Chain of events: This detailed report shows how the chain of events works. By removing only one link from the chain; this accident could have been prevented.
It's been well proven that all accidents are due to a chain of events. The RAF have known of this phraseology for many years and have used it to demonstrate many times how something could have been done, that would have prevented an aircraft accident from occurring.
Skydiving accidents are no different; if you're aware of the chain of events and how important it is for an accident to occur, then it's easy to remove just one of the links in the chain to prevent an accident before it has a chance to take place.This report is about a young skydiver who spent almost two years in hospital recovering from a preventable skydiving accident. I have chosen this particular incident because I had the opportunity to investigate it by talking to the skydiver himself and some of those associated with this accident.
There are nine links in this chain of events as follows:
Every two years the Parachute Industry Association (PIA) organise a parachute symposium which is attended by thousands of skydivers from around the world. Ironically, those who attend do so to learn about the latest trends, training methods, equipment and safety systems to prevent accidents from occurring. Participants attend lectures by industry professionals on every aspect of the skydiving industry.
The young skydiver was attending the symposium because he was training to become a parachute rigger and he wanted to participate in the PIA riggers education programmer and talk to all the manufacturers about their equipment.
He left the UK and traveled to the USA purely to attend the symposium. Because he was not planning to skydive he never took his equipment with him or made any arrangements that would normally be made when planning a skydiving holiday. During the symposium he met a skydiver who told him that they've arranged a parachute jump just down the road from the symposium at an airport where you can book a helicopter to take a flight around the city. They told him that there's a place available if he wants to join them.
The helicopter jump was organised by a very well known and experienced skydiver, who failed to mention that it wasn't being organised legally. The young skydiver wasn't aware of this and he was relying on the organisers reputation and experience. He admired this "skygod" and was thrilled that he had been invited to this event. Some skydivers will not condemn the organiser in fear of being hypocritical. After all, skydiving is about having the freedom to take risks and enjoy the thrill of the challenge they face.The fact is; the rules and regulations were not made to stop the fun, they were made to stop accidents like this from happening.
The least the organiser should have done is to make sure that everyone was aware of the risks and that everyone taking part was qualified and experienced for the planned jump. For an experienced skydiver, with many thousands of jumps, to organise an illegal parachute jump and then invite a young inexperienced skydiver to join them without knowing anything about him, or even asking him any questions, does not make sense to me. If the organiser had any sense he would have and should have stopped this young skydiver from joining him. He could have removed this link from the chain. Ironically, if the organiser had been at his home drop zone he would have done his job as a professional organiser and checked the documentation, training and experience of all participants. Unfortunately, because this was not a legally organised skydive he did not feel responsible and he can't be held accountable for the young skydiver who willingly took part in the skydive.
A pilot is ultimately responsible for the actions of his aircraft and those within it. He's governed by the civil aviation authority (CAA) or the foreign equivalent. In this incident, the pilot was flying under the authority of the federal aviation authority (FAA) who recognise him as the pilot in command. As a pilot in command he is aware that he has a responsibility to prove that his aircraft has been cleared to drop skydivers. He also knows that a skydive must be approved by the FAA before the event and he has to have written approval in place at least twenty four hours before the planned jump.The pilot agreed to take a group of skydivers and let them jump out, over the city, knowing it was illegal. If the pilot had stayed within the law this link in the chain would've been removed and the accident would not have happened. Incidentally, the pilot is the only person who's been held accountable and lost his pilots licence and his job. He regrets his decision, big time, and his defense was that he believed that all the skydivers were the best of the best, and that the risk of anything going wrong was very remote so he was happy to do someone a favour.
I class this skydiver as inexperienced because he was clearly out of his depth and had almost no chance of survival. You could argue that he was experienced because he was not classed as a student skydiver by the BPA and he, himself, believed that he was an experienced skydiver because that was his official classification and because he had almost two hundred jumps. He was very excited at the prospect of jumping out of a helicopter because he had never done that before, therefore, he decided not to mention his experience to anyone in case he lost this opportunity. If he had been honest with them, he may have lost his slot or they would have given him the right type of equipment suitable for his experience level and some advise to keep him safe. He was also sucked in by peer pressure because at one point he hesitated and started to decline the offer until the group encouraged him and offered to lend him some equipment.
This accident could have been prevented if only he had let the organiser know about his experience level. He knew that he should not be on this skydive and he knew that he was out of his depth but the closer it came to the jump the more he felt he was committed and couldn't back out. If he had followed his own instincts then this link of the chain would have been removed and the accident would not have happened. He didn't ask any questions even though he wanted to in fear of anyone finding out that he was not qualified for this jump and he really wanted to jump a helicopter.
The young skydiver initially told the organiser he can't join them because he doesn't have his documentation with him. The organiser replied by saying "don't worry, no one's checking docs" This question alone should have been an indicator to the organise that this was not an experienced skydiver and the reply should have been an indicator to the young skydiver that something is not right. No one is allowed to jump without the correct documentation so this should have been enough to remove this link from the chain and prevent this accident from happening.
