NTSB Report on Bill Phillips' Accident

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

"brian whatcott" wrote in message
...
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


The report itself never uses the term toxic. In Emergency treatment blood
levels alone are used to gauge toxicity. Urine levels are used for detection
alone.
The urine level for hydromorphone (Dilaudid) was elevated to a level that
would be toxic in blood tests but are not out of line in urine.. The report
has no listing for warfarin (Coumadin), warfarin being the active ingredient
in rat poisons.

As for me not a doc. I'm a Registered Nurse with specialty certifications in
Emergency Nursing, Prehospital Nursing and Flight Nursing (the crazy
*******s who fly out to car wrecks and start treatment there).


tom c

tom c wrote:
"brian whatcott" wrote in message
...
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


The report itself never uses the term toxic.

Hmmm....
Let me quote from the finding of facts:

The State of Utah, Office for the Medical Examiner, completed an autopsy
on the pilot. The manner of death was classified as an accident due to
blunt force injuries. The report noted “other significant conditions” of
atherosclerotic coronary artery disease, cardiomegaly, and
***acute mixed drug intoxication.**** [my asterisks]

The FAA Bioaeronautical Research Laboratory completed toxicology
testing. The tests were negative for carbon monoxide, cyanide, and
volatiles. The test was positive for the following tested drugs: 10.01
(ug/ml, ug/g) acetaminophen, 0.055 (ug/ml, ug/g) diazepam, 0.031 (ug/mL,
ug/g) dihydrocodeine, doxazosin, 0.152 (ug/ml, ug/g) hydrocodone, and
0.094 (ug/ml, ug/g) nordiazepam, detected in blood; 0.46 (ug/mL, ug/g)
dihydrocodeine, doxazosin, 1.755 (ug/ml, ug/g) hydrocodone, 0.54 (ug/mL,
ug/g) hydromorphone, and nordiazepam, were detected in urine.


"Drug intoxication" means the presence of toxic quantities of some drug
cocktail.

Brian Whatcott

"brian whatcott" wrote in message
...
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

Really, all of this is still just speculation whether there is some sound
reason that the canopy might not have been fully latched and on how BWB's
condition might have progressed during the flight if the takeoff and climb
had been uneventfull.

Taking the second issue first, it really does seem that Mrs Phillips would
have been quite familiar with the aircraft and also had skills far above
those of the typical AOPA Pinch Hitter level, if she is not a fully
qualified pilot; so while we are speculating as to the causes, I am willing
to speculate that pilot incapacitation was not the root cause of this
accident.

Which brings back to the issue of the canopy...

Peter

P.S.: Just as a slightly off topic aside: Even on a warm day at gross
weight and with full flaps deployed, a Piper PA38-112 Tomahawk will take off
and climb almost normally to the top of ground effect and a Cessna 150M will
climb slightly on a missed approach under the same conditions. No one
needed to be impared in any way to prove either of the above, or a few
others, although the first situation was helped along by an instructor who
was confident that the airplane could not get airborne.

Peter Dohm wrote:

Really, all of this is still just speculation whether there is some sound
reason that the canopy might not have been fully latched and on how BWB's
condition might have progressed during the flight if the takeoff and climb
had been uneventfull.

...I am willing to speculate that pilot incapacitation was not the root
cause of this accident.

Which brings back to the issue of the canopy...

I don't think pilot incapacitation is the root cause of the accident,
either. However, pilot *impairment* may well have been a contributing
cause.

Let's play NTSB here, and step through the known facts.

1. Was the canopy open at time of impact?

A. No damage to the canopy latches, and significant sideways impact
damage to the canopy hinges. Canopy was probably open at the time of
impact.

2. Had the canopy been properly latched at the time of takeoff?

Nothing overt, here. No detected damage to the latching mechanism. No
previous problems noted with the latch on the accident airplane.
Aircraft equipped with a pressurized seal that may have held the canopy
in place until the airspeed rose to the point where lift forces on the
canopy may have overcome the friction of the seal.

3. Would an unlatched canopy cause the airplane to be uncontrollable?

A. The kit manufacturer says no. Several owners of that aircraft type
have reported open canopies in flight with varying effects of control of
the aircraft.

There were two other accidents involving open Lancair canopies within
six months of Phillips'. In the first case, witnesses reported that the
pilot had trouble closing the canopy before takeoff. The canopy opened
after takeoff, and witnesses report seeing the canopy bob up and down
like the pilot was trying to close it. Engine power was lost, but as
there was no reaction, it's possible the pilot killed the throttle to
try to reduce the airflow over the canopy to assist in closing it. The
airplane pitched nose down and descended in a left-hand turn. No
mechanical cause was found for the reduction in power.

In the second case, the pilot apparently failed to latch the canopy. He
reports the canopy oscillated on its own, and that pitch control of
the aircraft became very difficult. The pilot brought the plane around,
but wasn't able to maintain the approach path and landed short.

