Nov 13, 2022 - JUDIE RCA

Anthony Luo

Judie

Megan Spee

Andy Meng Anthony Luo Conall Kingshott Ryan Chan Aidan Bowers (Deactivated)

Nov 13 2022

$1 in foam boards

Nov 13 2022

 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). Megan Spee launched the plane via Andy Meng 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. Megan Spee handed off the controls for a second but released the switch before Andy Meng 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, Andy Meng checked controller held by Megan Spee and noted that the switch wasn’t being held in position. This may have been caught earlier if he had checked earlier

🙋‍♂️ 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!

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

Very easily avoidable problem. Just communicate