Incident Reports

Description:
A student making their third jump had an uneventful freefall and canopy deployment and then piloted the canopy under radio instruction by a coach on the ground. The student was unable to make it back to the landing area and received instruction to land in a clear area. The coach, supervised by an instructor, instructed the student to flare at what appeared to the coach to be an appropriate altitude, although the student was actually 30-40 feet above the ground. The student then disappeared out of sight (the report did not indicate whether it was behind a tree line, terrain, building or other landscape feature), and the coach instructed the student to hold the flare until reaching the ground. The student had a hard landing and suffered multiple breaks to both ankles.

Conclusions:
This student made two previous jumps with safe landings. This situation may have had a better outcome if the coach, rather than guessing at an appropriate flare altitude, let the student determine it.

Description:
A Category H student, who had shown proficiency in canopy control and had not been guided by radio for eight to 10 jumps, flew a preplanned landing pattern to the center of the main landing area. He began the flare a couple of feet late but sped up the rate of the flare stroke to compensate. He lifted his legs to give the canopy more time to arrest the descent rate, which it did, achieving horizontal flight across the ground. The jumper elected to sit down and slide in the landing, but his right foot caught on the grass and folded under, breaking the ankle.

Conclusions:
Tandem instructors are experienced at performing slide-in landings with their students, but solo students should not attempt to land in this manner. A student who is unable to stand up a landing should always perform a PLF.

Description:
An instructor-assisted deployment student made a standard exit from the aircraft at the correct spot and performed a canopy controllability check. The weather conditions were appropriate for a student jump, with winds at about 5-10 knots and occasional light gusts. The student started the landing pattern with what the instructor felt were appropriate downwind and crosswind legs and turn to final approach. An instructor on the ground was in radio contact with the student, but the report did not state his location in relation to the student or what kind of view he had of the landing pattern. It did state that from the instructor’s vantage point, it initially appeared that the student was clear of all obstacles. However, the instructor realized shortly thereafter that the student might be over the hangar and told the student by radio, “If you are over the building, move to the side.” The instructor then told the student, “Standby,” likely in an attempt to tell the student not to flare yet. Immediately afterward, the student hit the hangar rooftop with no flare and fell an unreported distance to the pavement. The instructor immediately called 911, and the emergency medical technicians who responded took the student to a medical facility for examination. The report did not state what injuries the student sustained.

Conclusions:
Although the staff tasked with guiding students in by radio should make every effort to do so effectively, students are ultimately responsible for their landings and should understand this. Radio assistance is precisely that: assistance. Students must learn proper landing procedures and understand how to avoid obstacles independent of radio control. Instructors must run students through various landing scenarios during emergency-procedure reviews to build the students’ confidence in their decision-making skills and abilities under canopy. This student should have gone into half brakes as soon as he realized he was going to land on the building. This may have given him time to perform a flat turn to avoid landing on the building altogether and perform the rest of the flare as he reached the ground. Going into half brakes would also have changed the canopy’s glide path, which could possibly have allowed him to fly over the building to land in the open area on its other side. At the very least, it would have slowed his descent rate and given him more time to decide on an appropriate action.

Description:
During an AFF Category A skydive, a student flared much too high while landing. The staff member who was guiding the student in on radio told the student to hold the flare until reaching the ground. The student, whose legs were moving around prior to landing, held the flare but did not perform a PLF and broke an ankle. The student had surgery to repair the ankle later that week.

Conclusions:
This student would likely have walked away from this landing uninjured if they had repeatedly practiced PLFs and had a higher level of proficiency in performing them.

Description:
Following a student’s uneventful freefall, deployment at 4,300 feet and initial canopy flight during a Category E1 skydive, the instructor, who had already landed, observed the student entering the downwind leg of his landing pattern. The student turned at the appropriate location for his final approach but, at approximately 800 feet, was much higher than planned. The student continued his final approach in level flight, occasionally in half brakes, until he struck a tree at the north end of the landing area while about 30 feet above the ground. The canopy completely collapsed, and the tree did not arrest the student’s descent, so he landed hard. Within 30 seconds, a jumper who was a medical professional attended to the student, who was barely conscious. The student gradually became more aware of his surroundings and did not appear to have any major injuries. An ambulance took him to a local hospital where he was later released, reportedly with only a minor back injury that required a brace.

