AUSTRALIAN PARACHUTE FEDERATION
P.O. BOX 144, DEAKIN WEST ACT 2600
Phone 02 6281 6830, fax 02 6285 3989
Email:
[email protected] - Website:
http://www.apf.asn.au/
INTERIM FATALITY REPORT
Date of Accident: l4 March 2004 Main: PD Sabre l20
Drop Zone: Barwon Heads, Vic Reserve: PD 126R
Sex: Female Harness/Container: Javelin JI
Experience 200 Jumps AAD fitted? Yes - CYPRESS expert
and "C" Licence RSL fitted? No
qualifications: Star Crest Jump Type: 9-way RW
Packer "B"
Age: 24 years; Cause of Death: Injuries sustained from
Time in sport: 2I/2 years impact.
BACKGROUND
The deceased was a current jumper taking part in a 9-way RW jump to celebrate her 200th jump. It was her second jump of the day, the previous descent having been performed with the same equipment and without incident. Information from her log books is that she had not previously experienced a
malfunction or cutaway.
THE JUMP
The jump proceeded normally and the participants commenced to track away at about 4000 ft. There is video footage of the RW phase but it does not keep the deceased in frame after break-off. The video until break-off showed nothing unusual with the jumper or her equipment. She demonstrates adequate freefall skills, height awareness and control throughout.
There was little visual recorded evidence following break-off. Two jumpers reported seeing what they believed to be either a pilot chute in tow, or a bag lock but were unsure of details. Ground based witnesses stated they saw the malfunction develop into some type of main/reserve entanglement that remained until impact. From the reports received investigators believe that the main deployment commenced as normal at about 3000 – 3500 ft.
Impact was feet first at high speed with both the main and reserve canopies out of their respective deployment bags but each incapable of inflating due to the excessive amount of entanglement of the lines and risers. The freebag and reserve bridle were observed to separate from equipment immediately prior to impact and were located approximately 9 metres from the deceased.
The cutaway and reserve handles were found some considerable distance away and downwind form the impact site leading to the conclusion that they had been activated (and dropped) at a normal height.
EQUIPMENT INSPECTION
The value of the evidence presented was greatly enhanced by the rigid adherence to APF scene preservation protocols by those first on the scene. The investigators were able to examine the equipment in the original state and remove the gear to a controlled environment.
Damage to the main pilot chute and the inverted position of the hockey-sack handle strongly indicate that the main, collapsible pilot chute was un-cocked at the time of deployment (see separate paragraph below). In this condition it would create insufficient drag and therefore be consistent with the reports of a pilot-chute in tow followed by bag lock, either of which could be experienced in this circumstance.
The Australian Parachute Federation exists to administer and represent Australian Sport Parachuting. We achieve this by promoting and maintaining a high level of safety and by
improving the standard of Sport Parachuting to encourage participation and experience in performance.
Additionally the kill-line which would normally be used during a pre-jump equipment check to confirm that the packed pilot-chute is cocked, was not the right length to show the tell-tale mark in the window on the bridle. Also, had it been properly cocked the mark was so faded as to be virtually unnoticeable.
The rig was also fitted with non- standard and incompatible risers to attach the main canopy to the harness. These risers were manufactured as Reverse 3-rings (see separate paragraph below).
Blue marks matching the main deployment bag were found on the reverse bridle and the two sets of lines were found irretrievably entangled and twisted.
The rubber bands used on the main deployment bag were mismatched, of varying age and condition, and one at least was an us\n suitable type being very large and strong. This band had been double wrapped around the line stow and, coupled with the low drag effect of the uncocked pilot-chute, was the probable cause of the bag lock. A segment of this rubber band was found still stowed around a line tight but broken away from the bag.
The Cypres automatic activation device (AAD) did fire but the nature of the cut loop, being unusually frayed at the cut, has led the investigators to believe that it was not cut while under tension from the main reserve. (A Javelin container, due to the positioning of the cutter, is one of the few rigs that will still result in a cut loop even after manual reserve deployment has occurred).
COLLAPSIBLE PILOT-CHUTES
Modern parachutes utilize a pilot-chute deployment device that “collapses” as the main parachute leaves its deployment bag and after the pilot-chute has done its job of pulling out the main parachute. This is to reduce the parasitic drag of the pilot-chute while flying under the fully deployed parachute. The collapse is effected by a kill-line running down the centre of the bridle which turns the pilot-chute inside out by pulling down the centre. The pilot-chute must be “cocked” by being pulled out at each repacked. The state of a collapsible pilot-chute cannot be directly checked after the parachute is packed but most rigs incorporate a small window on the pilot-chute bridle which should allow a view of a mark on the kill-line if the pilot-chute is properly cocked ready for the next jump.
REVERSE 3-RING RISERS
On a reverse 3-ring riser, the two rings attached to the riser are closest to the jumper’s body and when packed lie under the riser. In order for the risers to be released, either the pilot-chute or main canopy must exert enough drag to lift the riser rings away from the harness.
On a standard riser the two rings are built on the outside and can disengage more easily than on the reverse design.
The advantage of reverse risers is that hey are generally stronger (for the same sized webbing) since no hole needs to be punched through the riser for the locking loop to pass through to meet the cutaway release cable. The ring release problem is solved by attaching the main harness ring higher on the harness so the riser will come clear of the jumper’s shoulder.
PROBABLE SCENARIO
Following the pilot-chute in-tow/bag lock the deceased probably began normal emergency procedures consisting of pulling the cutaway handle followed by pulling the reserve handle.
Since these handles were found very close together it is reasonable to assume that they were thrown away or dropped from a similar height. Since they were located a considerable distance from the impact site it may also be assumed that they were pulled early (high) in the emergency sequence.
