DCA18IA269

the drone pilot's incorrect control inputs due to insufficient knowledge of the aircraft flight manual procedures. Contributing to the incident was the close proximity of the observers, and the decision to conduct a demonstration near the observers in a confined area with no assistance.

The sUAS was operating under the provisions of Part 107 within Class G airspace. The pilot was appropriately certificated for the flight. Examination of the drone data logs revealed no anomalies with the aircraft or software. The drone responded to control inputs as expected. The pilot erroneously believed that the "down and in" CSC input would result in a landing or in-flight shutdown of the motors. The Phantom 4 user manual specifies that the "down and in" CSC shuts down the motors only when the drone is on the ground. Inputting that command in flight would result in the drone yawing right, pitching backward, and banking left. Logs indicated that the drone maneuvered consistently with the stick inputs. Further, the pilot indicated the drone would not land. Logs indicate that he used the Autoland feature, which scans the landing surface with optical sensors (Visual Positioning System or VPS) to determine if the surface is suitable. Logs indicate the VPS did not calculate a suitable landing surface. This is consistent with the pilot's report of trying to land on a plastic table, which likely created excessive reflections. In order to conduct a normal landing, the pilot would need to switch out of Autoland, or override it by holding the throttle (left stick) fully back for 2 seconds. Logs indicate the aircraft remained in Autoland mode, and the stick was not pulled fully back for more than ½ second at any time. The demonstration flight was conducted in a small area, confined by trees, and within close proximity of the observers, 10 feet or less according to witness statements. Although there is no evidence that the pilot flew directly over unprotected persons, or purposely in a hazardous manner, at the time that he perceived a problem with the drone and decided to crash it, the close proximity to the observers should have been accounted for either by warning them to clear away, having an assistant do the same, or to conduct the forced landing in an area clear of the observers. At the time of the incident, the university and CMI did not have any documented procedure for conducting such demonstrations. Although not required by regulation, the incident pilot did not have any documented aircraft-specific training that might have included the flight manual procedures noted above.

