Section/division Occurrence Investigation Form Number: CA 12-12a PARACHUTEACCIDENT REPORT AND EXECUTIVE SUMMARY Parachute Registration Reference: CA18/2/3/9036 N/A Date of Accident 28 April 2012 Time of Accident 1150Z Type of Parachute Container ICON Pilot 188 Type of Operation Skydiving Parachutist Licence No &Type Parachutist Experience Last point of departure PASA No: 3268 A Licence Total Number Jumps Age 39 Licence Valid Yes 85 Carletonville Aerodrome; Gauteng Number Jumps Past 12 Months & Last Month Next point of intended Carletonville Aerodrome; Gauteng landing Location of the accident site with reference to easily defined geographical points (GPS readings if possible) Carletonville Aerodrome at GPS coordinates: S26 22.0 E027 20.8 at Elevation 5000 AMSL Meteorological Information Number of people on board Synopsis Fine weather conditions prevailed at the time of the accident 1+0 No. of people injured 31 & 1 respectively 0 No. of people killed 1 On 28 April 2012, at approximately 1150Z, the parachutist who performed his 2 nd jump for the day, exited the aircraft 6000ft AGL. After the parachutist exited the aircraft, the parachute was observed to open normally and inflated fully after a free fall of 15 to 20 seconds. According to a witness, he observed the parachutist overhead the dropzone, heading downwind, but did not make any observed attempt to turn into wind for landing. The accident occurred at Carletonville Aerodrome at a GPS position of S26º 22.0 E027º20.8 at an elevation of 5000ft AMSL at 1150Z in day light conditions. Probable Cause The parachutist was involved in an uncontrolled landing in which he sustained fatal injuries. IARC Date Release Date CA 12-12a 25 MAY 2010 Page 1 of 10
Section/division Occurrence Investigation Form Number: CA 12-12a PARACHUTE ACCIDENT REPORT Name of Owner/Operator :Johannesburg Skydiving Club Manufacturer Model : ContainerICON Pilot 188 Nationality :South African Registration Marks :Nil Place :Carletonville Date :28 April 2012 Time :1150Z :Aerodyne Research Manufacturing Pty (Ltd) 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 12.03.1 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. 1. FACTUAL INFORMATION 1.1 History of Flight 1.1.1 On 28 April 2012 at approximately 1150Z the parachutist was exiting the aircraft forhis 2 nd jump of the day at 6000ft AGLat Carletonville Aerodrome Johannesburg Skydiving Club. 1.1.2 After the parachutist exited the aircraft, the parachute was observed to open normally and inflated fully after a free fall of 15 to 20 seconds. 1.1.3 According to a witness, he observed the parachutist overhead the drop zone, heading downwind, but did not make any observed attempt to turn into wind for landing. 1.1.4 The accident occurred at Carletonville Aerodrome at a GPS position of S26º 22.0 E027º20.8 at an elevation of 5000ft AMSL at 1150Z in day light conditions. 1.1.5 The parachute accident occurred at approximately 1150Z in day time conditions at the Carletonville Aerodrome, at a GPS coordinates ofs26 22.0 E027 20.8 at an elevation of 5000 AMSL. CA 12-12a 25 MAY 2010 Page 2 of 10
1.2 Injuries to Persons Injuries Pilot Crew Pass. Other Fatal 1 - - - Serious - - - - Minor - - - - None - - - - 1.3 Damage to Aircraft 1.3.1 The parachutist exited the aircraft normally with no damage caused to the aircraft. 1.4 Other Damage 1.4.1 Not applicable. 1.5 Personnel Information Nationality South African Gender Male Age 39 Licence Number PASA # 3268 Licence Type A Licence Licence valid Yes Type Endorsed Not applicable Ratings Current Medical Expiry Date Not applicable Restrictions Nil Previous Accidents Nil Parachutist Experience: Total Jumps 86 Total Past 12 Months 31 Total Past 1 Month 1 1.6 Parachute Information: (ICON: Harness Container) 1.6.1 Main Canopy: Type Pilot 188 Serial Number 252285 Manufacturer Aerodyne Research Manufacturing Pty (Ltd) Date of Manufacture April 2008 1.6.2 Reserve Canopy: Type Smart 190 Serial Number 12453 Manufacturer Aerodyne Research Manufacturing Pty (Ltd) Date of Manufacture April 2008 CA 12-12a 25 MAY 2010 Page 3 of 10
