The board president found clear and convincing evidence that the cause of the mishap was pilot error. The pilot violated regulatory provisions and multiple flight manual procedures, placing the aircraft outside established flight parameters at an attitude and altitude where recovery was not possible. Furthermore, the copilot and safety observer did not realize the developing dangerous situation and failed to make appropriate inputs. In addition to multiple procedural errors, the board president found sufficient evidence that the crew on the flight deck ignored cautions and warnings and failed to respond to various challenge and reply items. The board also found channelized attention, overconfidence, expectancy, misplaced motivation, procedural guidance, and program oversight substantially contributed to the mishap.
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