In short, everyone who experienced an open canopy and lived reported
that the airplane was at least somewhat controllable. There is only one
other instance of a fatality after a Lancair open canopy, and that case
exhibited a simple stall with no outward signs of control trouble.

(More discussion at:

http://98.192.103.179/forums/viewtopic.php?f=19&t=296

4. Was the pilot qualified to fly the aircraft?

A. Yes. ATP with 4,500 hours, including 150 in type.

5. Were there factors that may have affected the pilot's ability to
control the aircraft?

Evidence of use of sedatives, painkillers, and muscle relaxants. Side
effects of Vicodin can include dizziness, lightheadedness, drowsiness,
euphoria, changes in mood, and mental fogginess.


I suspect the NTSB probable cause will be similar to that of the April
2008 fatality: "The pilot's failure to maintain aircraft control.
Contributing to the accident was the pilot's distraction with the canopy
during takeoff." They'll probably add a comment about pilot impairment,
as well.

I don't think the heart trouble or the lying on the medical will even
gain a mention, in the Probable Cause. However, since Phillips gained
his medical by fraud, the insurance company has grounds to deny any claim.

Ron Wanttaja

"Ron Wanttaja" wrote in message
...

Let's play NTSB here, and step through the known facts.

1. Was the canopy open at time of impact?

A. No damage to the canopy latches, and significant sideways impact
damage to the canopy hinges. Canopy was probably open at the time of
impact.

Also in the report supporting this conclusion a The witnesses to the
crash who "... saw objects fall, ...off of or out of the airplane."

AND: "Law enforcement personnel that initially responded to the accident
site went to the area specified by the witnesses as the location where the
objects departed the airplane. At this location, personal effects including
clothing were identified."

Unless Bill and his wife were busily stuffing these items out the canopy
vent door just to confuse us, there seems little doubt that the canopy was
open at the time of the impact. We can speculate about everything else, but
this part of the accident sequence seems pretty sure to me.

Vaughn

"vaughn" wrote in message
...

"Ron Wanttaja" wrote in message
...

Let's play NTSB here, and step through the known facts.

1. Was the canopy open at time of impact?

A. No damage to the canopy latches, and significant sideways impact
damage to the canopy hinges. Canopy was probably open at the time of
impact.

Also in the report supporting this conclusion a The witnesses to the
crash who "... saw objects fall, ...off of or out of the airplane."

AND: "Law enforcement personnel that initially responded to the accident
site went to the area specified by the witnesses as the location where the
objects departed the airplane. At this location, personal effects
including clothing were identified."

Unless Bill and his wife were busily stuffing these items out the canopy
vent door just to confuse us, there seems little doubt that the canopy was
open at the time of the impact. We can speculate about everything else,
but this part of the accident sequence seems pretty sure to me.

Vaughn


Thank you for bringing the discussion back to the area of discussion most
applicable to this particular forum.

There is a good reason that I have placed several posts that would seem to
put me on both sides of the question of Bill's condition; and that reason is
that I really am. I believe that my position is reasonable and correct for
the following reason. Even if he was taking prohibited medications, and
overdosed as well, and then added one of the two most frequently fatal
deseases of pilots, Get-home-itis or Get-there-itis, and additional
outrages; we are still left with important questions that should interest us
as home-builders and potential home-builders:
1) Was the canopy open/unlatched?
(It very probably was)
2) Could this happen to an umimpaired pilot?
(Obviously yes, since it has happened several times)
3) Could an open/unlatched canopy be prevented, or
could the results be mitigated in a cost effective way?
(I think so, and think it needs further discussion)

As Stealth has pointed out, those canopies appear not to be a fail safe
design. One would initially presume that they would only open slightly and
maintain a slightly open position in trail, which was true in at lease one
instance and might presumably have been true of the test aircraft. However,
at least one other example apears to have behaved quite differently and I
personally doubt that the difference in shape would need to be much greater
than the thickness of a coat of paint to cause a dramatic difference in
behavior.

I suspect that a safety catch of a type common on the engine hoods of
automobiles and placed close enough to the latched position to preclude
oscillation, accompanied by the installation of a warning lamp when the
canopy is not in its fully latched position, would both mitigate the result
of an unlatched canopy and make the occurance less likely.

I still would not personally choose a hinged canopy; but those improvements
should be sufficient to render my other criticisms nearly moot.

Peter

"Peter Dohm" wrote in message
...
I suspect that a safety catch of a type common on the engine hoods of
automobiles and placed close enough to the latched position to preclude
oscillation, accompanied by the installation of a warning lamp when the
canopy is not in its fully latched position, would both mitigate the
result of an unlatched canopy and make the occurance less likely.

I agree 100%. Your car door latches automatically when you close it. We
would not tolerate car doors that did anything else, because if they did NOT
latch automatically, people would fall out of cars and be killed with
depressing regularity. Unlatched canopies kill people...why can't they be
made to latch automatically?

This ain't rocket science.

