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📋Incident overview

Postmortem owner

Anthony Luo

Plane

Pilot in charge

Visual ObserversAircraft

Judie

Related incidents

Incident date

Nov 13 2022

Approx. Damage Costs

$1 in foam boards

Report Date

Nov 13 2022

🔮 Executive summary

Both pilots lost control of Judie due to the pilot handover failing - primary PIC did not hold the handover button to hand control to safety pilot.

⏱ Incident timeline

Describe (approximate) timelines, cross correlate with telemetry/video recordings/etc if anyNo video, happened 30 sec to 1 minute after Judie takeoff.

⛑ Postmortem report

Instructions

Report

(warning) Leadup


List the sequence of events that led to the incident.

Lack of batteries, so Judie was flying on 5S (full throttle required to launch). Primary PIC launched the plane via Safety PIC throwing it. Plane was unstable in air, needed too much throttle to control.

🙅‍♀️ Fault


Describe what didn't work as expected. If available, include relevant data visualizations.

The pilot handoff was unsuccessful. Primary PIC handed off the controls for a second but released the switch before Safety PIC could land the plane

👁 Detection


Report when the team detected the incident and how they knew it was happening. Describe how the team could've improved time to detection.

Upon crash, Safety PIC checked controller held by Primary PIC and noted that the switch wasn’t being held in position. This may have been caught earlier if they had checked earlier (question)

🙋‍♂️ Response


Report who responded to the incident and describe what they did at what times. Include any delays or obstacles to responding.

  1. Witnessed plane crash

  2. Went to site of crash, unplugged the batteries, checked if the plane was at all damaged

  3. Discussed what went wrong + that you’re supposed to hold the switch in place, it does not actually latch

🙆‍♀️ Recovery


Report how the user impact was mitigated and when the incident was deemed resolved. Describe how the team could've improved time to mitigation.

No time for recovery, just crashed the plane.

🔎Five whys root cause identification


Run a 5-whys analysis to understand the true causes of the incident.

Aidan Bowers (Deactivated)

🗃Related records


Check if any past incidents could've had the same root cause. Note what mitigation was attempted in those incidents and ask why this incident occurred again.

🤔 Lessons learned


Describe what you learned, what went well, and how you can improve.

The farthest back right switch on the controller does not latch into place!

✅ Recommendations for future

Actionable Recommendation

Reasoning

Pilots make sure they are aware of the handoff procedures, especially if they differ from past procedures

Very easily avoidable problem. Just communicate