It is believed that the main/reserve entanglement resulted because the main failed to release when the cutaway handle was pulled. In a low drag situation (such as would occur with an uncocked pilot chute) it is reasonable to assume that the incompatible nature of the reserve risers would further contribute to the failure of the system to disengage the main canopy. If the deceased did not wait for main separation (or assist it by releasing the risers by hand) then the action of immediately pulling the reserve would have likely resulted in the entanglement. It would appear unlikely that the deceased delayed the reserve pull or tried manually to release the risers since if either had been attempted the cutaway and the reserve handles would need to be pulled separately and would have probably been found much further apart.
The descent speed was sufficient to trigger the Cyprus Expert AAD (which should have happened about 1000 ft) but the evidence strongly indicates that the reserve had already been deployed manually.
CONCLUSION
The poor packing discipline of using whatever line stow bands came to hand was the first link in this chain of events. Double stowing a very strong rubber band is never recommended and in this case almost certainly caused the bag lock.
The probable failure to cock the pilot-chute appears to be the second link in the chain. This could be caused by either inadequate packing discipline or a distraction while packing.
Since the kill-line mark would not show even under normal circumstances it is unlikely that this important check was part of the deceased’s pre-flight inspection. Failure to utilise this pre-flight check is the third link in the chain.
From here the initial problems were set in place, with the main parachute failing to deploy due to lack of drag from the pilot-chute which was unable to overcome the grip of the strong, double stowed rubber band.
The final equipment failure is the use of the non-standard reverse risers on a rig, which was not designed to use this style of release. Even a momentary hesitation in the release sequence would have been sufficient to entangle the reserve as it deployed.
It would appear that the lack of attention to equipment assembly, maintenance and packing may have all combined to produce this fatality. The fact that the deceased was a qualified Packer “B” entitled to pack main parachutes for students and other jumpers is a concern.
Individually, each link of this fatality chain has been repeatedly reported in published APF incident reports and if occurring in isolation may simply have led the jumper to dismiss the subsequent problem or malfunction as “just one of those things”. This fatality is an example of the classic “chain of events” when one failure leads to another, and so on to the tragic outcome. Perhaps even more tragically, if any one of the links in the chain had not occurred, the outcome may well have been different.
Safety officers should try to reinforce to all jumpers the lessons from this to try to prevent this kind of sequence recurring. This could be illustrated through the use of the “Reason Model” (available as an APF safety poster and from our web site) which illustrates how numerous safety layers concerning training and equipment can be put in place that can break such a chain of events.
Neil R. Cheney IA213,
Deputy ASO Victoria
HERALD SUN 17-3-2004
Natalie Sikora
and Cameron Smith
A MID-air kiss was the final goodbye for Melbourne skydiving couple Clare Barnes and Chris McDougall.
Just seconds later he watched in horror as his girlfriend of two years fell 420m to her death after her parachute malfunctioned over Barwon Heads.
The Kensington couple had just completed a nine-way formation and were free-falling when they exchanged a romantic kiss and flew away from each other to open their chutes.
“They had no idea the kiss would be their last,” Skydive City manager and co-owner Luke McWilliam said yesterday.
Ms Barnes, 24, the daughter of a British politician realised she was in trouble when her parachute malfunctioned and became entangled with her emergency chute.
Her 26-year-old boyfriend, a tandem master and world champion base jumper, could do nothing to help.
Mr McDougall, who works at Geelong-based Skydive City as a contract skydiver has made more than 5000 jumps, was yesterday trying to come to terms with Claire’s death.
“Chris is devastated,” said Mr McWilliam. “He was glad he was there and in particular that he kissed her goodbye, but nobody is happy about what has happened.”
“Some of the nine other jumpers were aware she was in distress and some weren’t, but her boyfriend realised she was in trouble and he landed with her, he was by her side.”
“She fought to free the main parachute from her and unfortunately it didn’t happen in time. She knew what was going to happen.”
Clare Barnes, daughter of Dennis MacShane, a British Foreign Office minister and Carol Barnes, a TV newsreader, met Mr McDougall through the skydiving world two years ago.
She planned to move to Australia to be with him.
Mr McWilliam said the nine-way formation was a special event designed to commemorate the talented skydiver’s 200th jump. He said she had jumped earlier in the day and repacked her own parachute, as do all experienced skydivers.
“She was in her normal happy, joyful mood,” Mr McWilliam said.
“She was probably the least experienced skydiver of the lot.”
An autopsy will be carried out today..
Last night her parents were due to fly to Melbourne with Claire’s brother James, 21, to make arrangements for her funeral.
In a statement issued through the Foreign Office, the family said: “She died as she lived, living at the edge of experience in a sport that gave her immense pleasure.”
A memorial service will be held at the centre, which has been closed as a mark of respect, some-time next week, Mr McWilliam said, The Civil Aviation Safety Authority and the Australian Parachute Federation are investigating the incident.
An Australian Parachute Federation safety officer returned to the scene yesterday where more equipment had been found.
Neil Cheney collected cutaway handles and the reserve ripcord from the Connewarre paddock where Clare landed.
“They will be very significant in the investigation,” he said. He told the Herald Sun the investigation had focused on Clare’s personal equipment because weather conditions were perfect for jumping.
Mr McWilliam yesterday defended his company against any wrongdoing and said it was unfair to blame the operation as being responsible for Claire’s death.
“It’s something beyond our control,” he said.
“We do everything possible to ensure people’s gear is well maintained and inspected before they go skydiving and that was the case here.”
Club Questions, Page 38.
Herald Sun 17/3/2004.
Makes you wonder
pol