The 2021 Non-Fatal Incident Summary
Safety & Training | May 01, 2022
The 2021 Non-Fatal Incident Summary

Director of Safety and Training Ron Bell

As the number of annual skydiving fatalities has decreased over the decades, non-fatal incident reporting has become increasingly important in determining where our sport’s safety and training standards need improvement. Although we strive for a year with zero fatalities, that happening wouldn’t make skydiving a safe sport. Skydiving is not a safe sport, nor will it ever be. It is a dangerous one that can be done safely. Safe skydiving takes constant vigilance against human tendencies like the normalization of deviance, the Dunning-Kruger effect and complacency, just to name a few.

Although drop zones and jumpers still contended with the COVID-19 pandemic in 2021, skydiving activity rebounded to pre-pandemic levels with approximately 3.57 million jumps made. This represented a 25% increase from 2020’s activity level. In 2021, there was also an increase in incident reporting: USPA received 252 incident reports, a 50% increase over the number of reports received in 2020. We believe that this represents a higher rate of reporting rather than a higher rate of incidents since the fatality rate for 2021 was one fatality in 357,000 skydives, the lowest fatality rate in history, and it is likely that our injury rates have declined similarly.

The Injury Severity Index

For the first time in this report, USPA has categorized the severity of the injuries sustained during incidents by developing an Injury Severity Index (ISI). The ISI uses a scale of 0-5, with zero representing no injury and the other levels as follows:

  1. Soft-tissue injury typically requiring only local first aid
  2. One broken bone or multiple breaks of a single bone or joint
  3. Multiple broken bones
  4. Traumatic brain or spinal cord injury
  5. Fatal (not included in this report)

This article analyzes information from 232 of the 252 incidents reported in 2021. (We removed reports of fatal incidents, as well as reports of non-fatal incidents that contained insufficient detail to be useful). In the following pages, we’ve categorized the non-fatal incidents by primary cause, followed by the percentage of overall instances that category represents. In the absence of adequate historical data on non-fatal incidents, this report compares 2021’s percentages to the average of 2019 and 2020.

Landing Problems
113, 49% (2019-2020–60%)

  • Intentional low turns: intentional high-performance maneuvers for landing. These usually involved a jumper who initiated a high-performance turn at an altitude too low for the parachute to return to straight and level flight before reaching the ground.Three subcategories of landing problems–each requiring different areas of training to prevent–compromise the overarching category. These subcategories of landing problems are:
  • Unintentional low turns: unplanned low turns, usually to avoid other parachutes in the air or obstacles on the ground.
  • Non-turn-related: includes improper landing techniques, landing on obstacles or encountering other hazards (such as deep water) while under a properly functioning parachute.
Intentional Low Turns
9, 4% (2019-2020–11.6%)

Of the 9 reports in this category, four involved C-licensed jumpers, four involved D-licensed jumpers and one involved a jumper whose license level was not reported. The good news is that no B-licensed jumpers were represented, as has been the case in previous years. In all but two of these reported incidents, the jumper broke a bone, with most reporting multiple broken bones. One of the jumpers suffered a broken femur and hip, numerous broken ribs, a punctured right lung, a lateral mass fracture to the C2 vertebra, fractures of the T2-T5 vertebrae, acromioclavicular joint separation, a fracture of the distal right clavicle and multiple pelvis fractures.

The C-licensed jumpers loaded their canopies at an average of 1.67:1 (well above the 1.2:1 recommended maximum wing loading for that license level) and had an average ISI of 1.75. The D-licensed jumpers loaded their canopies at an average of 2.1:1, with an average ISI of 2.75. This strongly suggests that severity of injury is directly related to how heavily jumpers load their canopies. Smaller canopies produce faster landing speeds and more significant injuries when their pilots make mistakes. When making high-performance maneuvers close to the ground, the tolerances are very unforgiving, and the consequences of mistakes are severe.

The experience level of the D-licensed jumpers was wide:  At the low end was a jumper with 520 jumps jumping with a wing loading of 1.6:1, and on the high end was a jumper with 4,500 jumps and a wing loading of 2.65:1. Because of the wide range of experience for D-license holders, one wing-loading recommendation does not fit all, but at a minimum they should stay under the recommended maximum of 1.4:1 until they have 1,000-plus jumps. And all jumpers must practice more advanced techniques under less aggressive canopies and learn how to get the best performance out of those canopies before downsizing.

