NTSB Report on Bill Phillips' Accident

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

On Sep 21, 11:52*pm, Ron Wanttaja wrote:
cavelamb wrote:
Ron Wanttaja wrote:
The NTSB has released the factual report:

http://www.ntsb.gov/ntsb/brief2.asp?...5&ntsbno=WPR09...

Well, kids, there you have it.

Well... not COMPLETELY cut and dried.

We've still got the issue about the main driver of the accident
sequence...whether the canopy was open, and how difficult an open-canopy
situation is to handle.

A number of Lancair owners have encountered open canopies and reported
that control was no big deal. *However, there have been three recent
Lancair accidents that involved open canopies. *The pilot survived the
most latest one, and gives a rather hair-raising report of what the
plane was like to fly.

http://www.ntsb.gov/ntsb/brief2.asp?...9&ntsbno=CEN09....

*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

The problem with trying to diagnose what ultimately caused an accident
where something unusual occured with the aircraft is determining the
subsequent events which might have contributed. Many of the major
aircraft accidents over the years have all been traced to a series of
events that combined to cause the accident.

One of the first KIS Cruisers to be finished by a homebuilder was
destroyed when the pilot side door opened during climbout following
takeoff. The pilot reacted by trying to reach up, grab the door and
either close or hold on to it. That action caused the pilots seat
cushion to shift and jam against the stick pushing it forward and to
the right. The plane took a nose dive and hit the ground before the
pilot could recover. In that case, the pilot was very lucky and
survived with major but recoverable injuries.

Something of that very nature could have occured in this instance.
Bill was a good pilot but a distraction of trying to get the canopy
closed may have led to some other problem that he was unable to
recover from in time.

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.

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 11:07:57 GMT, Stealth Pilot
wrote:

On Mon, 21 Sep 2009 15:10:59 -0700 (PDT), spanky
wrote:

On Sep 21, 8:50Â*am, Stealth Pilot wrote:
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?...5&ntsbno=WPR09...

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

according to that report of the accident it shouldnt have happened.
there was nothing wrong.

Stealth Pilot

...hate to disagree with you, but there was something very wrong,
apparently, with the most important component in the aircraft: the
pilot. According to the tox report, he had everything from Tylenol to
Valium to Vicodin to two different types of codeine derivatives to
FloMax to Ziloprim (and then some) in his system. He should never
have gotten out of bed, much less behind the wheel of a car or the
yoke of an aircraft. I knew Bill well enough to know that he probably
thought he could handle it. Events proved otherwise.

S McF

actually I meant problems (unserviceabilities) with the aircraft.

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. ask doctors
involved with long term pain medication or think to involvement with a
chronic alcoholic. the blood assay gives levels of drugs in the
individual but gives no real indication of the effect they have on the
individual. dont jump to conclusions without having some idea of the
medication history.

Stealth Pilot


The mixture of rocket fuel and rat poison Badwater Bill was always
bragging about would have had serious effects on the judgement and
reaction times of ANYBODY, no matter how long they were on them!!!!

"Ron Wanttaja" wrote in message
...
cavelamb wrote:
Ron Wanttaja wrote:
The NTSB has released the factual report:

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

Well, kids, there you have it.

Well... not COMPLETELY cut and dried.

We've still got the issue about the main driver of the accident
sequence...whether the canopy was open, and how difficult an open-canopy
situation is to handle.

A number of Lancair owners have encountered open canopies and reported
that control was no big deal. However, there have been three recent
Lancair accidents that involved open canopies. The pilot survived the
most latest one, and gives a rather hair-raising report of what the plane
was like to fly.

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

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.

--------much snipped----------
I reached the same conclusion, that the canopy was open; and also that the
remarks about the boarding stairs were poorly phrased and more likely should
have read that the stairs wuld retract as the canopy was lowered to be
latched.

In any case, despite BWB's quirks and medications we do keep coming bach to
the matter of the canopy, and perhaps to the matter of hinged forward
canopies in general. It is certainly worrysome, although not surprising,
that two documented cases of canopies opening at or after takeoff had such
radically different symptoms. From the little that I have read about boat
hulls and the use of a slight "spoon area near the transome to prevent
oscillation, I am inclined to infer that the difference between a canopy
that might simply open slightly in trail and one which might oscillate
wildly could be a nearly imperceptable difference near the upper trailing
edge--and could easily be less than the thickness of the paint on the canopy
frame.

Peter
My conclusion does not please me!

Peter Dohm wrote:


--------much snipped----------
I reached the same conclusion, that the canopy was open; and also that the
remarks about the boarding stairs were poorly phrased and more likely should
have read that the stairs wuld retract as the canopy was lowered to be
latched.

In any case, despite BWB's quirks and medications we do keep coming bach to
the matter of the canopy, and perhaps to the matter of hinged forward
canopies in general. It is certainly worrysome, although not surprising,
that two documented cases of canopies opening at or after takeoff had such
radically different symptoms. From the little that I have read about boat
hulls and the use of a slight "spoon area near the transome to prevent
oscillation, I am inclined to infer that the difference between a canopy
that might simply open slightly in trail and one which might oscillate
wildly could be a nearly imperceptable difference near the upper trailing
edge--and could easily be less than the thickness of the paint on the canopy
frame.

Peter
My conclusion does not please me!


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.

I'm going to stay with my first impression.
BWB had no business being in the left seat.


Richard

The superior pilot uses his superior judgment
to avoid having to use his superior skills.

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