2023-04-09 - RCA for 3S 4Ah Crashed Battery
Update the title following the format: Jan 01, 2023 - RCA Name
Incident overview
Postmortem owner | @Hamza Ali |
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Airframe | Tube |
Related incidents | Apr 09 Flight Test |
Incident date | Apr 9, 2023 |
Approx. Damage Costs | $25 |
Report Date | Apr 9, 2023 |
Executive summary
During the April 09 flight test, we crashed our Tube aircraft and damaged a LiPo. The LiPo was overheating and we contacted the necessary offices and departments to insure that it was immediately disposed of in a safe and secure manner.
Incident timeline
Describe (approximate) timelines, cross-correlate with telemetry/video recordings/etc if any.
-30s - Pilot lost orientation of aircraft
+/-0 - Pilot crashed aircraft
+1m - Noticed no puncture in any of the cells, decided to transport back to the bay
+ 2h Got to the bay, noticed battery was slightly warmer than other 3S packs
+ 2h30m - Attempted to communicate with safety office, got deferred to special constable (off hours)
+ 2h40m Special Constable came, investigated the situation
+ 3h Special Constable attempted to contact the safety office, unsuccessful, directed to contact the fire department
+ 3h30m Fire department concluded no risk, and left
+4h Special Constable re-attempts contacting the safety office
+4h30m Safety office / chemical spills people are successfully contacted, they pick up our batteries
Postmortem report
Instructions | Report |
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LeadupList the sequence of events that led to the incident. | We were unsure of the specific procedure to deal with damaged LiPo batteries and escalated the situation until we got into contact with the departments who were aware of how to deal with the problem. |
FaultDescribe what didn't work as expected. If available, include relevant data visualizations. | We had to call the special constable as well as the fire department in order to successfully dispose of the batteries in a safe manner |
DetectionReport when the team detected the incident and how they knew it was happening. Describe how the team could've improved time to detection. |
2. We saw that there was a problem when we noticed our LiPo batteries were getting warmer than we expected to as we began discharging our other batteries after the flight test. In doing so, we decided to contact the special constable and solve the immediate solution, get more information in order to develop proper procedures. |
ResponseReport who responded to the incident and describe what they did at what times. Include any delays or obstacles to responding. |
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RecoveryReport how the user impact was mitigated and when the incident was deemed resolved. Describe how the team could've improved time to mitigation. |
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Five whys root cause identificationRun a 5-whys analysis to understand the true causes of the incident. |
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Related recordsCheck 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. |
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Lessons learnedDescribe what you learned, what went well, and how you can improve. |
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Recommendations for future
Actionable Recommendation | Reasoning |
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Purchase a dedicated Ammo can for damaged batteries | It is unsafe and creates extra unnecessary risk to mix our good batteries and bad batteries |
Keep a bucket of sand to smother future situations | It is one of the only few ways to contain a LiPo fire |
Update LiPo operations procedure and Flight test response procedure (add situations on disposal fire, physical damage) | We need to know what to do when an incident like this happens again in the future |