1.7 Meteorological Information: 1.7.1 The following weather information was obtained by witnesses at the scene Wind speed / Direction Light/variable Visibility Good Temperature Unknown Cloud cover Nil Cloud base N/A Dew point Unknown 1.7.2 Natural light conditions prevailed at the time and place of the parachute accident at 1150Z.. 1.8 Aids to Navigation 1.8.1 Not applicable. 1.9 Communications. 1.9.1 Not applicable. 1.10 Aerodrome Information 1.10.1 The aircraft took off from Carletonville Aerodrome in order for the parachutists to execute parachute jumps at 6000ft and 11000ft respectively. Aerodrome Location Carletonville Aerodrome Co-ordinates S26 22.0 ; E027 20.8 Aerodrome Elevation 5000 AMSL Runway Designations 13/31 08/26 Runway Dimensions 1100m x 15m 1050m x 13m Runway Used 08 Runway Surface Grass Approach Facilities Nil 1.11 Flight Recorders 1.11.1 Not applicable. 1.12 Wreckage and Impact Information 1.12.1 The parachutist exited the aircraft normally as per the training he received. He activated his main canopy, which was observed to be fully inflated, but failed to steer the canopy into the wind for landing. 1.12.2 The flight path defaulted downwind and no flare was observed during the downwind landing in an open grassy field. CA 12-12a 25 MAY 2010 Page 4 of 10
1.13 Medical and Pathological Information 1.13.1 According to the pathological report the cause of death was as a result of Blunt Force Trauma to the head. 1.13.2 No results of toxicological examinations were available at the time of compiling this report. Should the results, once received, indicate that medical conditions may have affected the performance of the parachutist, this will be considered new evidence and the investigation be re-opened. 1.14 Fire 1.14.1 There was no fire. 1.2 Survival Aspects 1.2.5 The parachutist was located at approximately 2km from the drop zone selected area. Examination of the equipment used by the parachutist revealed that the equipment was in a serviceable condition at the time of the accident. 1.16 Tests and Research 1.16.1 The equipment was removed after the arrival of the paramedics and the South African Police Services. The equipment was not tampered with in any way and was boxed and sealed and sent to an approved parachute inspector. 1.16.2 The equipment was found to be serviceable in all respects 1.17 Organizational and Management Information 1.17.1 Not applicable. 1.18 Additional Information 1.18.1 Not applicable. 1.19 Useful or Effective Investigation Techniques 1.19.1 Not applicable. 2. ANALYSIS 2.1 Investigation of the equipment used by the parachutist revealed that the equipment was serviceable at the time and place of the accident. After the parachutist exited the aircraft, the canopy opened normally and inflated fully as observed by various witnesses. However, the parachutist continued on a defaulted downwind trajectory path and failed to direct the main canopy into the wind and during the landing, no flare was observed by any witnesses. From the above information, it appears that CA 12-12a 25 MAY 2010 Page 5 of 10
the parachutist could have been incapacitated at the time, although the autopsy report does not mention this or any suggestion in this regard. 2.2 The pilot was the holder of a valid A licence with a total of 85 parachute jumps. 2.3 Fine weather conditions prevailed which was subsequently not considered as a factor in this accident. 3. CONCLUSION 3.1 Findings 3.1.1 On 28 April 2012 at approximately 1150Z the parachutist exited the aircraft at 6000ft AGL for his 2 nd jump of the day. 3.1.2 The parachute was observed to open normally and inflated fully. 3.1.3 During the landing the parachutist failed to flare the parachute and was fatally injured. 3.1.4 The Container: ICON Pilot 188, parachute equipment was found serviceable and did not contribute to the cause of the accident. 3.2 Probable Cause/s 3.2.1 The parachutist was involved in an uncontrolled landing which he sustained causing fatal injuries. 4. SAFETY RECOMMENDATIONS 4.1 None. 5. APPENDICES 5.1 PASA report. Compiled by: J.J. du Plessis Date: 28 November 2012 For: Director of Civil Aviation Investigator-in-charge: Date:28 November 2012 Co-Investigator: Mark Bellingan (PASA) Date: 20 November 2012 CA 12-12a 25 MAY 2010 Page 6 of 10
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