Incident Reports

Description:
An experienced skydiver with 8,000 jumps deployed his cross-braced canopy of an unreported type and size at approximately 3,000 feet after an uneventful sunset 20-way formation skydive. The jumper was using a removable slider and after deployment, he checked it for canopy traffic, detached the slider and stowed it in his jumpsuit. Next, he moved the metal slider rings down the risers and away from the toggles and front-riser dive loops. However, the jumper missed clearing the right rear metal ring and when he released the toggles, the right brake line formed a hitch knot around the ring. The jumper tried to clear the knot for a few seconds, then briefly considered cutting away before realizing that he was already below his hard deck. Because he was unable to flare evenly with one toggle caught up, he attempted a rear-riser landing, which he had successfully performed during five previous jumps that day. Unfortunately, the impeded brake line changed the flight characteristics of the canopy, and the jumper was unable to set up and perform a proper landing. He struck the ground while still recovering from a dive, which caused a compression fracture of the lowest vertebra in his back. He was able to make a full recovery without surgical intervention.

Conclusions:
This seemingly minor problem turned into a major malfunction partially because the jumper was not prepared for the scenario and did not have a planned and practiced set of responses. Jumpers need to be well versed on the possible problems their equipment could cause. When jumpers use specialty equipment, they need to seek out those who are experienced with it to learn about the malfunctions that could occur. They then need to mentally and physically rehearse malfunction scenarios until they are able to perform them properly during an actual emergency.

Description:
A 46-year-old tandem instructor with more than 3,000 jumps, 27 years in the sport and 45 jumps in the previous 30 days exited from a Cessna Caravan for his sixth tandem of the day at the end of a three-day boogie weekend. The student had made several previous tandem jumps with this instructor. The exit weight of the tandem pair was approximately 250 pounds. They were jumping a United Parachute Technologies Sigma tandem system with a UPT VR360 reserve on a clear, 85-degree Fahrenheit day with reportedly light surface winds. The tandem pair made a stable exit into the relative wind, but the instructor forgot to deploy the drogue. Consequently, their freefall speed was fast, but the hand-mounted video camera footage showed that the pair was stable. At approximately 5,000 feet, the instructor attempted to deploy the main canopy, first by using the secondary drogue release, then by using the primary drogue release. These attempts were unsuccessful, since tandem main canopies will not deploy unless the drogue has been released. The pair rolled onto their sides just before the instructor deployed the reserve canopy at approximately 3,000 feet. The reserve canopy opened with approximately five or six line twists and began a cycle of surging and stalling, an intentional design feature (commonly referred to as the “rock and roll opening”) that provides the tandem reserve the descent rate of a round parachute until the brakes are released. This is a safety feature that prevents the tandem pair from traveling far from the opening point if the instructor is incapacitated. The canopy was also turning, and this combined with the stalls made it difficult for the instructor to resolve the line twists. The instructor was able to get out of the twists eventually, but not before the pair was below 1,000 feet. Fortunately, they were able to land safely in a clear, open area, although they were off the drop zone.

Conclusions:
A local instructor examiner reviewed the incident and took the instructor out of rotation until completion of retraining on emergency and standard UPT procedures. Since the instructor was familiar with the student, he may have been complacent and approached this jump as a fun jump, using less caution than he would have on a standard tandem. No matter how experienced the jumper or how routine the jump, we should never lose respect for the dangerous environment we operate in. Jumpers must remind themselves that the next jump is just as dangerous as the last and give their full attention to the details from beginning to end. Research shows that lack of sleep can have as much effect on decision making as drinking alcohol. Although there is no evidence that this instructor was suffering from lack of sleep, the jump took place at the end of a long boogie weekend, and fatigue could possibly have been a contributing factor in the instructor failing to deploy the drogue. Fatigue can have a very tangible effect on performance, and accidents and injuries at drop zones increase when jumpers are fatigued.

