Malfunction, Malfunction, Malfunction—The 2017 Fatality Summary

by Paul Sitter

Features
Monday, April 2, 2018

First-jump instructors often tell their students to expect a malfunction on the first jump, the 1,000th jump and every jump in between. Those instructors are right: Failure of the main parachute can happen to the least or the most experienced skydiver at any time. And if the jumpers don’t handle those malfunctions correctly, the results can be fatal.

In 2017, almost half of the 24 jumpers who died in the U.S. faced malfunctions. Unfortunately, the failure to safely land a canopy (a quarter of the mishaps) and other causes remain, but failure to handle a main-canopy malfunction was the biggest killer in 2017. Learning from the circumstances that surround the deaths that occurred in 2017 can help us all have a safer 2018.

Identifying the main cause of a skydiving fatality and placing it into one of six categories—no pull/low pull, malfunctions, freefall collisions, canopy collisions, reserve problems and landings—is challenging. For example, when a person experiences a malfunction, cuts away with plenty of altitude remaining, doesn’t deploy the reserve until very low and then has a pilot-chute hesitation, the resulting fatality has many causes. In a case like this, we try to determine the main or root cause and place the fatality in that category.

In this article, in parenthesis after each category title is the number of deaths and the overall percentage of deaths that number represents. Fatalities that don’t fit into one the six categories fall into a seventh category, “other.”

No Pull/Low Pull (1—4%)

Years ago, failure to deploy a parachute or deploy it on time comprised a staggering portion of annual fatalities (e.g., 40 percent from 1983 through 1987). Now, with all students and most experienced skydivers using automatic activation devices, the advent of more thorough training programs and the increasing dependability of parachute systems, there are far fewer deaths in this category than there used to be. In 2017, one skydiver’s death fell in this category.

Investigators found this jumper deceased near the airport with neither parachute deployed following an uneventful 8-way tracking dive and a normal breakoff. It appeared that his reserve container opened on impact and that he landed while still tracking. He did not have an automatic activation device installed on his equipment.

What could have prevented this death?

Investigators suspect that this was actually a suicide, but due to a lack of definitive evidence, this fatality remains categorized as a no-pull. Investigators found no obvious equipment problem and none of the other jumpers on the skydive reported any issues during the jump. We simply don’t know why the jumper didn’t deploy his parachute.

Because most jumpers now use automatic activation devices, many no- or low-pull cases that once would have been fatal, and therefore remained unexplained, now have survivors who can tell us what happened. Common causes are loss of altitude awareness because of distraction or lack of ground references, difficulty finding deployment handles and physical problems (for examples, see cypres.aero/category/saves/). The bottom line is that at 2,500 feet, a jumper without an open parachute is about 13 seconds from the ground.

Here are some of the things that can prevent no- and low-pull fatalities:

• Automatic activation devices are a proven defense against this type of accident. Therefore, they are a basic piece of skydiving safety equipment. Of course, in order for an AAD to save your life, you must use it … skydivers have died from not opening their parachutes while wearing AADs that were turned off. Because AADs are deliberately unobtrusive, it’s easy to overlook arming them before jumping. Checking that the AAD is armed and calibrated should be part of your equipment checks.
• Be completely familiar with your equipment. Periodically (not just on Safety Day) practice all procedures—including main deployment, cutaway and reserve pull—in a training harness. An ideal time to practice your emergency procedures, including a reserve-ripcord pull, is when your reserve is due for a repack. The more frequently you practice your emergency procedures, the less likely you are to react improperly when faced with an emergency on a jump.
• Do a thorough equipment check on yourself and also ask for an equipment check from someone else before your jump. Equipment checks are covered in detail in Skydiver’s Information Manual Section 4, category D.
• Tandem instructors must perform in-air practice touches of their deployment handles, and students do so as part of their training. However, this is also a good habit for any jumper to get into and is especially important when using unfamiliar equipment.

