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Diary of Events
Parachute Equipment

Confidential & Incident Report History

By Allan Hewitt

When I became a rigger examiner and chairman of the riggers committee I decided to do whatever I could to stop all the repetitive mistakes that were being made by reserve packers and riggers. However, it soon started to include instructors and then it grew to include all incidents that would help to educate skydivers and stop repetitive incidents from occurring

My involvement in starting the confidential system goes back to my experiences when I was a young skydiver. The first time I realised there was a problem was when I gave my reserve to my instructor for a reserve repack. Twenty minutes later he gave it back fully repacked, and I walked away thinking to myself that I pack my main better than he just packed my reserve. A few months later I watched a rigger pack a reserve and he took approx two hours while he inspected it, did some minor repairs and did a very impressive reserve repack. This was when I realised that there were very different standards when it comes to reserve packing. I then decided to became a reserve packer so I could do my own reserve.

By the time I became a rigger examiner I realised that the reason for so many equipment incidents was due to lack of education. Some riggers knew very little about rigging but they qualified because they had good sewing machine skills and other practical skills. I was fortunate enough to be able to travel around the world and learn direct from the manufacturers as well as senior riggers who loved to pass on their knowledge.

My first attempt to try and eradicate all the repetitive mistakes was to re-write the training syllabus for reserve packing and rigging to include a great deal of theory that was not previously taught. I then made sure reserve packers and riggers had the tools to do their job better. The BPA adopted my training syllabus's, my reserve packing manual, my safety notice index and other proposals and I was happy that this would have an impact on the amount of incidents.

After a few years it became apparent that all my efforts had improved the system; reserve packers and riggers were much more knowledgeable but the amount of incidents being reported had not changed. I started to explain the problem to a few riggers one day and said that I now believe that the real problem is because no one's policing the system, or being held accountable for their mistakes, and hardly anyone gets to hear about the incidents unless one of them happens to be on their drop zone, and even then only a hand full of people take an interest.

Rick Boardman then told me about a system that the RAF have about confidential reporting and how they use the reports to educate pilots to be more aware of problems so they can prevent it happening again. He also told me about a video they have which shows how accidents happen, so pilots are aware of the chain of events that lead up to an accident. It showed how individuals can help break the chain and prevent a potential accident from happening. I asked Rick to find out more information to see if we can duplicate it for parachuting. The result of this research was a paper written by Rick about a new BPA confidential reporting system that was published in the BPA magazine. From this date onwards all confidential reports came to me, and the BPA also sent me their official drop zone and instructor reports which were not confidential. I then wrote about the incidents and gave recommendations as to how this incident could have been prevented. Once again I was happy that this would help to reduce the amount of incidents being reported. Once again, I was wrong.

The number of reports never changed and the same incidents are still being repeated time and time again by different skydivers, reserve packers and riggers. Myself, Chris Jones and Rick Boardman have all written papers on this and we got together to set up a flight line checking system at the BPA AGM. The aim was to test a skydivers ability to find faults that would prevent some of the known incidents from happening again. We made the BPA membership more aware of how they can help to stop incidents from occurring.

Since this event the BPA changed the operations manual to include a system specifically for training flight line checking. My latest plan to try and prevent repetitive problems is through a website that focuses on safety in a way that doesn't lecture or force issues, but hopefully gets skydivers talking to encourage participation in reducing the amount of incident reports. It has a safety tip on every page, this then links to an explanation of the safety tip which in turn links to a real incident. I'm not one to give up and one day, hopefully soon, I will be able to say that all the same repetitive incidents have been reduced to an acceptable level.

Any skydiver who comes across a problem that compromises safety is encouraged to send in a report. The best way to prevent future problems is to recognise a problem and share it with others to prevent it from happening again. Almost all equipment problems are just repeats of a problem that someone else has had. The reporting system allows all skydivers to learn from the mistakes of others, so we can reduce the number of incidents and keep skydivers as safe as possible.

The person making the report can fill in as little or as much as they like. The identity of the person making the report will not be revealed unless they have signed the agreement. Please fill in as much information as possible but leaving a section blank is also acceptable.

I would like to make a special request to all instructors and riggers who fill out the BPA mandatory incident reports; please investigate all incidents with one thought in mind "what could have prevented this incident". I have read thousands of reports that say things like: he had a malfunction then cutaway, he had a pilot chute in tow and carried out his reserve drills, one of her control lines broke during flaring which resulted in a broken arm. Simple reports like this are a complete waste of time and are, quite frankly, irresponsible. The reports should explain the reason for the incident and what could have been done to prevent it.