Nov 27, 2022 - Phoenix RCA

1 Incident overview | 2 Executive summary | 3 Incident timeline | 4 Postmortem report | 5 Recommendations for future

Incident overview

Postmortem owner	@Anthony Luo
Airframe	Phoenix
Related incidents
Incident date	Nov 27, 2022
Approx. Damage Costs	? ~ 10$
Report Date	Nov 27, 2022

Executive summary

Phoenix Flew away after takeoff, and was disarmed mid-flight when it was deemed that we could not recover the drone in the air.

Incident timeline

Takeoff

+ 10s, hovering in teh air

+20s, drone flies away
+30s, Andy tries to bring drone back
+ 45s, drone doesn’t respond to throttle kill request
+60s, drone killed

Some biased pilots thoughts

[PIC] should have cleared the area before bringing the drone up. People were close and instead of asking them to move, PIC decided to bring the drone higher.
GPS mode probably would have helped a LOT
please only have one person talking. Too many voices is hard to track.
please be talking useful information (andy was constantly relaying orientation as much as he could, while some others were only asking me questions like “why is the drone so far” to which…the answer is…idk).
we probably want more pitch/roll angle….it seems that when it’s windy we’re constantly near the limit of what a drone can do.
probably should’ve decided to kill the drone earlier and bring it down in a field / on the road instead of in the trees.

Postmortem report

Instructions	Report

Instructions

Report

Leadup

List the sequence of events that led to the incident.

Took off and immediately climbed too high - could not clearly see orientation of the drone.

Pilot (Anthony) lost orientation of the drone once it was hit by some wind.

Drone slowly drifted further and further away.

Fault

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

Pilot lost orientation of the aircraft and was unable to recover control of the airframe.

Wind was too much for this airframe to handle.

Pitch/throttle issues where drone was not responsive.

Pilot error when they accidentally moved the disarm switch to the disarm position while trying to throttle down the drone… drone could not re-arm (attitude), and so it fell out of the sky basically.

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.

Issue was realized when the drone kept flying/drifting away to a point where it was very difficult to determine orientation.

Response

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

-

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.

Drone was recovered after a trek in the forest.

Five whys root cause identification

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

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.

Don’t fly too high until you have a handle of the drone.

Don’t be afraid to bring the drone down closer and re-evaluate your options before trying to recover it while it’s in the air.

Recommendations for future

Actionable Recommendation	Reasoning

Actionable Recommendation	Reasoning