NTSB Report on Bill Phillips' Accident

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

In article ,
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?

I don't see how any other medical system would have guaranteed finding
and fixing the problem.

The autopsy noted "a 'totally occluded' small left anterior descending
coronary artery with 'good collaterals² and otherwise normal coronary
arteries".

This is no indication of significant reduced cardiac function; the loss
of blood flow through the "small anterior artery" would be at least
partially offset by the "good collaterals", and frankly was probably
completely asymptomatic.

It might not even have been noted through a cardiac stress test,
although is also probably an early precursor of further cardiac
degradation a decade or two down the road.

Perhaps some other national medical system routinely requires periodic
CAT scans of all adults through life? Because nothing less would be
likely to have found that problem.

Earlier this year, my wife had a stent installed in her right coronary
artery, which was ~95% blocked. That is a major artery, and in her case,
without "good collateral" development to carry part of the load.

We only figured out there was a problem while hiking at the top of Mt.
Haleakala (we were visiting our daughter and son-in-law who live on
Maui) that she was more short of breath than expected. A couple months
later, she was showing similar symptoms working around the house, and we
dropped everything and got it looked at. Failed treadmill test, etc. led
to getting the stent installed a couple days later. And she's fine now,
getting better, and we're back to cycling more/farther/harder than we
have for a couple three years.

The point being that her condition was worse than his, and not
noticeable until it had progressed well beyond what was reported by the
NTSB.

what amazes me is how fast that blockage built up in his heart after
having an angiogram in '06 that showed his heart clear. I had one in
'97 that was clear and I've been thinking I was good to go for who
knows how long. Now I see how fast that stuff can build up inside
there. A good heads up on that one. In his case, the drugs probably
had more to do with this accident rather than his heart. But it will
be interesting to see their final report.

On Mon, 21 Sep 2009 07:42:22 -0700, 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

rich wrote:
what amazes me is how fast that blockage built up in his heart after
having an angiogram in '06 that showed his heart clear.

Re-read the NTSB report. The angiogram *didn't* show his heart was
clear, though that's what he told the FAA:

"The pilot’s most recent application for airman medical certificate in
May 2007... also 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...."

Others have stated that the occlusion mentioned may not have been that
impacting. But I don't think it justified Phillips claiming that it
"showed no blockage."

Ron Wanttaja

On Tue, 22 Sep 2009 18:57:04 -0700, Ron Wanttaja
wrote:

rich wrote:
what amazes me is how fast that blockage built up in his heart after
having an angiogram in '06 that showed his heart clear.

Re-read the NTSB report. The angiogram *didn't* show his heart was
clear, though that's what he told the FAA:

"The pilot’s most recent application for airman medical certificate in
May 2007... also 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...."

Others have stated that the occlusion mentioned may not have been that
impacting. But I don't think it justified Phillips claiming that it
"showed no blockage."

Ron Wanttaja

in your entire life you've never told a lie in a situation of great
duress????????

you wouldnt be human if you hadn't.

Stealth Pilot

"Stealth Pilot" wrote in message
...
On Tue, 22 Sep 2009 18:57:04 -0700, Ron Wanttaja
wrote:

rich wrote:
what amazes me is how fast that blockage built up in his heart after
having an angiogram in '06 that showed his heart clear.

Re-read the NTSB report. The angiogram *didn't* show his heart was
clear, though that's what he told the FAA:

"The pilot's most recent application for airman medical certificate in
May 2007... also 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...."

Others have stated that the occlusion mentioned may not have been that
impacting. But I don't think it justified Phillips claiming that it
"showed no blockage."

Ron Wanttaja

in your entire life you've never told a lie in a situation of great
duress????????

you wouldnt be human if you hadn't.

Stealth Pilot

Providing information that isn't true to a bureacrat is not lying. It is
just expediency.

Stu Fields

Stealth Pilot wrote:
On Tue, 22 Sep 2009 18:57:04 -0700, Ron Wanttaja
wrote:

Others have stated that the occlusion mentioned may not have been that
impacting. But I don't think it justified Phillips claiming that it
"showed no blockage."

in your entire life you've never told a lie in a situation of great
duress????????