Malfunction (11—46%)

The no-pull category and this one, malfunctions, both deal with failure to get a good parachute overhead on time. In 2017, these two categories comprised half of the total fatalities. Well-practiced emergency procedures and rapid, accurate decision making are the key to avoiding these hazards.

The last USPA member survey results indicate that one malfunction occurs approximately every 614 jumps (uspa.org/find/faqs/demographics). However, from a practical standpoint, all skydivers—including students—must be prepared for a malfunction on every jump. In 2017, the largest number of fatalities occurred in the malfunctions category.

Four people died in two incidents while tandem parachuting.

• In one, a tandem instructor and student were under a main canopy that initially flew normally but then began to spiral until impact with the ground. It appears that when the instructor attempted to release the steering toggles, one failed to release, causing the turn.
• In the second incident, the instructor deployed the drogue parachute during an unstable and tumbling exit, and the drogue entangled with the student’s leg. While extending an arm to capture the exit on a hand-mounted video camera, the instructor did not throw the drogue with a stable body position or face directly into the relative wind. The instructor deployed the reserve at about 2,500 feet, but it entangled with the drogue and did not clear in the remaining altitude.

In separate incidents, three jumpers—two wearing wingsuits—experienced malfunctioned main parachutes and cut away too low. One of the jumpers apparently had a hard opening, which may have slowed his reaction time and delayed reserve deployment. One of the other jumpers was equipped with a reserve static line, which would have immediately activated the reserve, but it was not hooked up.

• A student had a problem deploying his main parachute. His AAD deployed his reserve, but at about 200 feet his main parachute also inflated and formed a downplane with the reserve. He released his main but was too low for the reserve to move back above his head and slow his descent rate before he reached the ground.
• A jumper wearing a wingsuit and a BASE rig (designed for jumps off of fixed objects) with no reserve exited a balloon at approximately 6,000 feet and deployed his parachute at approximately 1,000 feet. He experienced an opening so hard that it caused the left riser to fail. The slider then acted as a cross-connector between the left and right risers, which kept the parachute inflated, although it was spinning rapidly. Without a reserve parachute or an intact riser, the jumper was out of options as the canopy spun into the ground. Although the low-altitude deployment seemed intended to emulate BASE, it was officially a skydive because it occurred from an aircraft (in this case, a balloon) and violated Federal Aviation Regulations, which require the use of a single-harness, dual-parachute system for an intentional (non-emergency) exit from an aircraft in flight.
• Two deaths occurred in separate incidents when the skydivers experienced spinning main parachutes and apparently did nothing to correct the problem. At least one of them had an opening hard enough to cause disorientation or loss of consciousness. 

In addition to the tips mentioned in the no-pull category, how could these deaths have been prevented?

Practice and commit to emergency procedures. We are evolutionally programmed to respond to a high-stress situation in one of three ways: fight, flee or freeze. Freeze is not an option in skydiving. Things go wrong and when they do, immediate action is required. Continual emergency practice is a way of establishing immediate, appropriate responses.

Tandem instructors have a special responsibility for the safety of their students. Additionally, two lives are at risk. Instructors must practice both normal and emergency procedures to a far higher degree of proficiency than an average skydiver.

Tandem manufacturer instructions for an entangled drogue call for immediate use of the reserve parachute.

Despite its reliability, do not depend on an AAD to deploy the reserve after releasing the main canopy. After a main parachute opens and slows a jumper’s fall rate, the device disarms itself. After a cutaway, the jumper has to accelerate back to near-freefall speeds before the AAD re-arms. This is something available altitude might not allow.

A high-performance canopy in a spin can lose altitude nearly as quickly as a person in freefall. Additionally, a spinning parachute can increase its spin rate—and consequently, its rate of descent—with each revolution. A spinning parachute is also disorienting, and the longer the spin, the more disorienting. Well-rehearsed emergency procedures are the best way of preventing this type of accident.

