NTSB Report on Bill Phillips' Accident

Ron Wanttaja wrote:
The NTSB has released the factual report:

http://www.ntsb.gov/ntsb/brief2.asp?...LA016& akey=1


This is the usual precursor to the final report, which usually contains
the same information with the addition of the NTSB's Probable Cause.

Ron Wanttaja

I skimmed it -
bwb weighed in at 246 lb & 5ft 11 1/2 in Anterior artery from heart
almost blocked.
Toxic cocktail of painkillers etc. None disclosed on medical.
Three plugs oiled up. The lid might have opened, scattering stuff.....

Brian W

On Mon, 21 Sep 2009 21:14:31 -0500, brian whatcott
wrote:

Ron Wanttaja wrote:
The NTSB has released the factual report:

http://www.ntsb.gov/ntsb/brief2.asp?...LA016& akey=1


This is the usual precursor to the final report, which usually contains
the same information with the addition of the NTSB's Probable Cause.

Ron Wanttaja

I skimmed it -
bwb weighed in at 246 lb & 5ft 11 1/2 in Anterior artery from heart
almost blocked.
Toxic cocktail of painkillers etc. None disclosed on medical.
Three plugs oiled up. The lid might have opened, scattering stuff.....

Brian W

on my last annual I found 3 plugs oiled up. effect on the engine
performance was nil.

I could be jaundiced here but surely the drugs were prescribed.
was the real failure a failure of the american medical system to
diagnose and correctly treat his blocked anterior artery?

stealth pilot

"Stealth Pilot" wrote in message
...
was the real failure a failure of the american medical system to
diagnose and correctly treat his blocked anterior artery?

I ain't no doctor, but diagnosing that takes some pretty $pecific and
sometimes very invasive tests that are not done without very good reason.

I also tend to focus on the canopy.
In that scenario the "real failure" was:
1) An improper (probably rushed) preflight check. (On any canopy plane, you
need to double and triple check that the canopy is secure.)
2) A failure to ignore the noise, wind, and swirling debris caused by the
open canopy and concentrate on flying the perfectly controllable airplane.

The drugs and the pilot's general health were probably certainly factors,
but even without the drugs, the same could have happened to many of us.

Vaughn

Stealth Pilot wrote:

I could be jaundiced here but surely the drugs were prescribed.
was the real failure a failure of the american medical system to
diagnose and correctly treat his blocked anterior artery?

Certainly, I'd say the drugs were prescribed.

As far as failure to diagnose the problem, check the NTSB report again:

"The pilot’s most recent application for airman medical certificate in
May 2007 noted a “precautionary” coronary angiogram in 2006 which
“showed no blockage.” ... Records obtained from the pilot’s cardiologist
regarding the angiogram (performed September 25, 2006) noted a “totally
occluded” small left anterior descending coronary artery with “good
collaterals” and otherwise normal coronary arteries."

So the diagnosis had been made. Phillips knew he had a problem; this
angiogram was performed over a year before his death. We don't know if
there had been any treatment other than drugs. I suspect not; his
cardiologist would probably have noted it on his records and it would
have been mentioned in the NTSB report.

There could have been many reasons why Phillips didn't have surgery to
alleviate the problem. Denial is common enough... "I feel fine...there
isn't a problem!"

Another factor is that surgery is hard to hide. Your friends know, your
enemies find out, and there's always that fear that one of the latter
will inform the FAA and get your medical canceled. All of us know
friends who have gone through the tremendous hoops necessary to get
their medicals back after heart surgery.

btw if you have been taking medications for some time the body adapts.
it is possible to have high levels of medications in the blood stream
that have next to no cognitive effect on the individual.

Certainly the body adapts, when exposed to large doses of drugs or
alcohol over a long period. We've heard stories of drunk drivers with
BACs above the line that would put most people unconscious. These
people can outwardly seem normal.

But this isn't just an issue of "Monkey Skills," as Phillips called
them. This is an issue of reaction time and decision making, especially
decision-making under stress with a less-than-nominal. cardiovascular
system. The NTSB didn't just note high levels of a cocktail of drugs
(vicodin, valium, paracodine, cardura, morphine derivatives, etc.)...the
term used was "acute mixed drug intoxication". This indicates to me
that the NTSB feels that the amount passed the line where normal
functioning was possible. The NTSB is likely to view the decision to
take off with a 20-knot gusting tailwind as an erosion of
decision-making skills due to the "drug intoxication."

Ron Wanttaja

In article ,
Ron Wanttaja wrote:

Stealth Pilot wrote:

I could be jaundiced here but surely the drugs were prescribed.
was the real failure a failure of the american medical system to
diagnose and correctly treat his blocked anterior artery?

Certainly, I'd say the drugs were prescribed.

