

INVESTIGATION AND HEARING

1. Investigation

The National Transportation Safety Board’s Northwest Region was

notified of the accident by the FAA’s Northwest Mountain Region Operations

Center at 0758 Pacific daylight time on April 11, 1996. The Safety Board’s

investigator in charge departed for the site on the first available commercial flight.

Safety Board personnel from the South Central Field Office, Denver, Colorado,

were the first investigators to reach the site, arriving shortly after noon.

Investigation groups were formed for human performance and

meteorology.

Parties to the investigation were the Federal Aviation Administration,

Cessna Airplane Company, and Textron Lycoming.

2. Public Hearing

There was no public hearing held or formal depositions taken for this

accident.
56

APPENDIX B

TRANSCRIPT OF AFSS WEATHER BRIEFING

Q Memorandum

U.S. Department

of Transportation CASPER AFSS

Federal Aviation 3777 Airport Parkway

Administration Casper, Wyoming 82604

Subject:

From:

INFORMATION: Transcription concerning Date: April 16, 1996

the accident involving N35207 Cessna Cardinal

on April 11, 1996 at 1424 UTC

Reply to

ATM, Casper AFSS Attn. of:

To: This transcription covers the Casper AFSS Prefight 4 position for the time

period from April 11, 1996, 1356 UTC to April 11, 1996, 1413 UTC.

Agencies Making Trarsmissions

Casper AFSS, Preflight 4

Pilot of Cessna Cardinal N35207

I hereby certify that the following is a true

subject aircraft accident involving N35207:

Abbreviations

PF

N35207

transcription of the recorded conversations pertaining to the

&

Quality Assurance Specialist

April 16,1996

1356

1357

1358

1359

1400

1401

1401:20 PF

1401:21 N35207

1401:24 PF

casper flight service

good morning this is cardinal three five two zero seven at uh

cheyenne

(unintelligible)
57

CYS-ATCT-182

N35207

Page 2 of 6

1401:25 N35207 like a weather briefing for a v f r flight from hereto lincoln

nebraska and will be direct

1401:31 PF

1401:34 PF

1401:41 PF

go ahead

*(uhhh)

at this time we have an airrnet for icing moderate below twenty

thou twenty four thousand in wyoming airmet for turbulence

both uh along the route possibly severe below eighteen

otherwise moderate i f r flight precautions are in effect likewise

along that route of flight theres a cold front just to the north of

your position actually they depict it through there now

1402:03 N35207 yea its startin to rain here

1402:07 PF okay and with regards to the rain showers is it we have uh on

the cheyenne uh oh bad time for my radar to die ha dog gone it

*(let) me try this other machine theres some tops above thirty

thousand just uh on uh virtually a line of it on a north south line

just west of your position an there movin from south to north at

this time so we have thunderstorms icing and i f r and urn not

looking for a lot of improvement cheyennes currently twenty six

hundred broken three thousand overcast ten miles with light rain

scotts bluff automated weather is twenty one hundred no is

twelve hundred scattered seven miles winds north east at twenty

gust to twenty three i hate these awoses every every one of them

out there thu other than scotts bluff *(is the) same ogalalas north

platte there all clear below twelve thousand sidney nebraska is

grand island is clear below twelve sidney clear below twelve well

if in fact its that good out there

1403:40 N35207 yea probably looks good out there from here lookin

(unintelligible) lookin east looks like the suns shining as a matter

of fact

1403:47 P F yea lets take a look at that airmetthats been issued again for the
58

CYS-ATCT-182

N35207

Page 3 of6

1404:03

1404:04

1404:42

1404:43

1405:01

1405:03

1405:10

1405:11

1405:14

1405:21

N35207

PF

N35207

PF

N35207

PF

N35207

PF

N35207

PF

i fr see it says from dikenson to scotts bluff to fifty south west

of scotts bluff to laramie to bozeman i f r conditions

yea i can imagine that

okay forecast for cheyenne thru seventeen z calls for two

thousand scattered to broken four thousand broken and light

thunderstorms after seventeen z lowering ceilings fifteen

rain

hundred feet along your route of flight uh scotts bluff just to the

north there calls for from fourteen to seventeen z i f r conditions

and rain and fog over at north platte ten thousand scattered until

seventeen z which is three hours from now then they say at north

platte thunderstorms four thousand scattered to broken

uh huh

lincoln uh this morning twenty five thousand broken chance of

thunderstorms by two p m mountain time and grand island

forecasting cirrus clouds thunderstorms late afternoon so if its if

you can venture out of there and

yea it looks pretty good actually

go get east it looks

and stay south lets see what akrons got yea akrons clear below

twelve so i don’t have any weather

okay

other than whats right at cheyenne uh adverse conditions

yea its raining here pretty good right now i mean its you know

steady but nothin nothin bad and to the east it looks real good

(unintelligible) you get winds at nine thousand at two thirty at uh
59

CYS-ATCT-182

N35207

Page 4 of 6

1405:35

1405:36

1405:43

1405:44

1405:48

1405:49

1405:50

1405:56

1405:57

1406:00

1406:02

1406:04

1406:06

N35207

PF

N35207

PF

N35207

PF

N35207

PF

N35207

PF

N35207

PF

N35207

startin out at about twenty and then omahas two forty at thirty

five so youll get a good push

Yea

theres a notam at lincoln theres a tower boy this just a huge

thing twelve hundred feet a g 1

wuh

nineteen east no lights on it

this is Iincoln

yea

okay

that would be the notams that i see here

okay

what else can i get for ya

well (unintelligible) thats it we’ll file

go ahead sir

its a v f r its uh cardinal three five two zero seven its a uh uh one

seven seven b slash uniform true air speed a hundred twenty nice

a hundred twenty knots departure point is cheyenne proposed is
60

CYS-ATCT-182

N35207

Page 5 of6

within the next uh half hour cruise altitude will be probably uh

somewhere around probably five thousand five hundred er no

seven thousand five hundred and route of flight will be direct to

uh to lincoln uh d uh d theres uh uh five uh five and a half hours

of fuel on board uh and uh the estimated time enroute is uh im

sorry is uh will be four hours and uh the the uh my name is joe

reid r e i d home airport is half moon bay thats h uh hotel alpha

foxtrot my telephone number there is four one five seven two six

three four one seven theres three souls aboard and weve got

we’re red white and blue

1407:08 PF wheres is that located uh half moon bay

1407:11 N35207 just south of san francisco about uh twenty five miles

1407:15 PF okay flight plans filed

1407:19 N35207 okay thank you sir and where do we call

1407:21 PF call us on twenty two i got to look five i think it is

1407:27 N35207 twenty two what

1407:30 PF no one twenty two three

1407:33 N35207 three oh okay and uh whos flight following who do i call for

flight following

1407:36 PF denver center

1407:39 N35207 okay do you have that number for around here

1407:39 PF one two five point nine
61

CYS-ATCT-182

N35207

Page 6 of6

1407:41 N35207

1407:43 PF

1407:44 N35207

1408

1409

1410

1411

1412

1413

twenty five niner thank you very much sir

have a good one

see ya la thanks bye

End Of Transcript

★This portion of the rerecording is not entirely clear, but this represents the best interpretation

possible under the circumstances.

I U.S GOVERNMENT PRINTING OFFICE 1997-425-182