Conclusions:
This student may have needed more instruction on obstacle landings, since he could have avoided this incident if he had gone into half brakes, performed a flat turn away from the trees, completed his flare just before getting to the ground and performed a PLF. Instructors should have students practice handling landing problems during every emergency review, including a walk-through all the way to a PLF, to increase their chances of successfully navigating these situations.

Description:
This jumper made a hop-and-pop skydive from 5,000 feet for his first jump of an advanced canopy course, a jump intended to show the course instructor how the jumper would normally land. While entering his designated landing pattern, the jumper performed a stall surge (brought the canopy to the brink of a stall and then allowed it to surge forward) just prior to performing a 90-degree front-riser turn to final approach at an altitude described as “appropriate” for a 90-degree turn. After making the turn, the jumper paused—possibly in an attempt to avoid landing near an aircraft taxiing beside the landing area—and then initiated a second 90-degree turn using front-riser and harness input, for a total turn of 180 degrees. He did not have enough altitude to complete the second part of the 180-degree turn and, according to a witness in the landing area, made no input to recover the canopy to straight-and-level flight before he struck the ground with his canopy still at a high angle of attack. The jumper received immediate assistance from those at the drop zone, but he died instantly from blunt-force trauma. Emergency medical responders declared him dead at the scene.

Conclusions:
Local jumpers stated that on many occasions, concerned peers told this jumper that he was being too aggressive with his canopy piloting and downsizing and needed to slow down. Investigators also discovered that although he reported having 350 jumps, his true jump numbers were closer to 275, which included 70 military static-line jumps and 25 military freefall jumps using 360-square-foot canopies. From the evidence, it appears that he had made approximately 180 civilian sport jumps. During the first jump of the course (a skill-assessment jump), the jumper chose to perform a stall surge, an advanced landing maneuver that he learned about at some point prior to the course. In this maneuver, the canopy pilot brings the canopy to the brink of a stall and then allows it to surge forward just prior to performing a high-performance front-riser turn. This jumper did not know (or chose to ignore) the fact that safety dictates performing this maneuver on 270-degree or greater turns for landing, since those turns are performed at a higher altitude and give the canopy a chance to recover if something goes wrong. Depressurizing a canopy close to the ground is hazardous because it becomes susceptible to weather anomalies such as thermals, turbulent air, rotors and other conditions that can make it unstable or even collapse, and altitude loss is unpredictable. The stall-surge maneuver was far outside this jumper’s abilities and knowledge. In order to attend this course, this jumper may have inflated his experience level and the type of experience he had. This incident illustrates the hazards of the Dunning-Kruger effect, which describes the psychological trait where people with below-average skill or knowledge tend to grossly overestimate their own abilities and where those who lack skill fail to recognize it in others. This is essentially the trait skydivers refer to when they use the phrase “200-jump wonder” (or 100-jump wonder or 500-jump wonder, depending on the situation). In this case, the jumper’s mentors and course director were unable to provide him appropriate advice and training because they didn’t have an accurate picture of his skills and experience. Skydiving has developed its standards through research and observation over many years. Jumpers should adhere to those standards to avoid storming headlong toward an incident that will likely end in injury or death.

Description:
After an uneventful freefall and normal breakoff during an 8-way formation skydive, this jumper deployed her main canopy at approximately 3,000 feet AGL. She then experienced two simultaneous malfunctions: line twists and a spinning main canopy that dove toward the ground. The jumper fought for control of the canopy until around 1,200 feet, then began initiating her emergency procedures. She cut away at about 900 feet. She then fought to get into a belly-to-earth orientation before deploying her reserve at about 200 feet. The reserve had just cleared the freebag when the jumper struck the ground.

