GA1383 (Skydiving & Parachuting)

Single Column View
Twists and tangles

Report text: [Parachute was] deployed at 3,000ft, fully open at 2,432ft, line twist so decided kick and pull.

Mistake no.1 – I did not look above line twist. Lines untwisted at 1,410ft and realised slider was snagged high up toward canopy.

Mistake no.2 – should have cutaway. Decided instead to release brakes to see if snag could be resolved, canopy bowed in middle, 1,000ft.

Mistake no.3 – should have cutaway. Instead decided canopy could be flown and landed. Canopy would only turn partially so ended up way off landing zone. Approaching ground only then realised how fast I was descending.

Mistake no. 4 – flared. Canopy did not slow it collapsed, fortunately landed on grass between trees and flat on my back. I think if I had done parachute landing fall broken leg(s) would have ensued.

Overall issue: Observation, altitude decision, slider design.

Main points: Slider strings have end tabs. Cutaway before hard deck

Lessons Learned: Look beyond obvious faults. Do not attempt to fly anything that is not big and rectangular. Decide early, if in any doubt whatsoever cutaway. Awareness, distraction.

This was an honest and insightful report. The reporter has candidly identified the causes of the problem and some nodal points where, in hindsight, different decisions could have been made. This rather fraught experience will almost certainly have permanently altered their skydiving behaviour.

For our skydiving readers, there is a detailed explanation of the equipment factors that led to the incident and additional specialist considerations at https://chirp.co.uk/hot-topic/skydiving-special/. In summary for non-skydiving aviators, one of the drawstring tabs had been able to come free and tangle in a ‘cascade’ (where two lines attached to the parachute are fused into a single line halfway down to the parachutist). This is a known but infrequent cause of malfunctions. While it is disappointing that the reporter has received no direct response to their email to the manufacturer, it is of note that the manufacturer is currently advertising this make of canopy as having ‘continuous Dacron lines’ (i.e. no cascades) and a ‘snag resistant collapsible slider’ so that ‘cascade related malfunctions are impossible’. It appears that the technical issue may have now been addressed.

 

CHIRP has a deal of sympathy for the reporter since jettisoning a main parachute which appears mostly open takes a degree of resolve, particularly if it looks as if it may improve shortly. It is easy to keep on trying to sort it out well past decision altitude, or even to forget about decision altitude, and then find one is also too low to cutaway and there is no easy way out. So, by ‘decision height’, the jumper should be sure that the canopy is large, rectangular and undamaged with lines that are clear, untangled and undamaged and that the canopy is fully controllable with turns in each direction and normal flare response to using the brakes. The controllability check is an essential part of a canopy check, which should follow immediately after ensuring there is no risk of collision with other canopies. If the canopy is flared for the first time at 20 feet above the ground, it is too late to do anything if it stalls or collapses (except for attempting a good landing roll if possible).

The reporter states that when their canopy collapsed near to ground level, they were thrown onto their back. They expressed the view that they may have broken their legs if they had attempted a PLF (parachute landing fall – a technique which spreads the impact across multiple body areas and reduces the risk of injury). The CHIRP skydiving members were of the unanimous view that a PLF remains the best way of reducing the risk of serious injury during a hard landing, even if a lower leg injury may occasionally be the price of avoiding a spinal, chest or head injury.

For a safe jump, the jumper will need to have a clear plan in their head long before walking out to the aircraft. The plan will include choreography of all jumpers to ensure clear airspace in time to deploy at an altitude which gives them an open and controllable canopy at or above their minimum opening height. They must have a clearly defined decision height in their head and be resolute that they will commit to emergency procedures if their canopy and lines do not look normal and behave normally by that height. The jumper must be resolute that any attempt to clear a problem will be interspersed with frequent altitude checks and will not go past decision altitude. Finally, they must have a clear minimum cutaway altitude since low cutaways may be fatal or life altering. Exact decision altitudes and minimum cutaway altitudes are determined by many considerations including exact type of equipment, Automatic Activation Device settings, local geography, jumper experience and currency. Student skydivers under training must do exactly as instructed. Licensed skydivers who are not clear about these altitudes should discuss with an advanced instructor before manifesting for their next jump. Any skydiver will benefit from regularly practising emergency drills in a suspended harness. Many drop zones run a safety day each Spring, providing supervised simple and complex emergency drills for any skydiver who wishes it.

 

Dirty Dozen Human Factors

In addition to the reporter’s own excellent analysis, the following ‘Dirty Dozen’ Human Factors elements were a key part of the CHIRP discussions about this report and are intended to provide food for thought when considering aspects that might be pertinent in similar circumstances.

Knowledge
– Information from manufacturers manual needs to be read and understood.
– Required opening height should be known and its implications understood.

Distraction
– Concentrated on twists rather than looking for problem above twists.
– Focused on task of resolving twists to the detriment of effective cutaway decisions.

Complacency
– Over-assumption of ability or habitual behaviour eg twists have always been resolved in the past

Assertiveness
– Indecisive about committing to a cutaway either above or at safe predetermined height (pressonitis)