Vaughn

vaughn wrote:
"Peter Dohm" wrote in message
...
I suspect that a safety catch of a type common on the engine hoods of
automobiles and placed close enough to the latched position to preclude
oscillation, accompanied by the installation of a warning lamp when the
canopy is not in its fully latched position, would both mitigate the
result of an unlatched canopy and make the occurance less likely.

I agree 100%. Your car door latches automatically when you close it. We
would not tolerate car doors that did anything else, because if they did NOT
latch automatically, people would fall out of cars and be killed with
depressing regularity. Unlatched canopies kill people...why can't they be
made to latch automatically?

This ain't rocket science.

Indeed. Check out the January instance of an open Lancair canopy,
specifically the entry the pilot made in the "Recommendations" section.

"In the "RECOMMENDATION" section of the NTSB Pilot/Operator Report, form
6120.1 the pilot stated;

"1. The airplane should be tested/modified to make sure the canopy
(oscillations) do not impair the pilot's ability to control the airplane,
"2. a canopy latch warning system, [should be installed] or
"3. [there should be] the installation of a secondary [safety] latch ."

http://www.ntsb.gov/ntsb/brief2.asp?...LA207& akey=1

Seems pretty reasonable to me.

The big drawback is that this is probably a fairly complex undertaking,
especially the warning system. Switches have to be positioned, wires
have to be run, power supplied, panel lights/horn installed, etc.

Not something out of the ordinary for an aircraft builder, but a bit
more complex if a person buys a completed aircraft rather than learning
the skills during construction. I bought my Fly Baby instead of
building it, but everything on it is dead-nuts simple. Plus, Phillips'
Lancair was a show machine... he probably wouldn't have tolerated the
kind of rough-holes, wires running-in-the-open bandage job that I'm
satisfied with (1/2 :-)

I do not know if Phillips had been in communication with other builders
regarding canopy issues. As I've related in other postings, most of the
comments seem to indicate the aircraft is adequately controllable. This
may have given him a false sense of security..."If those *******s can
fly the airplane with the canopy open, I'll have no trouble." This
would make him less likely to spend the money and accept the downtime to
have his airplane modified.

Ron Wanttaja

On Sat, 26 Sep 2009 20:55:06 -0400, "Peter Dohm"
wrote:

"vaughn" wrote in message
...

"Ron Wanttaja" wrote in message
...

Let's play NTSB here, and step through the known facts.

1. Was the canopy open at time of impact?

A. No damage to the canopy latches, and significant sideways impact
damage to the canopy hinges. Canopy was probably open at the time of
impact.

Also in the report supporting this conclusion a The witnesses to the
crash who "... saw objects fall, ...off of or out of the airplane."

AND: "Law enforcement personnel that initially responded to the accident
site went to the area specified by the witnesses as the location where the
objects departed the airplane. At this location, personal effects
including clothing were identified."

Unless Bill and his wife were busily stuffing these items out the canopy
vent door just to confuse us, there seems little doubt that the canopy was
open at the time of the impact. We can speculate about everything else,
but this part of the accident sequence seems pretty sure to me.

Vaughn


Thank you for bringing the discussion back to the area of discussion most
applicable to this particular forum.

There is a good reason that I have placed several posts that would seem to
put me on both sides of the question of Bill's condition; and that reason is
that I really am. I believe that my position is reasonable and correct for
the following reason. Even if he was taking prohibited medications, and
overdosed as well, and then added one of the two most frequently fatal
deseases of pilots, Get-home-itis or Get-there-itis, and additional
outrages; we are still left with important questions that should interest us
as home-builders and potential home-builders:
1) Was the canopy open/unlatched?
(It very probably was)
2) Could this happen to an umimpaired pilot?
(Obviously yes, since it has happened several times)
3) Could an open/unlatched canopy be prevented, or
could the results be mitigated in a cost effective way?
(I think so, and think it needs further discussion)

As Stealth has pointed out, those canopies appear not to be a fail safe
design. One would initially presume that they would only open slightly and
maintain a slightly open position in trail, which was true in at lease one
instance and might presumably have been true of the test aircraft. However,
at least one other example apears to have behaved quite differently and I
personally doubt that the difference in shape would need to be much greater
than the thickness of a coat of paint to cause a dramatic difference in
behavior.

I suspect that a safety catch of a type common on the engine hoods of
automobiles and placed close enough to the latched position to preclude
oscillation, accompanied by the installation of a warning lamp when the
canopy is not in its fully latched position, would both mitigate the result
of an unlatched canopy and make the occurance less likely.

I still would not personally choose a hinged canopy; but those improvements
should be sufficient to render my other criticisms nearly moot.

Peter



Just like the door issues on RV10 aircraft. It is possible to close
the door and throw the latch pins - and have one of the pins (I
believe the rear) OUTSIDE the cockpit instead ov through the
latchplate on the fuselage door-post.

I believe VANS has come out with a set of switches that will indicate
whether or not the pins have been properly fired home.