An inexpensive and relatively dependable backup to emergency procedures is a reserve static line. An RSL immediately begins opening the reserve container when a jumper releases the main parachute, regardless of altitude or descent rate. One type of RSL—the MARD (main-assisted-reserve-deployment) device—deploys the reserve even more quickly than a standard RSL.

Canopy Collisions (2—8%)

While there have always been canopy collisions, the forward speed possible with today’s canopies increases the chances that a collision will be fatal. However, both canopy collisions in 2017 were due to inadequate separation in freefall before deployment of the main canopy.

• After an 8-way formation skydive, two jumpers deployed near each other. They collided body to body and the canopies entangled. One jumper was able to cut away and sustained injuries while landing his reserve. The other jumper was either killed during the collision or knocked unconscious and killed by the landing under the entangled main canopies.
• A skydiver went low on a planned 5-way formation skydive. At breakoff altitude, he apparently tracked toward the formation instead of away from it and opened below another skydiver. The high jumper struck the lower jumper’s inflating canopy but wasn’t seriously injured. The lower jumper appeared to be initially unconscious but activated his reserve at about 500 feet while descending rapidly under his damaged main canopy. The reserve did not inflate before he landed on the asphalt parking ramp.

How could these fatalities have been prevented?

Even though a canopy opens in brakes, it still has forward speed. It is a jumper’s responsibility to ensure safe separation from other jumpers both before and after opening a parachute. SIM Section 5-1.H and “Foundations of Flight—Heading Control Using Rear Risers During Deployment” in the February 2018 issue of Parachutist have specific suggestions to avoid opening collisions.

Jumpers who end up low on a formation must remain aware of the location of the other jumpers while working to get back on level. When it is time to break off from the formation, the low jumper must still track way from the other jumpers to gain as much horizontal separation as possible before deployment.

High jumpers should avoid airspace above lower jumpers and be alert for pull indications (wave off) by anyone below their altitude.

Freefall Collisions (1—4%)

Freefall collisions occur frequently. Thankfully, most of the time the closing speeds are low and the result is minor tumbling and no injuries. But when closing speeds are high, severe injuries or fatalities can occur.

• Two wingsuit flyers were flying in formation. While transitioning to a face-to-face orientation, one jumper struck the other’s leg. While the jumper who was struck received only minor injuries, the other jumper died in the hospital from injuries sustained either during the collision or while landing under his AAD-activated reserve.

What can this fatality teach us?

Wingsuits are becoming more popular, but they do carry additional risk. Typical forward speeds are 40 to 90 mph, which increases the force of any impact. In addition, because the wingsuit restricts the jumper’s arms, head injuries are more likely because the jumper cannot use the arms as protection.

Emergency procedures under canopy become more complicated when wearing a wingsuit. Five of the jumpers who died in 2017 were wearing wingsuits. The SIM has specific requirements and recommendations for wingsuit flying in Section 6-9.

Reserve Problem (1—4%)

Reserve systems—which include the reserve container, pilot chute, bridle, freebag and canopy—are extremely reliable, but there are no guarantees in skydiving. Looking at the last 10 years, reserves failed to save jumpers in about 6 percent of the fatalities. This year unfortunately provided an example:

• A video flyer experienced a hard opening followed by a spinning main parachute. His cutaway was at an altitude that should have allowed a normal reserve deployment. However, he was spinning on his back when he pulled his reserve ripcord, and the reserve bridle caught behind him, possibly on some part of his camera helmet. He attempted to clear the reserve bridle for the remainder of the jump.

How could this death have been avoided?

With adequate altitude, a freebag-equipped ram-air reserve is designed to function even if the bridle is captured, but it is certainly not the best-case scenario. It is critical that a skydiver not have any snag hazards on his equipment.

Camera equipment, especially helmet-mounted equipment, is the most common snag hazard for a deploying reserve. The reserve container is very close to the skydiver’s head, so a deploying pilot chute, bridle and freebag pass very close to the helmet. If you jump a camera, make the camera and mount as snag free as possible. Eliminate corners and shelves and use a camera body that minimizes snag points.