I've only told a lie twice in my life. Uhhh, three, if you count now.
Uhhh...four? :-)

We're not talking a mere "lie," here, we're talking about a criminal
act. Lying on an FAA medical is good for a quarter-million-dollar fine
and/or a five-year prison sentence.

you wouldnt be human if you hadn't.

And I'm not catching the "duress" here. Phillips had nine months after
his angioplasty to decide what to say on his next medical. He did not
fly for hire; his livelihood did not depend on retaining his medical.
He didn't even *have* to take the medical... he could have let it expire
and continue to fly as a Sport Pilot.

So there was no "great duress." His option was to commit a felony, fly
without a medical, or not fly.

I don't want to come over all priggish here; there's probably a good
chance I'd continue to fly, with the same sort of conditions. The
difference would be that I don't think I'd commit perjury to do it, and
I wouldn't risk a passenger's life. There's a lot of peace of mind, in
flying a single-seat airplane....

From another posting...

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.

I'm not a medical person...you may be right. A guy on the POA forum who
claims he's an MD said that the levels of Vicodin was in the "high toxic
to low lethal range," and the codine was "at the top of Therapeutic and
approaching Toxic." One would hope this wasn't a daily occurrence.

The accident occurred in late October as Phillips and his wife were
coming home from their cabin in the mountains of Utah. It's possible,
given the lateness of the year, that they had been closing out the cabin
for the winter. Phillips may have overdone it; he may have thrown his
back out and started chugging pills.

Ron Wanttaja

"Ron Wanttaja" wrote in message
...
Stealth Pilot wrote:
On Tue, 22 Sep 2009 18:57:04 -0700, Ron Wanttaja
wrote:

Others have stated that the occlusion mentioned may not have been that
impacting. But I don't think it justified Phillips claiming that it
"showed no blockage."

in your entire life you've never told a lie in a situation of great
duress????????

I've only told a lie twice in my life. Uhhh, three, if you count now.
Uhhh...four? :-)

We're not talking a mere "lie," here, we're talking about a criminal act.
Lying on an FAA medical is good for a quarter-million-dollar fine and/or a
five-year prison sentence.

you wouldnt be human if you hadn't.

And I'm not catching the "duress" here. Phillips had nine months after
his angioplasty to decide what to say on his next medical. He did not fly
for hire; his livelihood did not depend on retaining his medical.
He didn't even *have* to take the medical... he could have let it expire
and continue to fly as a Sport Pilot.

So there was no "great duress." His option was to commit a felony, fly
without a medical, or not fly.

I don't want to come over all priggish here; there's probably a good
chance I'd continue to fly, with the same sort of conditions. The
difference would be that I don't think I'd commit perjury to do it, and I
wouldn't risk a passenger's life. There's a lot of peace of mind, in
flying a single-seat airplane....

From another posting...

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.

I'm not a medical person...you may be right. A guy on the POA forum who
claims he's an MD said that the levels of Vicodin was in the "high toxic
to low lethal range," and the codine was "at the top of Therapeutic and
approaching Toxic." One would hope this wasn't a daily occurrence.

The accident occurred in late October as Phillips and his wife were coming
home from their cabin in the mountains of Utah. It's possible, given the
lateness of the year, that they had been closing out the cabin for the
winter. Phillips may have overdone it; he may have thrown his back out
and started chugging pills.

Ron Wanttaja


Well, actually, he could not have [legally] flown that aircraft as a sport
pilot; but your basic point is well taken and I am really more than a little
dissappointed there seems to be so little new to learn. If the presumed
doctor on the POA forum is correct, then it would appear that BWB might have
taken some more medication just before departure--almost in the manner of a
college freshman chugging beer--and that his ability to fly was becomming
more degraded from moment to moment. All of that could be a dfpretty good
explanation of at least one way the the canopy latch might not have been
operated correctly and also how a noise level distraction might have gained
priority over simply "flying the airplane" and even suggests the possibility
that he might well have become incapacitated during the flight if the
takeoff and climb had been uneventfull.

BTW, all of this makes it seem almost appropriate to ask: does anyone here
know how Mrs Phillips got her nickname?

Peter
Staying with sliding and not hinged canopies!