In 2020, Jose Narvaez submitted a graduate research project on risk assessment, decision-making and their impact on skydiving safety to fulfill the final requirement for a Master of Science in Human Factors from Embry-Riddle Aeronautical University. This article is a summation of his most important findings and conclusions.
While there has been extensive academic research on how human cognition, risk-assessment and decision-making affect aviation accidents, there has not been much specific research in these areas regarding sport parachuting. So, I undertook this research project to gain an understanding of the factors that contribute to skydivers making poor decisions, identify different possible courses of action that would improve those decisions (further reducing fatalities and serious injuries) and spur more detailed research into this problem. Data collected by the USPA Safety and Training Department from 2014 to 2019 provided the primary source for the project. Reviewing and analyzing this data identified patterns and relationships that shed light on how otherwise competent skydivers assess situations incorrectly and make poor decisions.
In the United States from 2014 to 2019, 94 sport parachuting fatalities occurred in 14 major categories. This research project took a targeted approach, focusing on the seven categories of incidents with the highest likelihood of being fatal. Analysis of this data identified common contributing factors, themes or trends that manifested themselves across the categories, resulting in 203 instances of 69 distinct relevant details or contributing factors. In many of the accidents, two or more common themes combined to affect a jumper’s ability to assess a situation and decide on a course of action.
Situational Awareness
The data indicated that 34 of the 75 fatalities in the sample (45%) involved jumpers who encountered a malfunction or equipment problem and either did not respond appropriately or did not respond at all. In 18 of these instances, the jumpers involved also experienced a loss of situational awareness. These ranged in severity from being suddenly distracted close the ground to becoming disoriented due to a spinning malfunction.
The spinning malfunction, identified as a common theme in 10 of the instances, is particularly dangerous from a cognitive and decision-making-processes perspective. Seldom does a spinning malfunction begin gently. The rotation will cause the brain to receive conflicting information from the visual, vestibular and proprioception (the body’s ability to sense movement, action and location) systems. This can lead to spatial disorientation and confusion and induce vertigo. In severe cases, vertigo can completely incapacitate a person. The malfunction will also trigger the body’s natural reaction to fear, which includes the release of stress hormones. These hormones are known to alter the perception of time.
Combined with the loss of situational awareness, the jumper may have believed that they had more time than available to execute emergency procedures. The outcome of the accidents where a spinning malfunction and loss of situational awareness contributed to the jumper executing emergency procedures, executing them in the wrong order or not executing them at all (no reserve deployment), support this conclusion.
An Unexpected Finding
A very unexpected finding was that all eight fatalities in the “no or low cutaway/reserve deployment” category had the same two common themes: no reserve static line (or main-assisted-reserve-deployment device, a type of RSL) installed and a loss of situational awareness. The loss of situational awareness directly contributed to the jumpers deploying their reserve canopies too low for the reserve to fully inflate (in six of the fatalities) or cutting away the main canopies at a low altitude (in two of the fatalities). In one of the two fatalities, the jumper who cut away at a low altitude did not attempt to deploy their reserve canopy.
It is likely that seven of these incidents would have been survivable if the jumpers had equipped their parachute rigs with an RSL or MARD. Either of these devices would have initiated reserve canopy deployment immediately after release of the main canopy. Some jumpers who argue against using RSLs/MARDs state that in the case of spinning malfunctions, it is better to be able to get stable after cutting away to avoid entanglement or reserve line twists. However, the data on skydive fatalities used in this research project disproves this belief.
Cognitive Dissonance
The data identified 18 instances of decisions made a considerable time before accidents (e.g., not wearing an RSL, not performing a gear check, jumping a smaller or high-performance canopy) that had a direct bearing on the outcomes. They include the eight instances where jumpers did not equip their rigs with RSL or MARD systems, three instances where the physical evidence indicated that the equipment had not been maintained or inspected properly and five instances of jumpers who overestimated or overstated their experience and proficiency. In all these cases, the jumpers “knew better,” yet their actions were contrary to these beliefs. These instances can be considered a form of cognitive dissonance, the mental conflict that occurs when beliefs or assumptions are contradicted by new information.
By its very nature, sport parachuting appeals to people who have a very high risk-threshold. For them, the risk is within their individual risk-thresholds, partly because the rewards outweigh the risks. In the cases where jumpers exceeded their skills and abilities, it is highly probable that the boost in self-confidence gained from increasing their knowledge and experience encouraged these jumpers to underestimate the risks or overestimate their skills and engage in activities or disciplines for which they were not yet ready.
The analysis of the data supports the hypothesis that the errors in the human decision-making process are at the root of most sport parachuting fatalities. However, it was unexpected to discover that in many cases, many of the common themes identified did not impact the decision-making process directly during a jump. These factors influenced the jumpers to make faulty decisions before the jump, when they could afford to take their time to evaluate and decide on a course of action. Am I truly ready to downsize? Should I add an RSL to my new container? Should I attempt a high-performance landing in this weather? Those are examples of the decisions made on the ground, before (sometimes very long before) the jump. The jumpers’ decisions breached the safeguards and defense mechanisms in place to prevent human error and, combined with additional factors, resulted in fatal accidents. The challenge remains to find effective measures to address the root causes of these errors.
The full thesis is available here: parachutist.com/narvaez-analysis.
About the Author
Jose Narvaez, B-42922, a relative newcomer to the sport, has worked in the aerospace maintenance industry for 40 years. A U.S. Air Force veteran, he currently works for the Regulatory and Quality System Oversight organization of Boeing Commercial Airplanes, interfacing with the FAA and foreign Civil Aviation Authorities. He holds an FAA Airframe and Powerplant license, a Bachelor of Science degree in Aeronautical Studies and a Master of Science in Human Factors from Embry-Riddle Aeronautical University and a Master of Business Administration from the University of Phoenix.