Started drafting "investigation reports" for my incidents/crashes

[rjwmorrell]

So, I'm a bit of a nerd. That should be obvious, and probably applies to most people here given our chosen hobby/interest in drone flying. But sometimes I take it to new levels. I started drafting crash/incident reports, modelled after Transportation Safety Board air investigation reports. I've luckily only had two incidents, neither of which resulted in a loss of the aircraft, but I figure it's good practice to draft them -- I plan to lead the drive to implement a drone program at my work, a federal agency in Canada; after my career I plan a career in practicing law as a paralegal, and paralegals have standing in the Transportation Appeal Tribunal where errant drone pilots can find themselves appealing fines for incidents etc. I am a health & safety co-chair at work, and so I review accident investigations already, this drafting exercise helps me hone my skills there, too.

I thought I would share a redacted version of my last one to see what the members think. Please critique it... am I off on any technical details or conclusions? Would you have written anything differently? It was not a very serious incident, but it did illustrate an error I made in selecting to do an ActiveTrack mode at a poor location, and so presented a learning opportunity.

Here is the link to the PDF for this one. If you are interested in having me draft an investigative report for your own incidents you can PM me and if I have some time I can provide something.

RPAS INCIDENT REPORT A2301 redacted.pdf

drive.google.com

Cheers!

 

[agia57]

Sort of a Kathryn's Report -- except for drones.

 

[TonyPHX]

I think if you need this to satisfy something, great.

For me, I think it brings me no joy. Reading report-speak feels like an energy vampire draining my will to live.

 

[RodPad]

I read the post and the pdf at least 3 times. I really did know what I understood. I waited for some else to reply in case I'm missing something.

What is the goal or purpose?

Rod ..

 

[millbah]

Do we really need it? My humble comment.

 

[rjwmorrell]

I read the post and the pdf at least 3 times. I really did know what I understood. I waited for some else to reply in case I'm missing something.

What is the goal or purpose?

Rod ..

It's good practice, since businesses using drones may use them as prevention tools.

Also, it formalizes something that Transport Canada requires anyway in certain prescribed cases. It's a format they would be familiar with, at that, since it follows the TSB report format.

The Canadian Aviation Regulations require drone operators to produce an analysis of causes of incidents in certain cases (drone comes into contact with person, fly away into controlled airspace, CADORS report or police report is produced, etc). That self generated report must be retained for 12 months.

Incidents and Accidents — Associated Measures​

• 901.49 (1) A pilot that operates a remotely piloted aircraft system shall immediately cease operations if any of the following incidents or accidents occurs until such time as an analysis is undertaken as to the cause of the occurrence and corrective actions have been taken to mitigate the risk of recurrence:
  • (a) injuries to any person requiring medical attention;
  • (b) unintended contact between the aircraft and persons;
  • (c) unanticipated damage incurred to the airframe, control station, payload or command and control links that adversely affects the performance or flight characteristics of the aircraft;
  • (d) any time the aircraft is not kept within horizontal boundaries or altitude limits;
  • (e) any collision with or risk of collision with another aircraft;
  • (f) any time the aircraft becomes uncontrollable, experiences a fly-away or is missing; and
  • (g) any incident not referred to in paragraphs (a) to (f) for which a police report has been filed or for which a Civil Aviation Daily Occurrence Report has resulted.
• (2) The pilot of the remotely piloted aircraft system shall keep, and make available to the Minister on request, a record of any analyses undertaken under subsection (1) for a period of 12 months after the day on which the record is created.

As an accident investigator at work, it's great practice for me.

 

[rjwmorrell]

Do we really need it? My humble comment.

Do YOU need it specifically? Probably not.

 

[BigAl07]

Listen gang, need it or want it doesn't matter. If this Incident Reporting brings the OP happiness or completeness then that's great. If it's not for you, that's all good and fine. No need to rain on someone else's parade just because you don't want/like/need the parade in your life.

 

[TonyPHX]

Listen gang, need it or want it doesn't matter. If this Incident Reporting brings the OP happiness or completeness then that's great. If it's not for you, that's all good and fine. No need to rain on someone else's parade just because you don't want/like/need the parade in your life.

Not raining. Just gave comment.

 

[Robert Prior]

Interesting idea. Some points in no particular order:

• In the history of the flight section you mention that Active Track has two modes, and that it was engaged, but not which mode. That information is given later. It seems logical to include it here as well.
• In the safety message section I would add a suggestion about position the aircraft above all obstacles in the route. If you'd been above the wires, you wouldn't have hit them.
• Following on to my first point, information is split between the history of the flight section and the section on active track. I kept on flipping back-and-forth to figure out what happened. Maybe this is the way the TSB does it, but it seems to me either consolidating the sections or repeating information would make the report easier to understand. In the history section you don't mention that active track was cancelled (it's implied, I guess) but later in the active track section we learn that it was cancelled when the pause button was pushed, and the pilot resumed manual control.

 

[rjwmorrell]

So an example of a TSB report that involved a collision with a wire is here: Air transportation safety investigation A22Q0084 - Transportation Safety Board of Canada

The History section describes the overview of the incident flight. Then later they delve into technical causes, pilot error, etc. So the history may not be as detailed as the later sections.

I like your suggestions, yes the height of the obstacles and the position of the aircraft is important information to point to in the conclusion safety message. It wouldn't hurt to mention which ActiveTrack was being used in the history section, I agree.

For those wondering, the regulations do actually require the pilot to cease flight, and conduct an analysis of causes and prevention measures, then keep that on file for 12 months, if certain listed incidents or occurrences happen. This one wasn't explicitly a type of incident listed (arguably it could be since the aircraft became unstable during flight -- after hitting the wires ).