Because video cameras are now small, relatively inexpensive and easy to install, they have become much more commonly used among skydivers of all experience levels. Flying with a camera requires a higher level of planning, caution and awareness on any skydive, and the camera flyer must be aware of potential issues or malfunctions. Issues involving a video camera contributed to two of the skydiving fatalities in 2017. Those planning on flying cameras should be familiar with the recommendations in SIM Section 6-8 and should discuss gear options, camera technique and camera safety with an experienced camera flyer.

For decades, videographers have argued that they should not use reserve static lines in conjunction with camera helmets due to the risk of entanglement. However, there is no real-world data to support this claim. Use of an RSL, or better yet, a main-assisted-reserve-deployment device (a type of RSL) can help ensure the reserve deploys immediately following the release of the main canopy. These devices have proven to work correctly even during violent spinning malfunctions when a jumper was falling back to earth.

Landing Problems (6—25%)

Prior to 1993, a fatality while landing occurred about once every other year (generally a skydiver who didn’t see power lines or landed in water). Since then, and concurrent with the introduction of high-performance canopies, about one third of skydiving deaths (and many injuries) occur because skydivers fail to safely land their main canopies. In 2017, the six canopy pilots who died while landing represented a quarter of the total fatalities.

• Two jumpers died while attempting high-performance landings. Even at light to moderate wing loadings, increasing the forward speed and descent rate close to the ground greatly increases the chances of an injury or fatality.
• Two jumpers died while making low turns in attempts to face into the wind for landing.
• A jumper who was landing in heavy canopy traffic made an abrupt 90-degree turn just before landing. Investigators could not determine whether wake turbulence from another canopy or a dropped toggle caused the turn.
• One death—of a student with 18 jumps—was due to an unintentional water landing. The student’s canopy opened in a turn after deployment at about 4,000 feet. He released the canopy at about 800 feet, and his reserve ride was brief. He made only one turn under his reserve and landed in a pond. He drowned when he was unable to remove his new full-face helmet, which quickly filled with water when he went below the surface of the water.

What can we learn from these deaths?

Select the right equipment. High-performance, leading-edge canopies are impressive, but they are not for everyone. Do you really want to give up the ability to sink a canopy into a tight landing area in order to get great forward speed for an impressive landing? You are the consumer. Make sure you get a product that will serve you well across the full spectrum of the type of jumping you are likely to do.

Understand the performance characteristics of the canopy. Try turns and landing procedures while still far above the ground to learn the canopy’s performance.

If it appears that it will be difficult to make it back to the drop zone, identify alternatives early. When in doubt, take the alternative. It is much better to land in the middle of a wide-open field than to find yourself just a little too low to make it over trees or other obstacles.

Use caution when you downsize. Understand that your new canopy will likely have a higher turn rate and different flare and recovery characteristics. SIM Section 6-10 includes recommendations on moving to higher-performance canopies.

Full-face helmets are popular among experienced skydivers. For a student who is working on the basics, the complexity of trying to remove a helmet quickly is challenging. Skydiver’s Information Manual Section 5-1 recommends removing a full-face helmet after entering the water.

Other (2—8%)

These are deaths that don’t fit into the established categories. This year, there were two:

• After drogue deployment, a tandem instructor suffered a fatal heart attack. When he didn’t deploy his main, the automatic activation device opened the reserve parachute. The student suffered a minor injury on landing.
• A jumper did not attempt to deploy either parachute. According to media reports, he left a video indicating his intent to die.

How could these fatalities have been prevented?

The aging of Baby Boomers is reflected in the increasing average age of skydivers. With increasing age comes all the health problems associated with a graying population. Pilots and tandem instructors must have periodic physical examinations, and it’s a good idea for any skydiver, as well.

Skydivers tend to be an independent group, but if someone seems emotionally off, it doesn’t hurt to check in to see how they are doing. If someone is having problems, a parachute jump is not the best place to be.

