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#21
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NTSB Report on Bill Phillips' Accident
Ron Wanttaja wrote:
.... From the above report, you can see that the open-canopy accidents are catching the NTSB's notice. When the NTSB comes up with a "Probable Cause," they seem to factor in what a competent pilot should have been able to accomplish, in those circumstances. You'll see a lot of accident reports which list Pilot Error as the cause, even though the accident began with a mechanical failure, because the investigator thought the pilot should have been able to force-land safely. Works the other way, too. If the NTSB concludes that the aircraft was uncontrollable with the canopy open, that'll be listed as the primary cause. From what I can tell reading the report, it appears that the canopy *was* open. The latches were undamaged; the ground impact twisted the hinges forward and to the left, which probably wouldn't have happened if the canopy was properly latched. It all boils down to whether the NTSB concludes that the flight could have been safely completed had Phillips not been impaired. My guess is that the impairment won't be listed as the Primary Cause, but as a contributor. One thing interesting, though, is that Phillips' accident differs from the other two canopy-open cases. In those instances, pitch control became difficult, but neither pilot had trouble with roll. The SnF plane continued to fly straight out, the pilot in Colorado actually brought the plane back around the pattern and crashed on short final. In contrast, once the canopy opened, Phillips' Lancair started turning left and descended into the group. Do you know what this reminds me of? John Denver's accident. The main theory there was that Denver trying to turn a stiff fuel valve to switch tanks after the engine quit on takeoff. He turned to the left to try twist the valve...and his right foot applied pressure to the rudder, turning the plane in the opposite direction from where he was looking. Imagine Phillips' canopy coming open soon after takeoff. He turns towards the handle on the canopy to try pull the canopy down...which is probably mounted on the center section, above and to his right. This naturally extends his left leg, which pushes the rudder pedal and starts a turn to the left. The plane begins to descend, and goes into the ground while the pilot is fiddling with the canopy. The passenger, too, is looking up and behind at the canopy bow and doesn't notice the change in attitude. One of the things I've heard about the impact of drugs and alcohol is that the first thing to go is the ability to multitask. I wonder if that's what we're looking at, here....an unimpaired pilot would have detected the roll, while Phillips became too focused on closing the canopy. Ron Wanttaja I had a canopy open. Fortunately, it started flopping early in the takeoff roll and I stopped and fixed it. I recall it was a strong distraction - though I was still on the ground. It was a Fornier RF-4 (or RF-5, forget which) both of which had / have a long clear lid with a side latch. In contrast, a door is opened only against resistance on a Cessna 150 (while the parachute jumper jumped out...) Brian W |
#22
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NTSB Report on Bill Phillips' Accident
cavelamb wrote:
However an open canopy would effect handling (and I can see nightmares there), there is one point we've kind of skipped over... If the canopy latches were not damaged, then I would surmise that it was not latched. That would be pilot error - pure and simple. The fact that the latches weren't damaged doesn't mean the canopy hadn't been latched when the takeoff run began. Doors/canopies do pop open. It can sometimes be a matter of rig, so that there wouldn't necessarily be obvious evidence on the latch hardware post-crash. According to Phillips' geocities page, the plane had a pumped seal on the canopy. That may have applied some opening force in a case where latch wasn't up to snuff...or if it wasn't properly latched to start with. Are these kinds of seals normally interlocked with the canopy latches, so they won't inflate unless the latches are set? The NTSB report doesn't mention any previous problems with the latch...seems like any of Phillips' friends would have cued the NTSB investigator in if he'd been having problems with it. The plane was built by a "hired gun," so Phillip wouldn't have had a builder's understanding of how the system worked. The downwind takeoff does imply he was in a hurry, and thus more likely to forget to latch the lid. If the seals *were* interlocked with the latches, seems like the additional noise if the seals AREN'T filled would quickly cue the occupants that the canopy wasn't latched. But if the seals were able to be inflated with the canopy unlatched, there wouldn't be any sound cues...until the difference in pressure overcame the seal's friction and popped the canopy up. Ron Wanttaja |
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NTSB Report on Bill Phillips' Accident
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 |
#24
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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 |
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NTSB Report on Bill Phillips' Accident
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 |
#26
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NTSB Report on Bill Phillips' Accident
"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 |
#27
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NTSB Report on Bill Phillips' Accident
"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 |
#28
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NTSB Report on Bill Phillips' Accident
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 |
#29
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NTSB Report on Bill Phillips' Accident
"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! |
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NTSB Report on Bill Phillips' Accident
On Sep 24, 7:19*pm, "Peter Dohm" wrote:
"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. |
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