Conclusions:
This jumper was a current and active skydiver, and she deployed her main canopy at an altitude that would have allowed for a successful reserve deployment had she performed her emergency procedures immediately. It is not known why she stayed with the main parachute until she was at such a low altitude, although she may have become overly focused on attempting to clear the line twists and recovering the canopy to straight-and-level flight. Regardless, it appears she lost altitude awareness. Skydiver’s Information Manual Section 5-1 recommends that jumpers initiate emergency procedures by no lower than 2,500 feet for students and A-license holders and by 1,800 feet for B-, C- and D-license holders. SIM Section 4 recommends that jumpers locate the reserve handle before pulling the cutaway handle and pull the reserve handle immediately after cutting away the main canopy. This jumper’s equipment contained a traditional reserve static line, which—had it been connected—would have pulled the reserve ripcord immediately after release of the main parachute. Reportedly, this jumper usually connected her RSL, and it is unclear why it was not connected for this jump. Although she may have chosen not to connect it, it is likely that it was an oversight that no one caught in a gear check. This jumper had traveled on a commercial airline away from her home DZ for a winter skydiving trip and then made several jumps over a few days. It is possible that she disconnected her RSL to reduce the chance of the RSL lanyard snagging and accidently activating the reserve when passing through security or baggage claim. If this was the case, anybody in the loading area or during the climb to altitude on her multiple jumps could have noticed that the RSL was not connected and prevented this tragedy by bringing it to the jumper’s attention. It is also possible that she chose not to connect her RSL for some reason. However, testing and statistics show that in almost all circumstances—even violent, spinning malfunctions under moderately to highly loaded canopies—jumpers are much better off using an RSL than not. This circumstance—riding a canopy with spinning line twists to a low altitude and then trying to get stable after cutting away before pulling the reserve—is not uncommon. This jumper was likely a victim of cognitive tunneling, caught in the trap of trying to fix a canopy that couldn’t be fixed in the time remaining. Jumpers must initiate emergency procedures at or above the recommended hard deck. In this incident, as well as in many other similar ones, an RSL could have prevented the fatality. This fatality was the result of several errors that combined to create a fatal outcome. Removing any one of the errors may have changed the outcome and prevented the fatality. Jumpers need to say vigilant when handling, donning and using their equipment. In addition, they need to remain altitude aware, deploy at the correct altitude and be ready to initiate emergency procedures while there is still enough altitude remaining to safely deploy a reserve canopy.

Description:
AFF student who is also double-amputee (both legs) had made two prior jumps (ISP Category D2 and E1) that day. Cleared for self-supervision on the third jump of the day, the student exited stable at 13,500 feet. The student was able to perform and recover from a barrel roll and front flip, but when he did a back flip on this jump, he was unable to recover. While stuck in a back-to-earth orientation, the student continued attempts to roll over until approximately 1,200 feet. The student deployed the main canopy concurrently while the AAD activated the reserve. With the two canopies out, it immediately developed into a down-plane to which the student immediately cut-away. Now trailing his main due to a reserve static-line (RSL) entanglement he disconnected his RSL which released his main canopy from the entanglement. The student then landed off-field with no injuries.

Conclusions:
Due to the physical constraints of the student’s amputations and the efforts used in stability recovery, this student was beyond physical limits after completing two prior jumps. While unsuccessful in recovering from a back-to-earth orientation, the student lost altitude awareness. The student remembered 6,000 feet as the last altitude check. The main parachute deployed at 1,600 feet while the student was in a back-to-earth orientation. The student was retrained on altitude awareness and pull priorities. SIM Section 4-A 1. Solo: General Section C.6.c outlines the three pull priorities. Deploying in a stable body position will help to reduce the chances of experiencing a parachute malfunction, but a jumper should never sacrifice altitude for stability.

Description:
This jumper exited fifth for a 10-way formation skydive, which was his third jump of the day. Prior to the jump, he was alert and engaged during the dirt dive and received a gear check from the local Safety and Training Advisor. The other jumpers noted that he appeared stable and in control as the formation built. Although video taken by those on the jump shows that he went approximately 75 feet low of the formation, he appeared in control and as if he were working to rejoin the formation until the jumpers tracked away during breakoff. Experienced skydivers watching from the ground reported that after the other jumpers tracked away, this jumper remained in freefall until his reserve deployed at an altitude between approximately 400 and 700 feet. The reserve achieved line stretch, sniveled momentarily and inflated just as he passed out of the ground witnesses’ sight behind a tree line. A witness under canopy reported seeing this jumper’s reserve deploy and his canopy inflate immediately before he made impact in a small pond. Drop zone staff, led by the Safety and Training Advisor who was in radio communication with the now-circling jump plane, located the jumper and were on the scene 12 minutes later. They found the jumper unresponsive and submerged in two feet of water, 10 feet from shore with his face up and eyes open. After pulling him from the water, they performed CPR until emergency personnel arrived on the scene, which took 20 to 30 minutes due to the area’s remote location and heavily wooded terrain. The emergency personnel continued CPR and transported him to the hospital, where he was pronounced dead later in the day.