Description:
A jumper with 500 total skydives made a 2-way freefly jump from a Cessna 208B Grand Caravan on a clear, 75-degree Fahrenheit day with 3- to 5-mph ground winds. The jumper’s rig was equipped with a changeable-mode AAD that allows the user to adjust the activation parameters. The jumper was flying a Performance Designs Sabre 3 135-square-foot canopy loaded at 1.1:1. The freefall and the main-canopy deployment were uneventful. Once under canopy, the jumper made a series of aggressive but controlled toggle turns that continued until his reserve canopy deployed behind him at approximately 1,000 feet above ground level. When the jumper realized that the reserve had deployed, he discontinued turning, and the canopies settled into a stable biplane configuration with the main parachute as the dominant canopy. The jumper flew a standard pattern using the main canopy’s toggles and made a stand-up landing. The investigating Safety and Training Advisor remarked that the jumper handled the challenging, low-altitude emergency well. After the jumper landed, a Federal Aviation Administration Senior Rigger inspected the gear and determined that the cutter on the jumper’s automatic activation device had fired and severed the reserve closing loop. When interviewed, the jumper remarked that he was not familiar enough with the AAD to know whether he had set it properly for his experience level and canopy-flying style and suggested that he may have inadvertently set the AAD to student mode, which fires at a higher altitude and a slower descent rate than the standard mode. The investigator also interviewed the FAA Senior Rigger who had performed the last reserve repack. The rigger reported that he had inspected the AAD cutter during the repack but had not turned it on or altered its settings.

Conclusions:
This jumper could have prevented this incident if he had read the AAD owner’s manual, understood the firing parameters of each mode and set the AAD properly. Additionally, the skydiver did not receive a gear check at any point before the jump (although donning the equipment hid the AAD screen from view, so a gear check after putting the rig on would not have caught the issue). With the diversity of disciplines today, jumper must thoroughly understand the operating parameters of their automatic activation devices. There are many types of AADs on the market, including changeable-mode AADs, which can toggle between settings for solo students, tandem skydivers, experienced jumpers and high-performance canopy pilots. There are also specific AADs for wingsuit flyers. Jumpers need to refer to their owner’s manuals and learn the speeds and altitudes at which their specific AADs will activate or even disarm. Not having a thorough understanding could cause severe complications.

Description:
On a clear, 75-degree day with 15-mph ground winds, a jumper with 85 total skydives had an uneventful freefall and then deployed his Performance Designs Sabre 2 190-square-foot canopy, which he loaded at 1.2:1. His rig was equipped with an AAD specifically designed for students (non-changeable mode). When the jumper reached the activation altitude of his student AAD, approximately 1,000 feet, jumpers under canopy above him saw him performing spiral turns. His AAD then fired, and his reserve fully deployed. He successfully cut away his main parachute, leaving him under a reserve that was fully open and stable. At approximately 50 feet, the jumper attempted to turn into the wind for landing. He hit the ground with his right toggle pulled down to hip level. Investigators reported that the impact was so hard that the jumper broke both femurs and both feet and "exploded" his lower vertebrae. Previously, the local S&TA had warned this jumper that he shouldn’t jump his current canopy using a student AAD because turning too abruptly at a low altitude would cause the AAD to activate. The jumper ordered an appropriate AAD, which arrived the morning of the incident, but he decided to keep jumping the old one until he could have the new one installed. In addition, the jumper had reportedly received repeated warnings about making low turns, including just a few days before the incident, when he made a low turn to face into the wind for landing. At that time, the S&TA reminded the jumper that a wing must have time to recover to level flight for landing after a turn and that only minor corrections to a flight path are acceptable under 300 feet. The investigator speculated that the jumper may have returned to the habit of turning low after the two-canopies-out situation overwhelmed him. Regardless, if the jumper had been using an AAD appropriate for his type of canopy flight, he would have avoided this situation and had enough time to set up for an appropriate landing.

Conclusions:
With the diversity of disciplines today, jumper must thoroughly understand the operating parameters of their automatic activation devices. There are many types of AADs on the market, including changeable-mode AADs, which can toggle between settings for solo students, tandem skydivers, experienced jumpers and high-performance canopy pilots. There are also specific AADs for wingsuit flyers. Jumpers need to refer to their owner’s manuals and learn the speeds and altitudes at which their specific AADs will activate or even disarm. Not having a thorough understanding could cause severe complications.

Description:
After an uneventful freefall and initial canopy flight, a jumper with approximately 4,500 total skydives performed a 270-degree turn for landing under a Fluid Wings Air Wolf 67-square-foot canopy loaded at 2.65:1. It was reportedly a clear, 75-degree day with no ground winds. As the jumper completed the turn at about 150 feet, the AAD activated, deploying the reserve canopy. The two canopies formed an unstable downplane, and the jumper hit the ground hard while attempting a parachute landing fall. The jumper broke one ankle and shattered the heel on the other foot. This jumper reportedly used a container equipped with a standard, non-changeable-mode AAD but swapped out the main canopies depending on what type of skydive he was making. When he was planning on making a high-performance landing, he would switch off the AAD. In a rush between loads, this jumper forgot to turn off his AAD before this jump. If the jumper had invested in an AAD designed specifically for high-speed landings (one that requires a higher speed to activate and that ceases operation below 330 feet), he could have avoided this outcome.