The young skydiver flew to the USA with travel insurance but it did not cover him for skydiving as he never intended on jumping. During a legal skydive all jumpers are covered for third party insurance through their parachute association and most skydivers, the sensible ones, take out hospital and repatriation insurance when traveling abroad. Knowing he wasn't insured should have stopped him agreeing to the skydive as he had taken out the hospital and repatriation insurance on previous occasions. Saying no because he had no insurance would have removed this link from the chain and the accident would not have happened. The USA hospital bill exceeded a million dollars, which of course he could not pay. The hospital did an amazing job of keeping him alive but his treatment was limited to survival only. He had to stay in hospital for a long time before he could fly home in a normal cheap seat aircraft and he had to buy three seats because he could not sit down. Before he left the hospital he had to sign a monthly payment plan to pay for his treatment and when he arrived back in the UK he spent over a year in hospital before he could leave due to his injuries and the amount of treatment he needed. Knowing he wasn't insured should have removed this link in the chain.
When the young skydiver said he couldn't jump because he hadn't brought his equipment with him. The organiser offered to lend him one and gave him a Stiletto 135. This is another issue that I can't get my head around; to lend someone you don't know a high performance canopy without asking him if he's experienced or qualified to jump it, is beyond ridiculous. The manufacturer at that time recommended a minimum of a thousand jumps before jumping a stilletto. They also required their dealers to get a signed document from their customer to state that they are qualified and know the risks of jumping a high performance canopy. The organiser was not only aware of this, he was a dealer and on many occasions he had to get a signed document. If he had followed the manufacturers guidelines in this instance then this link in the chain would have been removed and the accident would not have happened. Basic common sense should also have removed this link in the chain.
The young skydiver had never jumped anything smaller than a two hundred square foot docile student canopy. He knew what a Stiletto was and he knew what size it was as all his instructors had one. He had seen first hand how fast and radical they could be. He accepted the equipment believing that it will be ok if he's careful and flies it slowly. He admitted that it was stupid to accept it but the opportunity to jump a helicopter and the feeling of belonging to such a highly respected group of skydivers got the better of him. When down sizing to a smaller or a different type of canopy design it's extremely important to do it under guidance, with the right advise and training area. If this jumper had stood by his own "common sense" instead of letting his ego and this opportunity get the better of him this link in the chain would have been removed and the accident would not have happened.
The young skydiver had never had a brief on helicopter jumping and to complicate things even further; the exit height was only two thousand feet, which is ten thousand feet lower than he was used to. He exited the helicopter and did a long delay because he wanted to make sure that he got clear of the downdraft from the helicopter blades, before he deployed. Believing in this myth, wherever it came from, compounded his problems by giving him a low opening. What made it even worse was that his canopy which was well known to open slowly, did exactly that; it opened slowly and by the time he was under a fully deployed canopy, it was time to set up for landing.
The young skydiver said "when I took my brakes off I turned to a field that was the other side of the motorway but the parachute dived downwards and I lost control" he hit the ground at the same time as the canopy and woke up in hospital. If he had been briefed on jumping from a helicopter or even been briefed about the aircraft or even his canopy deployment characteristics, then this link of the chain may have been removed which could have improved his odds of preventing this accident.
The jumper was not qualified to do a demo jump or been trained on demo jumping and had only ever jumped at parachute centre's with very large landing areas. When he was at two thousand feet the organiser pointed out the landing area which was a small field in a very busy city area with a major motorway next to it. When his canopy opened he was above a safe landing area and all he had to do, according to the other skydivers, was to flare his canopy and land. However, he had been briefed to land on the other side of the motorway and he wanted to get their. He stated that he though that was important and he had to react quickly as he was very low. He was not aware that one turn on the Stiletto could lose him so much height so quickly.
Jumping at a place other than a parachute centre takes a great deal of training and this type of jumping is very different to normal skydiving. The young skydiver knew he was not qualified to jump outside of a parachute centre yet he still agreed to jump. He said he was very scared prior to the exit because of the city below him and didn't want to jump but felt like he had to. If he had followed his gut feelings this link in the chain would have been removed and this accident would not have happened. What is more unbelievable though is that all the other skydivers were very experienced skydivers with lots of experience in jumping outside of a parachute centre environment, yet not one of them asked if he had ever done a demo before.
It's easy to criticise the young skydiver and criticise the organiser as well as the other jumpers, and they do have a lot to answer for, however, the issues mentioned in this incident are all very common. Human nature, peer pressure, new challenges and lack of knowledge play a big part in every incident and the chain of events is without doubt, the solution to reduce skydiving incidents. The procedures in place are already well tested and do reduce the amount of accidents. It's important that every accident gets investigated with the frame of mind "how can we prevent this from happening again". The biggest issue as far as I am concerned is educating all skydivers of all experiences and qualifications to share the load. This can only work if all skydivers learn about previous accidents, how they happened and what can be done to make sure they don't make the same mistakes. The more links that we can put in place to prevent accidents the better but this only works if the systems are well known and skydivers believe in them and follow them.We need to continue to educate each other by discussing what's happened and how we, as individuals, can help to stop it happening again. If everyone takes a small role then the load is shared and well known problems will be recognised and incidents will not happen. Stay alert, ask questions,don't be afraid to say you don't know or you're not sure about something. Don't rush into anything, learn one skill at a time and follow your instincts. Almost every skydiving accident has happened before to many people and those people learnt from that incident and never made the same mistake so why can't we learn from the mistakes that others make. Above all try not to judge them but instead try and work out what can be done that could have prevented their accident. Judging people and blaming them for their own stupidity puts you in a greater risk bracket because you will believe that it wouldn't have happened to you. Until something similar does.