General Comments

Beginners. The sport has made real improvements for the safety of beginning skydivers, but we can do better. During 2017, 17 percent of those who died (four jumpers) were student skydivers with fewer than 25 jumps. Sadly, that included two tandem students who were making their first jumps. Student equipment is very dependable and USPA’s Integrated Student Program is comprehensive and has a solid safety record. The more proficient an instructor is, the safer the student jump is. The need for tandem instructor proficiency is starkly obvious.

Experienced skydivers. About one-third of USPA members have more than 1,000 jumps. Experience should be a real advantage in facing the challenges of skydiving, but overconfidence and complacency are killers. The average number of jumps for the people who died in 2017 was 1,953.

Equipment. The equipment a skydiver chooses to use plays a large part in safety. Here are some recommendations:

• Helmet—At least two of the jumpers who died on landing were not wearing a helmet. A traumatic brain injury is likely to be debilitating or fatal. A hard helmet adds an extra measure of safety on landing, as well as throughout the jump.
• Automatic activation device—There hasn’t been a strong argument against using these lifesaving devices in decades … except the financial one. But what’s your life worth? While nothing is foolproof, these devices are close.
• Reserve static line/main-assisted-reserve-deployment device—RSLs and MARDs (a type of RSL) are simple, inexpensive backup safety devices. After jettisoning a main canopy, seconds count. Every year, including this one, fatalities occur when jumpers cut away and either don’t deploy a reserve or deploy it too low. While there are times when you wouldn’t want an immediate reserve deployment (e.g., during a canopy formation skydive), they are few and far between.
• Altitude awareness—Jumpers need to stay altitude aware on every skydive, and their awareness should be heightened when vertical speeds are higher than usual or when learning a new discipline. Modern altimeters are very precise and accurate, but wearing a secondary altimeter (either visual or audible) can help in cases of equipment failure or malfunction. It is also a good idea to get familiar with how the ground and horizon look at various altitudes to build sight pictures for your altitude awareness. Altitude awareness is essential for executing properly timed normal and emergency procedures.
• Canopy—Canopy selection is one of the most critical gear decisions you can make. Ask yourself whether you are using a canopy that you can land safely on your worst day.
• Reserve size—Along with downsizing main canopies, jumpers are also downsizing their reserves, with pack volume being the main factor. Reserves have maximum weight limitations, and it’s not a good idea for jumpers to ignore them. The reserve parachute is your last chance. Do you really want to run the risk of overstressing and damaging it during opening? Additionally, you’ll use your reserve in extreme situations. Do you want to land under a heavily loaded reserve while injured or even unconscious?

Hard openings. While hard openings have been around as long as parachutes, zero-porosity canopies and no-stretch lines add to their severity. Hard openings can and have resulted in unconsciousness, serious injury and even death. Pack carefully. If someone else is packing for you, make sure it is someone you trust. Reported or suspected hard openings were a factor in at least four of this year’s fatalities.

Accident reporting. It is hard to avoid skydiving hazards if we don’t know what they are. A skydiving mishap can have tragic results. Sharing the circumstances that led to a mishap with the skydiving community can help prevent an accident in the future. Safety and Training Advisors, drop zone operators and everyday skydivers can and should share what they know about accidents. USPA has a reporting system in place to share information on accidents without compromising or embarrassing a specific jump operation or jumper. It is a shame not to use it.

Conclusion

Skydiving today has the potential to be safer than ever. The gear is solid, we’ve got generally great jump aircraft and pilots, excellent training is available for instructors and students, and people in the sport care about their brothers and sisters in the sky. During the last 10 years, two years had fewer than 20 fatalities. The average has been just over 22. Contrast that with the 1970s, when the sport averaged more than 40 deaths a year with far fewer people skydiving.

However, no one can legislate fatalities out of skydiving. USPA, the industry, drop zone operators and instructors can do everything possible to keep the sport safe, but in the end it is up to each skydiver to use the tools available to minimize risk for themselves and for the people who jump with them.