Conclusions:
With the diversity of disciplines today, jumper must thoroughly understand the operating parameters of their automatic activation devices. There are many types of AADs on the market, including changeable-mode AADs, which can toggle between settings for solo students, tandem skydivers, experienced jumpers and high-performance canopy pilots. There are also specific AADs for wingsuit flyers. Jumpers need to refer to their owner’s manuals and learn the speeds and altitudes at which their specific AADs will activate or even disarm. Not having a thorough understanding could cause severe complications.

Description:
A jumper with 500 total skydives made a 2-way freefly jump from a Cessna 208B Grand Caravan on a clear, 75-degree Fahrenheit day with 3- to 5-mph ground winds. The jumper’s rig was equipped with a changeable-mode AAD that allows the user to adjust the activation parameters. The jumper was flying a Performance Designs Sabre 3 135-square-foot canopy loaded at 1.1:1. The freefall and the main-canopy deployment were uneventful. Once under canopy, the jumper made a series of aggressive but controlled toggle turns that continued until his reserve canopy deployed behind him at approximately 1,000 feet above ground level. When the jumper realized that the reserve had deployed, he discontinued turning, and the canopies settled into a stable biplane configuration with the main parachute as the dominant canopy. The jumper flew a standard pattern using the main canopy’s toggles and made a stand-up landing. The investigating Safety and Training Advisor remarked that the jumper handled the challenging, low-altitude emergency well. After the jumper landed, a Federal Aviation Administration Senior Rigger inspected the gear and determined that the cutter on the jumper’s automatic activation device had fired and severed the reserve closing loop. When interviewed, the jumper remarked that he was not familiar enough with the AAD to know whether he had set it properly for his experience level and canopy-flying style and suggested that he may have inadvertently set the AAD to student mode, which fires at a higher altitude and a slower descent rate than the standard mode. The investigator also interviewed the FAA Senior Rigger who had performed the last reserve repack. The rigger reported that he had inspected the AAD cutter during the repack but had not turned it on or altered its settings.

Conclusions:
This jumper could have prevented this incident if he had read the AAD owner’s manual, understood the firing parameters of each mode and set the AAD properly. Additionally, the skydiver did not receive a gear check at any point before the jump (although donning the equipment hid the AAD screen from view, so a gear check after putting the rig on would not have caught the issue). With the diversity of disciplines today, jumper must thoroughly understand the operating parameters of their automatic activation devices. There are many types of AADs on the market, including changeable-mode AADs, which can toggle between settings for solo students, tandem skydivers, experienced jumpers and high-performance canopy pilots. There are also specific AADs for wingsuit flyers. Jumpers need to refer to their owner’s manuals and learn the speeds and altitudes at which their specific AADs will activate or even disarm. Not having a thorough understanding could cause severe complications.

Description:
This 43-year-old jumper with one year in the sport and 59 total jumps was flying a 190-square-foot Fluid Wings Nexus canopy on a chilly but clear and calm day. To work on accuracy, the jumper chose a windsock as the intended landing target. Unfortunately, the jumper was a little too accurate, and after making a turn to the final leg of the pattern, was on a direct course to hit the windsock. The jumper then initiated a last-minute turn to avoid the collision. In the confusion of the moment, the jumper forgot to flare or perform a parachute landing fall. The hard landing knocked the jumper unconscious.

Conclusions:
There are far better options than picking an obstacle for a target when practicing accuracy. With a one-pound bag of flour, a jumper can draw a circle in a landing area visible from the start the landing pattern, and it will last for weeks. A one-pound bag of time-released fertilizer applied early in the year will also green up a target area, and it can last the entire season. Jumpers can also use a soft and flexible road cone, which they can move around to simulate different scenarios. These options require a little forethought, but all jumps do. A little planning can go a long way!