As far as failure to diagnose the problem, check the NTSB report again:

"The pilot¹s most recent application for airman medical certificate in
May 2007 noted a ³precautionary² coronary angiogram in 2006 which
³showed no blockage.² ... Records obtained from the pilot¹s cardiologist
regarding the angiogram (performed September 25, 2006) noted a ³totally
occluded² small left anterior descending coronary artery with ³good
collaterals² and otherwise normal coronary arteries."

So the diagnosis had been made. Phillips knew he had a problem; this
angiogram was performed over a year before his death. We don't know if
there had been any treatment other than drugs. I suspect not; his
cardiologist would probably have noted it on his records and it would
have been mentioned in the NTSB report.

There could have been many reasons why Phillips didn't have surgery to
alleviate the problem. Denial is common enough... "I feel fine...there
isn't a problem!"

Exactly. The doctor would not have been likely to prescribe surgery, but
keep an eye peeled for further developments. Even something are
relatively simple as installing a stent has some risk associated with
it, and you're looking at a year or three of follow up medications,
lifestyle changes.

Just installing a stent, with nothing else done, can increase the risk
of inducing a coronary by generating blood clots.

On Tue, 22 Sep 2009 07:58:33 -0700, Ron Wanttaja
wrote:

Stealth Pilot wrote:

I could be jaundiced here but surely the drugs were prescribed.
was the real failure a failure of the american medical system to
diagnose and correctly treat his blocked anterior artery?

Certainly, I'd say the drugs were prescribed.

As far as failure to diagnose the problem, check the NTSB report again:

"The pilot’s most recent application for airman medical certificate in
May 2007 noted a “precautionary” coronary angiogram in 2006 which
“showed no blockage.” ... Records obtained from the pilot’s cardiologist
regarding the angiogram (performed September 25, 2006) noted a “totally
occluded” small left anterior descending coronary artery with “good
collaterals” and otherwise normal coronary arteries."

So the diagnosis had been made. Phillips knew he had a problem; this
angiogram was performed over a year before his death. We don't know if
there had been any treatment other than drugs. I suspect not; his
cardiologist would probably have noted it on his records and it would
have been mentioned in the NTSB report.

There could have been many reasons why Phillips didn't have surgery to
alleviate the problem. Denial is common enough... "I feel fine...there
isn't a problem!"

Another factor is that surgery is hard to hide. Your friends know, your
enemies find out, and there's always that fear that one of the latter
will inform the FAA and get your medical canceled. All of us know
friends who have gone through the tremendous hoops necessary to get
their medicals back after heart surgery.

btw if you have been taking medications for some time the body adapts.
it is possible to have high levels of medications in the blood stream
that have next to no cognitive effect on the individual.

Certainly the body adapts, when exposed to large doses of drugs or
alcohol over a long period. We've heard stories of drunk drivers with
BACs above the line that would put most people unconscious. These
people can outwardly seem normal.

But this isn't just an issue of "Monkey Skills," as Phillips called
them. This is an issue of reaction time and decision making, especially
decision-making under stress with a less-than-nominal. cardiovascular
system. The NTSB didn't just note high levels of a cocktail of drugs
(vicodin, valium, paracodine, cardura, morphine derivatives, etc.)...the
term used was "acute mixed drug intoxication".

Ron
Acute in the medical sense is quite different from our usual meaning.
typically we laymen use acute to mean serious.
In medical terms acute just means 'of short duration'
we laymen also use chronic to mean serious whereas in medical terms
chronic just means 'of long duration'
so the term "acute mixed drug intoxication" just means a situation
that hadnt occurred for a long period. it doesnt mean that he had a
huge mixed drug intoxication problem, just one that had occurred at
the time.(unless of course the report was written by laymen)
we have little way of knowing what impairment that may have caused
because as others have commented he took lots.

rat poison is probably the warfarin that is used to break up blood
clots.

so yes the canopy was the direct cause, but long before that the heart
problem.

if we were honest the draconian aviation medical assessment for
pilots also played a part in the accident. maybe if it wasnt so
draconian, people would get the medical treatment they needed.
in australia we see lots of pilots change to ultralights and self
assessment during a clear period and go on to fly lots of hours that
would be denied to them all without much problem.
pilot medicals are after all a throwback to the days when governments
kept civil pilots as a fighting reserve and wanted them to be fit to
military standards. it is largely irrelevant now.
if we were really interested in civil aviation safety we wouldnt bar
pilots from flying, we'd more actively treat them.

the other aspect that comes from this fatal accident is that the
canopy design on that aircraft isnt fail safe. the slide back canopy
on the Jodel aircraft (as an example) can pop open or even be
deliberately opened in flight and the worst that happens is that it
flies itself shut. The Thorp T18 has a similar style of fail safe
canopy.
I'll bet not many people would have the intelligence to change the
canopy design on that design to something that was fail safe.

so yes there are lots of lessons that can be learnt from bill's prang.
the question is "will we actually learn them?"
Stealth Pilot

"Stealth Pilot" wrote in message
...
------------------much snipped---------------

