The skydiving aircraft
Tandem parachute UPT Micro Sigma, registration 31Z Double malfunction, Queenstown, 10 January 2018
Status
Closed
Occurrence Date
Report Publication Date
Jurisdiction
NZ
What happened
On 10 January 2018, NZONE Skydive was conducting commercial tandem skydiving operations from its Queenstown site near Lake Wakatipu, when a tandem pair experienced a double parachute malfunction.
The tandem pair was the last of nine tandem pairs to exit the aeroplane at 14,000 feet (about 4,300 metres) above the site. The droguefall stage was uneventful and the tandem master deployed the main parachute slightly higher than usual in order to reach the parachute landing area with ease.
The main parachute did not open symmetrically and the lines twisted. After unsuccessful attempts to correct the line twist, the tandem master cut away the main parachute and deployed the reserve parachute. By this time the tandem pair had drifted further out over the lake.
The reserve parachute opened, but tension knots in the suspension lines prevented the canopy fully inflating, which distorted its shape. This caused the tandem pair to spin in a clockwise direction. The tandem master was unable to overcome the centrifugal forces generated by the fast spin rate, which prevented the tandem master making a safe recovery. The tandem rider donned their lifejacket for an impending water landing; however, the tandem master did not have a lifejacket. Just prior to impact, the tandem master took action to minimise the spin rate and the impact forces expected at the moment they struck the surface of the lake.
After impact with the water, the tandem master was able to clear the lines entwined around both their legs and assist the tandem rider to partially inflate their lifejacket. Attempts to inflate the lifejacket further were unsuccessful. The tandem master was rescued after a short period of time, but the tandem rider was not found and remains lost in the lake.
Why it happened
The Transport Accident Investigation Commission (Commission) found that the asymmetric opening of the main parachute canopy and subsequent line twist were likely due to the way the main parachute had been packed. The cause of the tension knot forming in the suspension lines of the reserve parachute could not be conclusively determined.
The tandem rider’s lifejacket likely could not be inflated sufficiently to support their head above water. The reason for the lifejacket not inflating fully and its state of serviceability before it was used could not be conclusively determined. In addition, the tandem master was not equipped with a lifejacket, which decreased their ability to remain afloat.
The Commission also found that the operator’s planned water emergency response did not have due regard to the minimum survival time for people immersed in cold water. This increased the likelihood of the water emergency response not providing timely assistance.
What we can learn
The Commission considered several aspects of this accident to be safety issues that had the potential to affect other parachuting activities in New Zealand:
- maintenance programmes ensure that equipment is airworthy and able to perform its functions when required. The operator’s lack of a maintenance and inspection programme for lifejackets introduced a risk to the operation
- rules and operating procedures are put in place to ensure a basic level of operational safety is achieved. If this guidance is not well defined, organisations that are required to comply may not achieve consistent or desired outcomes. The Civil Aviation Rules did not clearly define the minimum safety requirements for tandem parachute descents being conducted near significant bodies of water. This resulted in inconsistencies between the parachuting entities guided by the Civil Aviation Rules such as parachute organisations and Part 115 parachute operations, and increased the risk to parachutists
- standards are in place for emergency equipment to ensure it meets a set of minimum requirements. The standards referenced in the Civil Aviation Rules for lifejackets did not consider the specific requirements for parachuting. There is a risk that products certified to these standards will not be suitable for parachuting conditions
- emergency response plans ensure that timely assistance can be provided in an emergency. These plans need to consider the likely environments in which emergencies will occur. In not adequately considering the minimum survival times for people immersed in cold water, there was a risk that any water emergency response by the operator would not be able to provide timely assistance
- effective safety management in the entire parachute sector relies on the assessment of occurrence data. Without key fields being recorded by the Civil Aviation Authority for parachute occurrences that include the equipment fitted to the parachutes, the effectiveness of this tool for safety management in the sector is reduced.
Since this accident the operator has made several improvements to its policy and procedures regarding the safety issues identified. As such, no recommendations have been made to address those issues.
The Commission made two recommendations to the Secretary for Transport and one to the Director of Civil Aviation:
- the Commission recommends that the Secretary for Transport review and revise Civil Aviation Rule Parts 105 (Parachuting Operating Rules), Part 115 (Adventure Aviation Certification and Operations) and Part 149 (Aviation Recreation Organisations Certification) for parachuting operations, in conjunction with the Part 149 organisations’ operating procedures and standards, to reduce the potentially adverse consequences of an unintended water landing
- the Commission recommends that the Secretary for Transport review and revise Civil Aviation Rule Parts 105, 115 and 149 for parachuting operations, in conjunction with the Part 149 organisations’ operating procedures and standards, to define flotation devices that are suitable for use by parachutists
- the Commission recommends that the Director of Civil Aviation review the parachute accident and incident reporting system under Civil Aviation Rules Part 12 (Accidents, Incidents, and Statistics) and Advisory Circular AC12-1 (Mandatory occurrence notification and information), in conjunction with the Part 115 parachute operations and Part 149 organisations’ requirements, to provide a more effective national resource to manage the sector’s safety.
The key lesson identified from the inquiry was that if a parachute operation is based near a significant body of water, the operator needs to consider and mitigate the additional risks presented by a parachutist unintentionally landing in the water.
All parachutists would benefit from gaining practical or simulated experiences of a water landing before being issued with their initial parachutists’ certificates.
All parachute-sector participants may benefit from continued engagement with each other to improve industry guidance and the safety of parachuting in New Zealand.
