PARACHUTE ACCIDENT REPORT AND EXECUTIVE SUMMARY

Transcription

1 Section/division Occurrence Investigation Form Number: CA 12-12c PARACHUTE ACCIDENT REPORT AND EXECUTIVE SUMMARY Parachute Registration Type of Parachute Reference: CA18/2/3/8246 N/A Date of Accident 28 January 2007 Time of Accident 0930Z Main Skymaster Container Naro R4/6 Reserve Tempo 250 Type of Operation Skydiving Training Licence Type Student Skydiver Age 22 Licence Valid N/A Skydiving Experience Total Number Jumps 20 AFF 10 level Yes Last point of departure Next point of intended landing Nylstroom - Modimolle Airfield (FANY) Nylstroom - Modimolle Airfield (FANY) Location of the accident site with reference to easily defined geographical points (GPS readings if possible) Approximately 30 feet from landing zone at Modimolle Airfield Meteorological Information CAVOK. Number of people 1 No. of people injured 0 No. of people killed 1 Synopsis The student skydiver was undergoing accelerated free fall (AFF) skydiving training. He exited the aircraft at altitude of 5500 feet AGL with the intention to do a clear and pull manoeuvre. For some unexplained reason the student skydiver went in to pull the ripcord but missed the handle. In the process, he lost the stable body position (not in correct position to maintain control of his body in relation to relative wind) and then dropped his head to look for the ripcord. After finding the ripcord, he pulled it but flipped over onto his back whereby the pilot chute went through his legs. The time when the main parachute came out some lines hooked the student skydiver s legs, causing the main parachute to spiral. The student skydiver managed to cut away the parachute, but with remaining lines entangled on him. It appeared as though the student skydiver became disentangled and fell away from the disabled main parachute. The investigation determined that the reserve free bag was still attached to the reserve and appeared to have choked the opening of the reserve. The bridle seems to have prevented the reserve from opening due to entanglement. The skydiver was fatally injured in the accident. Probable Cause The student skydiver de-arched during the accelerated free fall, resulting in situation whereby some lines entangled around his legs when the parachute deployed. The reverse parachute activated but did not deploy due to reserve parachute and reserve deployment bag was entangled with each other. IARC Date Release Date CA 12-12a 25 MAY 2010 Page 1 of 15

2 Section/division Occurrence Investigation Form Number: CA 12-12a Telephone number: address of originator: PARACHUTE ACCIDENT REPORT Name of Owner/Operator Manufacturer of Parachute Equipment Nationality : South African Registration Marks : None Place Date : 28 January 2007 Time : 0930Z : PAC 750XL Charter Partnership/Skydive Extreme : Parachute Industries of South Africa : Nylstroom - Modimolle Airfield All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South African Standard Time is UTC plus 2 hours. Purpose of the Investigation : In terms of Regulation of the Civil Aviation Regulations (1997) this report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to establish legal liability. Disclaimer: This report is given without prejudice to the rights of the CAA, which are reserved. Skydiving Descriptions: AAD AFF Body Position Canopy Container Cut Away Drop Zone Automatic Activation Device Senses rate of descend and altitude, then attempts to mechanically activate the reverse parachute if the skydiver passes below a set altitude at a high rate of descent. Accelerated Free Fall Student receives training on free fall jumps, accompanied by qualified Jump Master. Skydiver free fall body posture variations in the body position makes free fall manoeuvres possible. The major component of parachute system comprised of fabric membranes that connect to the parachute harness by suspension lines and provide the means for the jumper to descend safely. The element of the parachute that houses the main and reserve canopies to the skydiver. To release the main parachute, cutting away is a standard emergency procedure prior to deploying the reserve. It involves using a release system activated by pulling a handle. Skydiving operating centre. CA 12-12a 25 MAY 2010 Page 2 of 15