The other day I had an encounter with police while flying. That one is *explicitly* listed in the regulations. So the report format here provides a great, through template to follow for Canadian pilots, even if Transport Canada never asks to see them, at least you've complied with the regulations. Granted, the analysis probably doesn't need to be this formal or thorough. However, it's a model that's easy to follow once you've read a few of these TSB reports.

 

[RodPad]

BigAl07

mavicpilots.com

Well I'm not very smart with a lot of words.
"Please critique it..."
I thought it meant Please criticize it.

Sorry to all and.

rjwmorrell

mavicpilots.com

Rod ..

​

 

[Robert Prior]

So an example of a TSB report that involved a collision with a wire is here: Air transportation safety investigation A22Q0084 - Transportation Safety Board of Canada

I'll have a look at that. The only TSB report I've read was the one for the collision between a single-engine plane and a York police drone which was hovering in the flight path. That one taught me that TSB reports are not the same as the engineering and education reports I used to read (which are written partly with an eye towards who will be blamed for an incident).

 

[Robert Prior]

"Please critique it..."
I thought it meant Please criticize it.

I think the best analogy is "constructive criticism". What worked, what didn't, and suggestions for improvement.

 

[rjwmorrell]

I'll have a look at that. The only TSB report I've read was the one for the collision between a single-engine plane and a York police drone which was hovering in the flight path. That one taught me that TSB reports are not the same as the engineering and education reports I used to read (which are written partly with an eye towards who will be blamed for an incident).

It's not a drone incident, so don't expect to see anything drone related.

There was one other drone related TSB report, pre-2019, if memory serves it was a small private aircraft on final somewhere in Quebec that hit one.

 

[Robert Prior]

There was one other drone related TSB report, pre-2019, if memory serves it was a small private aircraft on final somewhere in Quebec that hit one.

So the police are responsible for 50% of drone-related aviation collisions in Canada, eh?

(I know, small sample size, not statistically significant, etc. I'm reminded of the time my principal was upset that 50% of the students in a category failed the EQAO literacy test. I tried pointing out that the single student who failed — there were only two students in that category — had arrived in Canada the previous week and couldn't speak English. She understood that, and didn't expect them to pass, but 50% was still too high a failure rate!)

Relating to the YRP collision, a buddy who used to be a cop said that it was highly likely that the incident commander was railroading the pilot, pushing them to fly farther than regulations allowed etc — and police culture doesn't welcome disputing orders in the field. Something that wasn't in the TSB report, probably because no one would admit it on record. We were talking about organizational cultures — police, education, aviation — and aviation seems to have much the better way of handling incidents.

 

[Robert Prior]

It wouldn't hurt to mention which ActiveTrack was being used in the history section, I agree.

Either that, or don't mention that there are two types, just that Active Track was which used and put the details in the subsequent section. Either works, but I don't know which better fits the TSB style.

(I'm currently proofreading a novel and a science education report, so I'm in nit-picking mode.)

Would it be worth creating a template for drone pilots? An outline of the structure, with a list of what should go in each section. (This section should include a map kinda thing.) This may be a very silly idea — my computer room is hot and I'm a bit giddy with overheating.

 

[rjwmorrell]

Either that, or don't mention that there are two types, just that Active Track was which used and put the details in the subsequent section. Either works, but I don't know which better fits the TSB style.

(I'm currently proofreading a novel and a science education report, so I'm in nit-picking mode.)

Would it be worth creating a template for drone pilots? An outline of the structure, with a list of what should go in each section. (This section should include a map kinda thing.) This may be a very silly idea — my computer room is hot and I'm a bit giddy with overheating.

I was eventually going to template it for my own purposes. Thanks for taking the time!

 

[rjwmorrell]

So the police are responsible for 50% of drone-related aviation collisions in Canada, eh?

(I know, small sample size, not statistically significant, etc. I'm reminded of the time my principal was upset that 50% of the students in a category failed the EQAO literacy test. I tried pointing out that the single student who failed — there were only two students in that category — had arrived in Canada the previous week and couldn't speak English. She understood that, and didn't expect them to pass, but 50% was still too high a failure rate!)

Relating to the YRP collision, a buddy who used to be a cop said that it was highly likely that the incident commander was railroading the pilot, pushing them to fly farther than regulations allowed etc — and police culture doesn't welcome disputing orders in the field. Something that wasn't in the TSB report, probably because no one would admit it on record. We were talking about organizational cultures — police, education, aviation — and aviation seems to have much the better way of handling incidents.

Could be more than 50%. There was another incident in the CADORS (aviation occurrence reports) but for whatever reason TSB did not produce a public report. It was an RCMP helicopter hitting an RCMP drone in BC. Sort of an "own goal" as they say in soccer.

My uncle was an airline pilot for a UK carrier (the red one, not the blue one). He was explaining to me once that the culture on airline cockpits has had problems in the past at many airlines, and even today at smaller ones. The experienced captain who knows best and is never questioned etc.

 

[shb]

I had three incidents where I hit wires. The first was close to home, and the mavic 3 hit a 75 ohm video cable that was crossing the street. Fortunately, it didn't crash and recovered by itself. It did have one propeller damaged that I replaced.. The second I'm not sure about, but I think it hit a guy wire and I never found it. The third it hit a guy wire at 240 feet and crashed into a tree. I was able to recover it, and have it repaired. Just wondering if DJI drones are designed to right themselves after hitting wires, and continue to fly, if they're not damaged. Probably. When you say "but control was regained", was that by something you did, or something the drone did?