HISTORY OF FLIGHT On August 14, 2018, at 1330 eastern daylight time, at the Mountain Lake Biological Station, Blacksburg, Virginia, a Dà-Jiang Innovations (DJI) Phantom 4 small unmanned aircraft system (sUAS, commonly known as a drone), registration FA3HCWCR4X, operated by the Virginia Tech Conservation Management Institute (CMI), collided with a bystander resulting in minor injuries. There was no damage to the drone. The flight was an educational demonstration flight conducted in Class G airspace under the provisions of 14 Code of Federal Regulations (CFR) Part 107. Visual flight rules conditions prevailed at the time of the incident. The flight was part of a demonstration for students of the Virginia Tech College of Natural Resources and Environment. There were six students observing the flight. According to the pilot, the demonstration was intended to consist of a short, automated flight over a pond using the DroneDeploy control application (app) to show how mapping surveys were conducted, followed by a manual flight to view wildlife in the pond. On the day of the incident, the pilot conducted a mapping flight prior to the demo. The pilot reported that, during the mapping flight, he attempted an automatic landing but the drone "missed its homepoint," and the Director of CMI hand-caught the drone. The pilot reported that he "used the manual shutdown procedure, which worked correctly." The flight demonstration area was near a small beach and grassy area adjacent to the pond (figure 1). The area and the pond were surrounded by trees. Plastic lawn chairs and tables were in the area. Figure 1 – Photo of Operating Area The six students who were observing the demo flight were located less than 10 feet from the pilot. There was no visual observer or other assistant to the pilot for this flight. He started the demo in manual flight mode, and took off from a plastic picnic table on the berm of the pond. He reported the flight was normal, although the wind picked up a little bit during the flight. He flew the drone back to the picnic table for landing but reported that it would not touch down onto the table. The pilot reported that he made numerous attempts to land and attempted "the shutdown procedure," but the drone flew off to the side. He then reported that he climbed the drone back up and attempted an automatic landing and a landing in the grass, again using the "shutdown procedure," but the drone did not respond as he expected. He reported that he did not feel comfortable having one of the students try to hand-catch the drone, so he decided to crash it. The drone flew laterally and struck one of the students resulting in the injury, then continued into bushes where it stopped. The pilot reported that the "shutdown procedure" that he used was to position the two control sticks (called a Combination Stick Command, or CSC) "down and in," meaning that the left (throttle/yaw) stick is pulled fully back and to the right, and the right (pitch/bank) stick is pulled fully back and to the left. Examination of the logs revealed that, at 1 minute10 seconds before the end of data, the drone was being maneuvering at low altitude near the home point in GPS mode. Then the pilot partially decreased throttle followed by the "down and in" CSC. Figure 2 – First CSC command 1:10 prior to end According to the DJI Phantom 4 User Manual, the "down and in" command shuts down the motors immediately when the drone is on the ground. Alternatively, a method to stop motors on the ground is to retard the throttle straight back and hold for 3 seconds (figure 3). The method for emergency stop of motors in flight or prior to the drone sensing that it has landed is to pull the throttle back and to the right while simultaneously pressing the Return to Home button (figure 4). Figure 3 – Excerpt from Phantom 4 User Manual, Stopping the Motors Figure 4 - Excerpt from Phantom 4 User Manual, Stopping the Motors in Flight The log data showed that, while the drone was still in the air, it responded to the pilot's "down and in" CSC input by pitching up, yawing right, and banking left. Logs indicated a "braking" message indicating the obstacle avoidance/visual positioning system (VPS) was activated. The data showed that, when the pilot then neutralized the sticks, the drone hovered. Another braking message was recorded consistent with proximity to objects or persons. Fifty-four seconds prior to the end of data, the pilot activated the drone's "Autoland" feature, and the drone hovered briefly before the pilot input another "down and in" CSC. The drone again responded in pitch, yaw, and roll. The data showed that, 49 seconds prior to the end of data, the pilot increased the throttle, and the drone climbed while still in Autoland mode. Ten seconds later, the pilot released the throttle, and the drone descended with no stick input, consistent with its Autoland feature. During the descent, another "down and in" CSC was given by the pilot, and again, the drone responded consistently. The logs indicated that, following each CSC, the drone's obstacle avoidance activated, consistent with the low altitude and proximity to objects and persons. The drone subsequently climbed and then reentered an Autoland mode descent, and, at 28 seconds prior to end of data, the pilot reduced the throttle and held it fully back for less than a half second. The drone's automatic Landing Protection feature activated, consistent with the drone detecting an unacceptable surface to complete a landing while in Autoland mode. Twenty-two seconds before the data ended, the sequence repeated, with the pilot reducing the throttle, but not fully and only for 1.2 seconds. The DJI Phantom 4 User Manual describes numerous factors which will prevent the Autoland feature from completing the landing (figure 5). Figure 5 - Excerpt from Phantom 4 User Manual, Landing Protection The drone was maneuvered at low altitude until the pilot input a "down and in" CSC 4 seconds prior to the end of data; the drone responded in pitch, yaw, and bank, followed shortly by an ESC (electronic speed controller) error, which is consistent with the propellers striking objects. According to witnesses, the drone struck the ground and moved laterally toward the bystanders. The injured person attempted to jump out of the way, but the propellers struck her in the lower legs. The drone continued into nearby shrubbery, and the pilot retrieved it and shut down the power. INJURIES TO PERSONS First aid was conducted at the incident scene. The injured bystander received multiple lacerations to both legs requiring nine stitches, glue, and butterfly bandages at a hospital outpatient urgent care. PERSONNEL INFORMATION The drone pilot held a Federal Aviation Administration (FAA) Part 107 Remote Pilot Certificate and had logged a total of 3.7 hours as Remote Pilot in Command (RPIC), most of which was on the senseFly eBee fixed-wing drone and the 3D Robotics (3DR) Solo quadcopter. He had logged 8 minutes RPIC on the Phantom 4 but reported about 2 hours of experience with it as a hobbyist. He was also experienced acting as Visual Observer and other crew positions. He did not hold any manned aircraft certificates. His training on the Phantom 4 consisted of performing some basic maneuvers at a practice field using various DJI GO 4 functions, and practicing using the DroneDeploy flight control app. He reported experiencing no incidents during this training. AIRCRAFT INFORMATION The Phantom 4 is an sUAS of quad-copter configuration, about 13 inches in diameter. It is powered by four electric brushless motors and a 4-cell 15.2v lithium-polymer battery. The maximum takeoff weight is 3 pounds, maximum altitude is about 19,685 feet msl, and its maximum endurance is 28 minutes. Specified maximum range of the remote controller is 3.1 miles. The drone is equipped with a GPS/GLONASS