3 Jumpmaster Jump Run Jumpsuit Out Landing Rigger A skydiver, senior jumper or instructional rating holder, who coordinates boarding and exit order, jump flight procedures, spotting, and emergency operations with the pilot. The predetermined flight path of the aircraft to put the skydivers in position over the airport. The suit worn by skydivers which are designed for specific skydiving applications. Skydiver landing off target. Someone with a certificate from PASA indicating that they met requirements to be a parachute rigger. 1. FACTUAL INFORMATION 1.1 Parachuting Occurrence History A group of twelve skydivers in a PAC 750 XL aircraft took off from Modimolle Airfield on a skydiving flight. The pilot flew the aircraft on a jump run with the intention for the skydivers to jump from it. During the jump run flight the aircraft climb to a suitable altitude abeam the airfield where the skydivers jumped from it. The aircraft flew an uneventful flight and landed safely on the ground back at Modimolle Airfield According to the pilot, all the other skydivers jumped at altitude of to feet above ground level (AGL). The student skydiver was the only one that jumped at approximately 5500 feet AGL. During the aircraft descend and approach to the airfield, he was told in a radio transmission to standby. After a few seconds the aircraft was then cleared to come in for the landing at the airfield. On the ground, the pilot was then informed that one of the student skydiver freefall to the ground and he was fatally injured According to the Jump Master/AFF Instructor, before they boarded the aircraft and embarked on the skydiving flight, he personally checked the student skydiver equipment. He was satisfied with the serviceability and condition of the skydiving equipment. The student skydiver was on his level 10 accelerated freefall jump. It was a solo jump, whereby the student skydiver was required to do a clear and pull manoeuvre. He was to leave the aircraft, then stabilise before deploying the parachute. The AFF Instructor was going to watch the student skydiver s technique Due to one-to-one tuition, the AFF Instructor checked that they were flying in the correct area over the drop zone to exit the aircraft. The AFF Instructor ensured that the student skydiver was into the correct position in the aircraft door and told him to exit. The student skydiver exited the aircraft very well and he was stable in a good body position. CA 12-12a 25 MAY 2010 Page 3 of 15

4 1.1.5 During the accelerated free fall, the student skydiver went in to pull the ripcord but missed the handle. In the process, he lost the stable body position (not in correct position to maintain control of his body in relation to relative wind) and then dropped his head to look for the ripcord. After finding the ripcord, he pulled it but flipped over onto his back whereby the pilot chute went through his legs. The time when the main parachute came out some lines hooked the student skydiver s legs, causing the main parachute to spiral. The student skydiver managed to cut away the parachute, but with remaining lines entangled on him for approximately 2 to 3 seconds. It appeared as though the student skydiver became disentangled and fell away from the disabled main parachute. The AFF Instructor thought that the student skydiver would deploy his reserve parachute at this time. The AFF Instructor observed that the reserve parachute was not deploying. The AFF Instructor landed safely and he was informed that the student skydiver was involved in a fatal accident. 1.2 Injuries to Persons The student skydiver was fatally injured in the accident. 1.3 Damage to Skydiving Equipment The skydiving equipment sustained substantial damage. 1.4 Other Damage None. 1.5 Personnel Information Jumb Master/AFFInstructor: Nationality South African Gender Male Age Licence Number D656 Licence Type Skydiver Licence valid Yes Static Line (JM 630), Accelerated Freefall (AI47), Ratings Tandem (TM118ST), PRO (PRO292), Technician (RP85), Coach (CH75F) Previous Accidents/Incident None CA 12-12a 25 MAY 2010 Page 4 of 15

5 1.5.1 The Static Line Jump Master rating was issued in May The Static Line Instructor in October 1996 and AFF Instructors rating on 26 October The Jump Master/AFF Instructor was an active member of PASA and his membership was valid at the time There were no anomalies identified with the performance of the Jump Master/AFF instructor concerning the training of the student skydiver. Student Skydiver: Nationality South African Gender Male Age 22 Licence Number Non-licensed Training Type AFF Student Skydiver Ratings None Previous Accidents/Incident None According to a Parachute Association of South Africa (PASA), the student skydiver was participating in the skydiving sport for 6 months at the time of the accident. He was in the process of level 10 accelerated freefall (AFF) parachute training course. The student skydiver had already logged 20 jumps when involved in the accident. 1.6 Parachute Equipment Details The parachute equipment was made up of three main parachute systems components and reserve automatic activation device (AAD): (i) The three main parachute systems components consisted of one main and one reserve parachute packed into a specialised backpack with chest strap and leg straps cinched to keep the student skydiver securely fastened. See below information: Container: Type Naro Serial Number Manufacturer Parachute Industries of SA Date of Manufacture June 1997 Main Canopy: Type Skymaster 290 Serial Number Manufacturer Parachute Industries of SA Date of Manufacture June 1997 CA 12-12a 25 MAY 2010 Page 5 of 15

