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

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

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 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

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 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

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!

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.