Description:
This jumper, who had two years in the sport and 390 jumps, exited a Cessna 208 Super Caravan for a 2-way sit-fly jump. Approximately 1,500 feet after exit, the jumper had a premature opening while in a sit. The canopy, a 139-square-foot unreported model made by NZ Aerosports, deployed normally. The jumper sustained no injuries or equipment problems from the early deployment.

Conclusions:
Initially, investigators suspected that a loose bottom-of-container pilot-chute pouch caused the early deployment, but video revealed that the container opened prior to the pilot chute coming loose and that the jumper experienced an out-of-sequence deployment and a brief horseshoe malfunction (where the canopy is attached to the container by two points). Fortunately, the pilot chute eventually came out or the outcome could have been much worse. Investigators could not determine exactly when the pin became dislodged, but they suspect it happened during the exit. The two jumpers exited the aircraft facing one another, and this jumper may have rubbed the container against the door frame. Earlier that day, the jumper had noticed that the closing loop seemed looser than usual but did not make any further inspections or adjustments to it. Jumpers must not be lackadaisical about gear maintenance; their lives literally hang in the balance. If something does not seem right, take the time to investigate and rectify the problem before it results in an injury or worse. Premature deployments can be very serious. They quite regularly cause hard openings, which can result in damage to equipment, injury or even death. They also greatly increase the chance of entanglement. Had these jumpers had a bad exit or simply been in the wrong place at the wrong time, one or both could have become entangled in the trailing equipment. Fortunately, Lady Luck was watching over these jumpers.

Description:
This 47-year-old jumper, who in 28 months accumulated 350 total jumps (200 of which were in the previous year) was performing outside video for a tandem pair. The freefall portion of the skydive and the deployment were uneventful. The jumper then flew his 139-square-foot Precision Aerodynamics Crossfire 3, which he loaded at 1.33:1, toward the landing area. It was a clear day with light 5- to 8-knot winds on the ground. The jumper opened fairly far from the landing are and used rear-riser input to make it back. This jumper barely made it to the landing area but was flying opposite the established landing direction. At that point, the jumper initiated a 180-degree turn at a low altitude. The jumper immediately realized that the turn was too low and attempted to flare. However, it was too late for the canopy to recover, and the jumper struck the ground at a high rate of speed. The jumper sustained a broken femur, broken pelvis, lumbar-transverse-process fracture and a small facial fracture. The jumper was airlifted to the hospital and despite the serious injuries is expected to make a nearly full recovery.

Conclusions:
Although this jumper was active in the sport and had made 200 jumps in the last year, they did not have the time in the sport or the jump numbers to be able to fly a high-performance canopy, and the low-altitude emergency made this clear. The Skydiver’s Information Manual recommends that C-licensed skydivers load their canopies at 1.2:1 or less and that jumpers have a D license before using any canopy 150 square feet or smaller. Jumpers often use their recent jump numbers to justify aggressive canopy choices. How well and accurately a jumper can land their canopy in near-perfect conditions is not a good barometer of canopy skills. A far better metric is how well a jumper can handle bad landing conditions. This jumper likely fixated on landing onto the wind (not a landing priority) and experienced a self-induced low-altitude emergency by choosing to make a last-minute low turn. This jumper would have fared much better landing downwind or performing a slow, flat, 90-degree turn to land perpendicular to the wind line. Experiencing this problem on a larger, more forgiving canopy would have lowered the chance of injury and also provided the experience necessary to safely navigate the same problem after eventually downsizing. Most importantly, jumpers need to recognize early when they may not make it back to a landing area and begin planning for an alternative at an appropriate altitude.

Description:
A 34-year-old jumper with an impressive 227 total jumps in nine months in the sport flew a 190-square-foot canopy of an unknown make and model on a clear, 60-degree day. The report then stated simply, “Hard landing. Didn’t finish flare.”

Conclusions:
Although we appreciate jumpers filing incident reports at all, regrettably, this report did not offer much useful detail. Consequently, we are unable to provide much useful guidance beyond saying that when a flare or landing seems off, jumpers should perform a parachute landing fall. Therefore, we can only speculate. It is hard to believe that a jumper as current as this one would simply forget to flare. Could it be that someone or something caused a distraction? USPA’s Incident Reporting Form (available at uspa.org/ir) now includes a speculation section in addition to the description section, which is just for facts. By including speculation on why or how an incident occurred, USPA may gain an insight that cannot be derived from just the facts alone. When combined with information from other reports, even the smallest details can uncover dilemmas that reveal a larger problem.