6 Reserve Canopy: Type Tempo 250 Serial Number Manufacturer Parachute Industries of SA Date of Manufacture June 1997 Reserve Static Line Yes The skydiving equipment was repacked on 05 September The skydiving equipment was checked again by the AFF Instructor before the jump on the day of the accident. The AFF Instructor was satisfied that the skydiving equipment was in a serviceable condition The student skydiver was using the following peripheral skydiving equipment: Hard Helmet, Clear Goggles and Altimeter. All the peripheral equipment was in a serviceable condition prior to the accident The student skydiver was appropriately dressed with proper clothing for the exercise The parachute and peripheral equipment was the property of the skydiving training institution: Skydive Xtreme. 1.7 Meteorological Information The weather conditions on the day were CAVOK. 1.8 Aids to Navigation The student skydiver was having an altimeter instrument. The altimeter gave him information of height/altitude above the landing area. The altimeter was in a serviceable condition. 1.9 Communications The AFF instructor was the last person that communicated with the student skydiver. Their communication was very brief inside the aircraft. It was the time when the instructor checked that the student skydiver was standing at the correct position in the aircraft door. He told the student skydiver to exit (jump) from the aircraft. After the jump, it appears as though the student skydiver did not communicate with anyone Normally communication equipment are installed in the helmet. The evidence shows that the student skydiver did not have any radio communication equipment installed. CA 12-12a 25 MAY 2010 Page 6 of 15

7 1.10 Aerodrome Information: Nylstroom Modimolle Airfield was used as the drop zone for the skydiving operations in the area. The aerodrome location was at GPS reading S E Figure 2, shows the drop zone for the skydiving operations Skydiving Flight Recorders There was no skydiving flight recording equipment Skydiving Equipment and Impact Information According to PASA report, there was one set of main parachute lines that entangled with the leg of the student skydiver during the accelerated freefall, causing the parachute to spiral. The student skydiver managed to release the main parachute but the lines still remained entangled around his legs. The student skydiver found himself in a head-down position. The student skydiver managed to cut away the main parachute. The reserve parachute was subsequently deployed. CA 12-12a 25 MAY 2010 Page 7 of 15

8 The evidence found during the onsite investigation shows that the reserve parachute and reserve deployment bag entangled with each other after the reserve was activated. It happened due to the unstable position of the student skydiver. The reserve parachute bridle was found wrapped around the mouth of the deployment bag which stopped the reserve deployment The evidence shows that the automatic activation device (AAD) activated but failed to cut the closure loop which indicates that the reserve already been activated. Without the deployment of the reserve there would have been little or no drag and hence a high speed impact followed in the vicinity of the landing zone. Figure 3, shows the skydiver landing zone and impact site Medical and Pathological Information The medico - legal post-mortem examination of the student skydiver was carried out by a State Chief Specialist Forensic Pathologist at Northern Transvaal Coffins, Mokopane on 30 January The Pathologist concluded that the cause of death was multiple injuries consistent with freefall from height. CA 12-12a 25 MAY 2010 Page 8 of 15

