If I understand correctly we are still waiting on the final report that determines root cause.

I offer it just to keep us all up to date as the process slowly moves forward, and otherwise without comment, as we don't have their root cause determination, and therefore I fear pontificating would just stir up hurt feelings all around, all over again.

There is a published pdf of the formal report, however not sure how to post that. If someone does, please do so.
Published 10-20-16

http://www.ntsb.gov/_layouts/ntsb.aviat ... 1d333b9403

NTSB Identification: WPR15FA010A

-M3X

http://www.ntsb.gov/_layouts/ntsb.aviation/brief2.aspx?ev_id=20141012X30001&ntsbno=WPR15FA010A&akey=1

Try this link.

The docket is also available for public review. To access the documents in the docket go to: http://dms.ntsb.gov/pubdms/search/, enter the accident number (WPR15FA010A), select mode of transportation (aviation) and click on the "FIND" button on the bottom right side of the screen. A new screen will present with the accident number (WPR15FA010A) in blue. Click on that number. There are 19 documents pertinent to the investigation in the docket. Quite a lot of information, including witness reports, reports of electronic data analysis, site diagrams, toxicology reports, and other documents are presented for review.

PapernScissors wrote:http://www.ntsb.gov/_layouts/ntsb.aviation/brief2.aspx?ev_id=20141012X30001&ntsbno=WPR15FA010A&akey=1

Try this link.

The link in the quote above is for the Cessna 170. I have discovered that a second factual report addresses the Savannah. See: http://www.ntsb.gov/_layouts/ntsb.aviation/brief2.aspx?ev_id=20141012X30001&ntsbno=WPR15FA010B&akey=2

I think the FAA needs to check their "Facts" for a factual report. The Savannah is listed as having a 100hp Rotax O-360-A4M

PapernScissors wrote:

PapernScissors wrote:http://www.ntsb.gov/_layouts/ntsb.aviation/brief2.aspx?ev_id=20141012X30001&ntsbno=WPR15FA010A&akey=1

Try this link.

The link in the quote above is for the Cessna 170. I have discovered that a second factual report addresses the Savannah. See: http://www.ntsb.gov/_layouts/ntsb.aviation/brief2.aspx?ev_id=20141012X30001&ntsbno=WPR15FA010B&akey=2

I am really, really bothered by the medical information in this report. No matter our feelings about the pilot, this is unacceptable.

Cary

Cary wrote:I am really, really bothered by the medical information in this report. No matter our feelings about the pilot, this is unacceptable.

Cary

+100
Thanks for pointing it out, I hadn't yet read the Savannah factual, assuming it the same as the Cessna. I have read a lot of these; this is the first time I have seen such a list. I wanted it to be an error, as this is the cocktail of someone at least twice his age and very ill, but they don't make mistakes like that in testing.

Just read the Savannah factual.

Damn.

Wow. That is so sad in so many ways.


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Troy Hamon wrote:Wow. That is so sad in so many ways.

My thoughts too. Really tragic.

That report for the Savannah did not make for easy reading.
http://www.ntsb.gov/_layouts/ntsb.aviat ... 10B&akey=2

Goddammit. WTF!

soyAnarchisto wrote: WTF!

+1

NTSB wrote:It was powered by a Rotax experimental O-360-A4M, 100-hp engine.

My trust has been shaken.

Zzz wrote:

NTSB wrote:It was powered by a Rotax experimental O-360-A4M, 100-hp engine.

My trust has been shaken.

Something's clearly wrong about the engine designation, perhaps a cut & paste blooper. Hard to imagine the other stuff being all a mistake, though.

Cary

'The pilot of the Savannah reported no medical conditions or medical medications to the FAA on his last medical.' (which was back in 2011...)

This is the stuff I lose sleep over.

At least the AME didn't know so can't be held laible for certifying the airman but that does not reduce the damage done.

Quite the medical concoction there. Glad my name is not on the prescription bottles.

Cary wrote:Hard to imagine the other stuff being all a mistake, though.

Agreed. Just read all the associated docs. The medical statements and tox reports seems clear and unambiguous. Also, seems there are really two medical reports: one the NTSB (toxicology) performed in DC, and another, the autopsy (+tox) performed in NV. Having that redundancy in testing with the same result adds confidence.

Any experts in these matters are invited to correct my assumptions.

-M3X

Delete

Akt

I understand the need to seek some reconciliation in this matter via the results of investigation, but I too groaned when I saw the topic come back up. M3X, I get it. Many here are curious too. Perhaps it is different for me and a few others who have some insight into both the accident and the pilot's background.

So I will tell you right now, regardless the results of the tox screen, that was not the cause. The cause was 100% one pilot with very poor judgement, a dangerously impulsive pattern of flying behavior, and one final screw up after being warned many, many times in similar situations. I personally witnessed it once in person and actively avoided the pilot entirely thereafter.

I've been reluctant to weigh in here, and have typed and retyped this reply many times and deleted it. I don't want his family members to suffer as the memory of their child is tarnished, though they likely aren't viewing this site anymore. But I will just say it because many seem to be clinging to the toxicology report as causality. It was bad pilot judgement, reckless flying at the end of a long pattern of the same. The pilot of the 170 was the complete opposite and I mourn him and think of his family members often.

Z

Zane: Appreciate your thoughtful response. This is an upsetting experience for all.

What drives me to read and understand NTSB accident reports is the desire to understand the chain of failures so I can steer my process and procedures to break that chain. That is the mission of the NTSB; help interested parties break the chain. We owe it to those that have fallen before us. Every improvement in aviation safety was preceded by a chain of failures that, looking back, seemed obvious.

Zzz wrote:So I will tell you right now, regardless the results of the tox screen, that was not the cause. The cause was 100% one pilot with very poor judgement

I would counter the tox screen report directly indicates poor judgement. Not reporting honestly to the AME, along with that cocktail was proof for me. My father is a senior Pharmacist who emailed me this morning "I'm sure that his judgement was in question just by the choice of adding the THC and diphenhydramine to the meds he was already taking in addition to the obvious side affects."

The purpose of an NTSB investigation is to give interested parties, not present, an understanding of what occured, and through that understanding steer policy and behavoir to prevent future occurances. In that this inquiry has served the public well.

I wasn't there, but understand poor judgement is the likely root cause based on this evidence. You and others that knew the parties, understand poor judgement first hand.

When working as a professional pilot we studied relevant NTSB reports, warts and all, so it would never happen again. These reports are for us, the flying public. For me, it is scant comfort, but comfort nonetheless, to know there is something to be learned from tragedy, and the NTSB is founded on that value. I believe we owe it to those we lost.

For some this exercise is upsetting, and unhelpful. For those folks perhaps ignoring the accident analysis section would be best.

Zzz wrote:The pilot of the 170 was the complete opposite and I mourn him and think of his family members often

On this, those who knew him, and those who didn't, can all agree. I am from a similar demographic with a young-adult child, and I think of him often, and how easly it could have been me in that plane.


-M3X