Conclusions:
A Federal Aviation Administration Senior Rigger, who inspected the equipment at the scene, and the local authorities found no evidence of an equipment problem. The automatic activation device manufacturer received the AAD for inspection and retrieved its data, which showed that it activated properly at the assigned altitude. The data also showed that there was a brief delay in deceleration right after activation (possibly due to a pilot-chute hesitation) and that the jumper continued decelerating until the reserve opened fully immediately before impact. This corroborates eyewitness testimony. Autopsy results indicate the victim suffered a “significant cardiac event” during the skydive and that this caused the jumper’s death prior to his impact with the pond. Since the jumper was engaged and alert until breakoff and then took no further action, this is likely when he experienced the heart attack. The jumper, who was 57, had no apparent medical issues and had not declared any on his waiver, but conversations between investigators and family members later revealed that heart disease ran in the victim’s family. Skydiver’s Information Manual Section 2-1-C states that all skydivers engaging in skydiving must possess at least a current FAA Third-Class Medical Certificate, carry a certificate of physical fitness for skydiving from a registered physician or agree with this statement: “I represent and warrant that I have no known physical or mental infirmities that would impair my ability to participate in skydiving, or if I do have such infirmities, that they have been or are being successfully treated so that they do not represent any foreseeable risk while skydiving. I also represent and warrant that I am not taking any medications or substances, prescription or otherwise, that would impair my ability to participate in skydiving.” As the jumping population ages, more jumpers are at risk of experiencing medical emergencies during skydives. Most medical experts recommend that men and women over age 40 receive medical checkups at least once a year. Those who have a family history of heart disease or other health issues should consult with a doctor about additional screening. Skydiving places stress on the body and gives jumpers a good reason to stay on top of medical problems.

Description:
After an uneventful freefall and normal main-canopy deployment at approximately 6,000 feet during a tandem skydive, the instructor followed routine tandem procedures, which included performing a check for canopy controllability and adjusting the harness for landing and the comfort of the student. The instructor then briefed the student on how to steer and land the canopy. About two minutes of silence followed. After the silence, the student reported feeling “jostling” behind him and then saw his instructor’s legs coming up in front of him. He reached back and discovered his instructor was no longer with him. The student, realizing he was alone and not flying toward the airport, used the toggles that he still had in his hands from the briefing to turn the canopy to face the airport and line up with the runway. He followed the runway until he landed near the end of it. He landed in a sitting position with his legs up, as he had learned in his ground briefing before the jump, and walked away unassisted. Medical professionals examined him later and reported that he sustained only minor bruising. Several agencies immediately began an exhaustive search for the instructor using aircraft and other techniques. They found him deceased approximately 27 hours later in a heavily wooded area northwest of the intended landing area.

Conclusions:
Multiple organizations—including the state police, the Federal Aviation Administration and the gear manufacturer—conducted an extensive, almost two-month-long investigation into this incident. The FAA and the gear manufacturer performed an inspection of the equipment and found no defects. After interviewing industry experts and concluding that an experienced skydiver would not accidentally loosen a harness enough to slip out, the state police ruled the death a suicide. They did not report whether the instructor left behind a note. Additionally, the coroner sent fluid and tissue samples to a medical lab for toxicology testing, which tested for a variety of substances, including cannabinoids. Unlike a standard urinalysis, which tests for the inactive metabolite THC, post-mortem testing detects the primary psychoactive agents in marijuana—Delta-9 THC and Delta-9 Carboxy THC—and can determine whether a person was actively under the influence of marijuana at the time of death. The report for this jumper indicated that he had sufficient levels of Delta-9 THC and Delta-9 Carboxy THC in his system to be considered under the influence and suggests that he had likely ingested marijuana shortly before the jump. Being under the influence of marijuana may have affected this jumper’s judgment. It is against FAA and USPA regulations to skydive while under the influence of drugs or alcohol. Federal Aviation Regulation Part 105.7 states the following: “No person may conduct a parachute operation, and no pilot in command of an aircraft may allow a person to conduct a parachute operation from that aircraft if that person is or appears to be under the influence of— (a) Alcohol, or (b) Any drug that affects that person’s faculties in any way contrary to safety.” Additionally, tandem instructors must hold an FAA Third-Class Medical Certificate, which requires reporting drug use—legal or illegal—since the last renewal of the medical. Thankfully, positive test results for drug or alcohol use following a skydiving fatality are rare. It goes without saying that jumping while impaired by any drug or alcohol adds risk not only to the impaired jumper but all other jumpers on the load, the pilot and the drop zone owner, as well as people on the ground.