9 1.14 Fire None Survival Aspects The accident was considered to be not survivable. It is the opinion of the investigator that apart from the parachute equipment, the student skydiver had no other defence against injury Tests and Research According to an article Parachuting from website: absoluteastronomy.com stating that about 30 skydivers are killed each year in USA; roughly one death for every jumps (about 0.001%) Skydiving Operation: The information below was taken from a website: Wikipedia Accelerated Free Fall (AFF) is a method of skydiving training. The method of skydiving training is called accelerated because the progression is the fastest way to experience solo freefall, normally from 10,000 to 15,000 feet Above Ground Level (AGL). In static line progression, many more jumps are required to experience solo freefall, but the jump are less expensive for the student as one instructor can dispatch multiple students per load, whereas under accelerated freefall, one or sometimes two instructors are dedicated just to one student. In most AFF programs, two instructors jump with the student during their first three AFF jumps, although some programs may use only one instructor. On initial levels, the instructor(s) hold on to the student until the student deploys their own parachute. Hence, this method is classified as Harness Hold Training. The AFF instructors have no physical connection to the student other than their grip on the student, so once the student s parachute is deployed the instructors fly away and deploy their own canopy Accelerated Freefall Progression: The information below was taken from PASA Manual of Procedures: The accelerated freefall (AFF) programme was instituted in 1982 as a process as compared to the traditional static line progression. The AFF programme is an intensive training programme and will give you a true taste of modern sport. The ground training is a bit more extensive than static line to prepare the student seconds of freefall. The AFF programme consists of ten levels of progression, each consisting of a ground training secession and a minimum of one jump. Each level has to be completed successfully, by meeting pre-determined learning and safety objectives, before moving on to the next one. CA 12-12a 25 MAY 2010 Page 9 of 15

10 (a) (b) On the first AFF jump, you exit the aircraft at feet with two AFF Instructors grip on you from the moment you leave the aircraft until your parachute begin opening. On level 1 to 3 you will be assisted by two AFF Instructors. The student to pull own rip cord, to be altitude aware, have body position and be able to do manoeuvres. The student to show general awareness and demonstrate safe canopy control including the landing. RHS Instructor AFF Student LHS Instructor Figure 7, taken from PASA Manual of Procedure, shows example of level 1 to 3 AFF training. (c) (d) On level 4 to 7 require only one AFF Instructor to assist you in learning solo skill, demonstrate ability to regain stability frontloops or backloops. Ability to move forward delta or track, show more individual mind work i.e. start sequence on own. On levels 8, 9 and 10 are a minimum of three solo jumps: Two are Instructor assigned task jumps, while the third is a low altitude hop and pop Level 10 Skydive Solo Skydive Clear and Pull. The objective of level 10 skydiving training is as follows: (i) (ii) (iii) (iv) (v) (vi) Student to pull own rip cord. Student must be altitude aware. Student to have good body position. Student to show general awareness. Student to have a safe landing. Student to show control and open within 5 seconds of leaving aircraft. CA 12-12a 25 MAY 2010 Page 10 of 15

11 (vii) Unassisted climb out. (viii) Student to clearly demonstrate safety and independence. (ix) Exit 4500 feet Graduate Skydiver: Both AFF and Static Line, on completion of the full course, qualify the student skydiver as a GRADUATE SKYDIVER. The most important thing to remember is (i) (ii) (iii) Pull the rip cord. Pull at the correct altitude Preferably pull stable The skydiving equipment was examined by Parachute Industries of South Africa (Pty) Ltd. The findings identified during the examination process were presented to PASA in a report. The report concluded as follows: (i) All the parachute equipment that was inspected was in a serviceable condition prior to the accident Organizational and Management Information According to PASA, they are an ARO and conduct parachuting activities as authorised by CAA via RASAA. Based on the authorisation, PASA authorised Skydive Xtreme to conduct parachuting operations as per the MOP. Skydive Xtreme are one of PASA members via the Association of Drop Zone Operators (ADZO). The membership authorised Skydive Xtreme to conduct student skydiving training as per the MOP. PASA has no formal written certification documentation in respect of approving or authorising of the member training organisations Skydive Xtreme specialises in tandem skydiving. Their training institution is located in Limpopo Province and operates from Modimolle Airfield. The student skydiver that was involved in the accident was receiving training at the institution. The training institution was conducting skydiving training in accordance with PASA Manual of Procedures The on site investigation was carried out by Parachute Association of South Africa (PASA) on behalf of South African Civil Aviation Authority (SACAA). After PASA concluded their investigation, an accident report was generated wherein they determined the probable cause of the accident. A copy of the accident report was forwarded to the SACAA for approval. CA 12-12a 25 MAY 2010 Page 11 of 15