Ron
Acute in the medical sense is quite different from our usual meaning.
typically we laymen use acute to mean serious.
In medical terms acute just means 'of short duration'
we laymen also use chronic to mean serious whereas in medical terms
chronic just means 'of long duration'
so the term "acute mixed drug intoxication" just means a situation
that hadnt occurred for a long period. it doesnt mean that he had a
huge mixed drug intoxication problem, just one that had occurred at
the time.(unless of course the report was written by laymen)
we have little way of knowing what impairment that may have caused
because as others have commented he took lots.

rat poison is probably the warfarin that is used to break up blood
clots.

so yes the canopy was the direct cause, but long before that the heart
problem.

if we were honest the draconian aviation medical assessment for
pilots also played a part in the accident. maybe if it wasnt so
draconian, people would get the medical treatment they needed.
in australia we see lots of pilots change to ultralights and self
assessment during a clear period and go on to fly lots of hours that
would be denied to them all without much problem.
pilot medicals are after all a throwback to the days when governments
kept civil pilots as a fighting reserve and wanted them to be fit to
military standards. it is largely irrelevant now.
if we were really interested in civil aviation safety we wouldnt bar
pilots from flying, we'd more actively treat them.

the other aspect that comes from this fatal accident is that the
canopy design on that aircraft isnt fail safe. the slide back canopy
on the Jodel aircraft (as an example) can pop open or even be
deliberately opened in flight and the worst that happens is that it
flies itself shut. The Thorp T18 has a similar style of fail safe
canopy.
I'll bet not many people would have the intelligence to change the
canopy design on that design to something that was fail safe.

so yes there are lots of lessons that can be learnt from bill's prang.
the question is "will we actually learn them?"
Stealth Pilot


I agree with you on both points, and really doubt that there is much real
reason for medical certification unless passengers are being carried for
hire--and even then a case could be argued that the requirement is currently
more stringent than needed except in single pilot operation.

As to the canopy, the only defense of the tilt forward designs that I have
ever been able to understand is that they do make it much easier to enter
and exit the aircraft under normal conditions, and much the same could be
said of the side hinged designs.

Personally, both have made me just a little nervous when I have sat in them
on the ground at shows and I would prefer to stay with the many sliding
canopy designs--with the addition of hand holds on the windshield hoop or on
the underside of the glare shield and also a ridge across the floor, if one
is not already present, in order to easily heave myself up to a standing
position in the case of the tailwheel types.

BTW, so far, all of the RV builders who I know personally have stayed with
the sliding canopies.

Peter

On Fri, 25 Sep 2009 05:30:52 +0000 (UTC), Clark
wrote:

Stealth Pilot wrote in
:

[snip]

Ron
Acute in the medical sense is quite different from our usual meaning.
typically we laymen use acute to mean serious.
In medical terms acute just means 'of short duration'
[snip]

Nope. It means of severe and short duration so far.

Don't minimize this one. Bill was obviously way over the line to be flying a
plane. If we try to hide it behind fancy words then we are doing ourselves a
disfavor.

that's the problem. bill wasnt obviously anything. he could have had a
pair of knickers over his face or have been blinded by something in
his eyes. you leap to the drugs aspect as the cause.
the stupid canopy design used on the aircraft was a greater factor in
the accident than his blood chemistry.

ymmv
Stealth Pilot

"Stealth Pilot" wrote in message
...
that's the problem. bill wasnt obviously anything. he could have had a
pair of knickers over his face or have been blinded by something in
his eyes. you leap to the drugs aspect as the cause.
the stupid canopy design used on the aircraft was a greater factor in
the accident than his blood chemistry.

ymmv
Stealth Pilot

Some clarifications;

Acute in a clinicians realm is either a new sudden onset such as AMI (Acute
Myocardial Infarction) or a sudden flare up of an old condition such as
Acute Exacerbation of COPD.

Chronic is an ongoing but currently stable problem. Chronic Obstructive
Pulmonary Disease. Chronic conditions over the course of time cause
deterioration and for many mortality. Example would be Pulmonary Fibrosis.

In another post a "doctor" from POA said Bill's "Vicodin Level" was near
lethal. There is no such thing as a Vicodin Level. Vicodin (Lortab, Norco
etc) is a combination of acetaminophen (Tylenol) and hydrocodone. In the
report Bill's acetaminophen level was barely at the low end of therapeutic
and the hydrocodone and metabolites were sub therapeutic.

This isn't meant as defense of anyone it is only a clarification from a
clinicians perspective.


tom c

tom c wrote:
....
Some clarifications;

....
In another post a "doctor" from POA said Bill's "Vicodin Level" was near
lethal....
tom c




Hmmmm...you too may be a "doctor" or even a doctor, so let me ask: which
elements of the drug cocktail reported in BWB's corpse would lead to the
official description of a "toxic" quantity?

I could mention that aspirin and codeine, and paracetamol
(acetaminophen) and codeine are over-the counter pain killers in Europe,
so presumably it is not that element that is drawing approbation...
One supposes it is the rat-poison?

Brian Whatcott