Who may benefit
Parachutists, tandem riders, operators, parachute organisations and the New Zealand adventure tourism industry will benefit from this report.
On 10 January 2018, NZONE Skydive was conducting commercial tandem skydiving operations from its Queenstown site near Lake Wakatipu, when a tandem pair experienced a double parachute malfunction.
The tandem pair was the last of nine tandem pairs to exit the aeroplane at 14,000 feet (about 4,300 metres) above the site. The droguefall stage was uneventful and the tandem master deployed the main parachute slightly higher than usual in order to reach the parachute landing area with ease.
The main parachute did not open symmetrically and the lines twisted. After unsuccessful attempts to correct the line twist, the tandem master cut away the main parachute and deployed the reserve parachute. By this time the tandem pair had drifted further out over the lake.
The reserve parachute opened, but tension knots in the suspension lines prevented the canopy fully inflating, which distorted its shape. This caused the tandem pair to spin in a clockwise direction. The tandem master was unable to overcome the centrifugal forces generated by the fast spin rate, which prevented the tandem master making a safe recovery. The tandem rider donned their lifejacket for an impending water landing; however, the tandem master did not have a lifejacket. Just prior to impact, the tandem master took action to minimise the spin rate and the impact forces expected at the moment they struck the surface of the lake.
After impact with the water, the tandem master was able to clear the lines entwined around both their legs and assist the tandem rider to partially inflate their lifejacket. Attempts to inflate the lifejacket further were unsuccessful. The tandem master was rescued after a short period of time, but the tandem rider was not found and remains lost in the lake.
Why it happened
The Transport Accident Investigation Commission (Commission) found that the asymmetric opening of the main parachute canopy and subsequent line twist were likely due to the way the main parachute had been packed. The cause of the tension knot forming in the suspension lines of the reserve parachute could not be conclusively determined.
The tandem rider’s lifejacket likely could not be inflated sufficiently to support their head above water. The reason for the lifejacket not inflating fully and its state of serviceability before it was used could not be conclusively determined. In addition, the tandem master was not equipped with a lifejacket, which decreased their ability to remain afloat.
The Commission also found that the operator’s planned water emergency response did not have due regard to the minimum survival time for people immersed in cold water. This increased the likelihood of the water emergency response not providing timely assistance.
What we can learn
The Commission considered several aspects of this accident to be safety issues that had the potential to affect other parachuting activities in New Zealand:
- maintenance programmes ensure that equipment is airworthy and able to perform its functions when required. The operator’s lack of a maintenance and inspection programme for lifejackets introduced a risk to the operation
- rules and operating procedures are put in place to ensure a basic level of operational safety is achieved. If this guidance is not well defined, organisations that are required to comply may not achieve consistent or desired outcomes. The Civil Aviation Rules did not clearly define the minimum safety requirements for tandem parachute descents being conducted near significant bodies of water. This resulted in inconsistencies between the parachuting entities guided by the Civil Aviation Rules such as parachute organisations and Part 115 parachute operations, and increased the risk to parachutists
- standards are in place for emergency equipment to ensure it meets a set of minimum requirements. The standards referenced in the Civil Aviation Rules for lifejackets did not consider the specific requirements for parachuting. There is a risk that products certified to these standards will not be suitable for parachuting conditions
- emergency response plans ensure that timely assistance can be provided in an emergency. These plans need to consider the likely environments in which emergencies will occur. In not adequately considering the minimum survival times for people immersed in cold water, there was a risk that any water emergency response by the operator would not be able to provide timely assistance
- effective safety management in the entire parachute sector relies on the assessment of occurrence data. Without key fields being recorded by the Civil Aviation Authority for parachute occurrences that include the equipment fitted to the parachutes, the effectiveness of this tool for safety management in the sector is reduced.
Since this accident the operator has made several improvements to its policy and procedures regarding the safety issues identified. As such, no recommendations have been made to address those issues.
The Commission made two recommendations to the Secretary for Transport and one to the Director of Civil Aviation:
- the Commission recommends that the Secretary for Transport review and revise Civil Aviation Rule Parts 105 (Parachuting Operating Rules), Part 115 (Adventure Aviation Certification and Operations) and Part 149 (Aviation Recreation Organisations Certification) for parachuting operations, in conjunction with the Part 149 organisations’ operating procedures and standards, to reduce the potentially adverse consequences of an unintended water landing
- the Commission recommends that the Secretary for Transport review and revise Civil Aviation Rule Parts 105, 115 and 149 for parachuting operations, in conjunction with the Part 149 organisations’ operating procedures and standards, to define flotation devices that are suitable for use by parachutists
- the Commission recommends that the Director of Civil Aviation review the parachute accident and incident reporting system under Civil Aviation Rules Part 12 (Accidents, Incidents, and Statistics) and Advisory Circular AC12-1 (Mandatory occurrence notification and information), in conjunction with the Part 115 parachute operations and Part 149 organisations’ requirements, to provide a more effective national resource to manage the sector’s safety.
The key lesson identified from the inquiry was that if a parachute operation is based near a significant body of water, the operator needs to consider and mitigate the additional risks presented by a parachutist unintentionally landing in the water.
All parachutists would benefit from gaining practical or simulated experiences of a water landing before being issued with their initial parachutists’ certificates.
All parachute-sector participants may benefit from continued engagement with each other to improve industry guidance and the safety of parachuting in New Zealand.
Who may benefit
Parachutists, tandem riders, operators, parachute organisations and the New Zealand adventure tourism industry will benefit from this report.
Location
Lake Wakatipu (-45.097222,168.730556) [may be approximate]