12 1.18 Additional Information Skydiving equipment: Skydivers are required to carry two parachutes (main and reserve). The reverse must be periodically inspected and re-packed (whether used or not) by a certificated parachute rigger. There are many skydivers that use an automatic activation device (AAD) that opens the reverse parachute at a safe altitude in the event of failing to activate the main parachute themselves. Other equipment includes a visual or audible altimeter to determine exact altitude According to the AFF Instructor, the free fall rate of fall is approximately 200 feet per second after terminal velocity is reached. It takes approximately 12 seconds to reach terminal velocity after exiting the aircraft The accident report was delayed due to PASA report being missing. PASA delivered the report to SACAA shortly after the accident, but it was misplaced and subsequently lost. Due to inability of AIID management to make a decision on what to do with the completion of the report under the prevailing circumstance of the PASA report being missing. The accident file remained open all these years waiting for a decision to be made about its closure. Eventually the IIC decided to conduct an investigation and recover the lost information needed to write the report for SACAA. The difficulty was that most people involved in the occurrence had already forgotten about the accident. However, they were able to give some information which could IIC in this regard Useful or Effective Investigation Techniques None. 2. ANALYSIS 2.1 Ordinarily skydiving is by its nature a high speed risk activity and may course or result in serious injury or death. Occasionally things go wrong where the skydiver, parachute equipment, drop zone and/or aircraft used fails to perform as intended. This is the reason why intensive AFF training programme in skydiving is very important. 2.2 The Parachute Association of South Africa (PASA) is responsible to ensure that AFF training programme for skydivers are reputable and safety is observed at all times during the training process. Reference is made to PASA mission statement: To foster, develop and facilitate sport parachuting, in its facets, within South Africa, in the safest and most progressive manner, on behalf of its members. CA 12-12a 25 MAY 2010 Page 12 of 15

13 2.3 The skydiving training institution Skydive Xtreme was one of PASA members. Skydive Xtreme was appropriately authorised by PASA to conduct skydiving training. All the training was carried out in accordance with quality processes of PASA manual of procedure (MoP), which was geared of ensuring that everything was done safely. 2.4 In terms of the MoP, the initial levels of AFF programme the student skydiver exits the aircraft with two AFF Instructors who will maintain a grip on him/her from the moment he/she leaves the aircraft until parachute begins opening. As the student skydiver gain more experience and progress through other levels in the programme, he/she end up being assisted by only one AFF Instructor. The time when the student reach level 10, then a minimum of three solo jumps are required, where two are instructor assigned task jumps and the third is a low altitude hop and pop or clear and Pull. 2.5 The student skydiver involved in this accident was undergoing an accelerated free fall (AFF) jump on the day. His experience in skydiving was already at a significant stage after having completed total of 20 jumps between levels 1 to 9. There was no proof found that indicated he had any medical condition which may have prevented him from jumping. The student skydiver was in the process of level 10 training and required to conduct a low altitude solo clear and pull jump. He was supposed to leave the aircraft, then stabilise before deploying the parachute. 2.6 The evidence shows that prior to the student skydiver exiting the aircraft, the Jump Master/AFF Instructor inspected the skydiver s equipment and he was satisfied that their equipment was serviceable. The Jump Master/AFF Instructor also ensured that the aircraft was at correct location over the drop zone. The student skydiver was the only one who was jumping from a low altitude (5500 feet AGL). There was no inclement weather condition which may have prevented the skydiving operation from continuing as planned. 2.7 Since this was a solo jump for the student skydiver, the Jump Master/AFF Instructor helped him only as far as the aircraft door. The Jump master/aff Instructor saw that the student skydiver exited the aircraft very well and he was stable in a good body position. The student skydiver then went in to pull the ripcord but missed the handle. In the process, he lost the stable body position (not in correct position to maintain control of his body in relation to relative wind) and then dropped his head to look for the ripcord. After finding the ripcord, he pulled it but flipped over onto his back whereby the pilot chute went through his legs. The time when the main parachute came out some lines hooked the student skydiver s legs, causing the main parachute to spiral. The student skydiver managed to cut away (jettison) the parachute, but with remaining lines entangled on him. It appeared as though the student skydiver became disentangled and fell away from the disabled main parachute. 2.8 The safety advantage of skydiving lies in situations of probability of an unlikely main parachute malfunctioning as it was the case here and an even less probability of having double malfunction of the reserve parachute. But as identified in the investigation, the reserve parachute was deployed with plenty of altitude for a normal activation to take place. The automatic activation device (AAD) had CA 12-12a 25 MAY 2010 Page 13 of 15

14 activated but failed to cut the closure loop which indicates that the reserve had already been activated. The reserve parachute and reserve deployment bag entangled with each other after the reserve was activated. It happened due to the unstable position of the student skydiver. The reserve parachute bridle was found wrapped around the mouth of the deployment bag which stopped the reserve deployment. The reserve parachute was the skydiver s last defence of being involved in the accident. Without the reserve parachute deploying, the skydiver was going to have little chance of survival after the ground impact. 2.9 The free fall rate of fall is described to be 200 feet per second after terminal velocity is reached. It takes roughly 12 seconds to reach terminal velocity after exiting the aircraft. The implication is that it was vitally important for the skydiver to have his parachute deployed, which would have given him the necessary air resistance to prevent continuing to accelerate toward the ground. Knowing that force (ground impact) equals mass (student skydiver body and skydiving equipment) times acceleration (200 feet per second). One can just imagine the trauma which the skydiver was exposed to during the high speed impact with the ground. 3. CONCLUSION 3.1 Findings The student skydiver was undergoing a accelerated free fall (AFF) skydiving training by Skydive Xtreme at Modimolle Airfield Skydive Xtreme allocated an experienced AFF Instructor to give skydiving training to the student skydiver The training documentation held at Skydive Xtreme shows that the student skydiver had done 20 jumps and he was also in the process of receiving AFF Level 10 skydiving training According to the AFF Instructor, the training exercise was clear and jump which requires the student skydiver to leave the aircraft, then stabilise before deploying the parachute The AFF Instructor was also the Jump Master, responsible for load of skydivers boarding the aircraft and jumping The Jump Master/AFF Instructor conducted an inspection to check the skydivers parachute equipment prior to the jump and he was satisfied that the equipment was serviceable According to the AFF Instructor, he communicated with the student skydiver inside the aircraft ensuring that his position was correct and told him to exit the aircraft The other skydivers jumped at to feet above ground level (AGL) and the student skydiver was the only one that exited the aircraft at 5500 AGL According to the AFF Instructor, the student skydiver de-arched during the free fall which resulted in some lines becoming entangled around his legs when the parachute was deployed. CA 12-12a 25 MAY 2010 Page 14 of 15

15 The student skydiver managed to cut away and deploy the reserve parachute at the correct altitude, but the reserve parachute did not deploy due to reserve parachute and reserve deployment bag was entangled with each other The free fall rate of fall is approximately 200 feet per second after terminal velocity is reached. It takes approximately 12 seconds to reach terminal velocity after exiting the aircraft Both main and reserve parachutes was disabled, the result would be that the student skydiver had no other defences preventing him impacting the ground with the free fall rate of fall which ended up being a fatal fall The SACAA delegated its responsibility to investigate the skydiving accident to PASA. The SACAA skydiving accident report is based on information from PASA accident report findings. 3.2 Probable Cause/s The student skydiver de-arched during the accelerated free fall, resulting in situation whereby some lines entangled around his legs when the parachute deployed The reverse parachute activated but did not deploy due to reserve parachute and reserve deployment bag was entangled with each other. 4. SAFETY RECOMMENDATIONS 4.1 None. 5. APPENDICES 5.1 None. Compiled by: Jeremiah Visser Date:... For: Director of Civil Aviation Investigator-in-charge: Date:.. Co-Investigator:.. Date:. CA 12-12a 25 MAY 2010 Page 15 of 15