Unintentional Low Turns
11, 5% (2019-2020–7%)

One jumper died making an unintentional low turn in 2021, and 70% of the jumpers who survived unintentional-low-turn incidents reported breaking at least one bone. The Injury Severity Index for this category is 2.45, slightly above the 2.3 ISI of the intentional-low-turn category. Although A-licensed jumpers accounted for 55% of incidents reported in this category in 2021, B-licensed jumpers dominated this category in 2020. The last few years of analysis shows that low-experience jumpers are prone to making unintentional low turns, and in many cases had recently downsized their canopies. However, other factors also emerged this year. 

Some of these low-experience jumpers made unintentional low turns to avoid an obstacle after experiencing landing-pattern complications due to winds higher than student wind limits. Although a jumper enjoys no wind restrictions after becoming A-licensed, they must gradually increase their personal wind limits as their skill and confidence grows. The skill required to land in winds rises exponentially with wind speed. As the winds get higher, turbulence can roll out farther from obstacles and be more violent, and traffic patterns can become more unpredictable.

Low-experience jumpers may also have stopped rehearsing their emergency procedures after becoming licensed, and it’s finally catching up to them. Instructors can help mitigate these problems by emphasizing low-altitude emergencies during student training and reminding their graduates to continue rehearsing them for their entire skydiving careers.

Non-Turn-Related
93, 40% (2019-2020–41%)

There were 94 reports of non-turn-related incidents in 2021, and only one of them was fatal, which indicates that even if you encounter a problem, most straight-in approaches are survivable. Most of the jumpers had low experience levels, with just a handful being very highly experienced. (The jumpers had an average of 898 jumps each but a median of only 60.) The ISI for these incidents is 2.2, higher than might be expected. However, when factoring in wing loading, the reason becomes clearer.

The average ISI increases significantly with wing loading. Although landing in a straight line with a level wing remains the safest landing technique, wing loading plays a significant role in the type and severity of injuries sustained.

To find out more common causes of landing injuries to low-experience jumpers, we broke down the non-turn related incidents into further subcategories:

  • Obstacle: Hit an obstacle
  • Pattern: Performed a poor landing pattern
  • Turbulence: Encountered turbulence, and it was the primary cause of the injury
  • Flare/PLF: Flared and/or performed a parachute landing fall poorly or not at all
  • Tandem Student: Student didn’t keep their legs up for landing
  • Other: Report did not include enough information to properly categorize

For the third year in a row, the Flare/PLF category accounted for the highest percentage of the non-turn-related incidents. In most cases, the failure to flare or PLF, not the poor performance of either, was the cause of injury. Contributing factors included distracted landings due to obstacles on the ground, canopy traffic, ground grade (landing uphill or downhill), turbulence and students landing with their legs up like they were trying to perform a tandem slide-in landing. Jumpers who attempted to run out fast landings or slide them in rather than performing a PLF typically broke an ankle or wrist in the process. Presumably, jumpers who chose to PLF during bad landings fared better and therefore did not file a report.

Skydiver’s Information Manual Section 4-A says, “You should be prepared to perform a parachute landing fall every time you land,” and follows that up with, “A stand-up landing should be attempted if you touch down softly and are confident that you can comfortably remain on your feet.” Farther down the section, it says, “Anytime you must land in an alternate landing area off the airport property, perform a parachute landing fall.” The PLF is a necessary tool that every skydiver should rehearse periodically to stay proficient.

Students should run through emergency procedures, including low-altitude emergency procedures, every day. This should include PLF practice from an elevated surface. Unfortunately, this kind of structured practice often ends when someone receives an A license. Once licensed, jumpers—especially A- and B-licensed jumpers—must take it upon themselves to keep these bone-saving skills sharp.

Equipment Problems
65, 28% (2019-2020–3.6%)

Although the percentage of incidents represented by the “Equipment Problems” category jumped significantly compared to the previous two years, this is likely because jumpers learned that they should report incidents such as automatic activation device activations, hard openings and cutaways (which comprise 86% of this category). The most common reported equipment problems were: 

  • AAD Activation
  • Cutaway
  • Hard Opening
  • Misrouting
  • Premature Deployment
  • Unstable Exit
  • Reserve Deployment
AAD Activations

USPA received 27 incident reports of AAD activations in 2021, eight of which fell under equipment problems. All but one (who made a turn at 50 feet to face into the wind under the reserve) reported landing safely. All eight involved jumpers spiraling their canopy below their AAD activation altitude, which caused the AAD to activate while they were under a fully functional main canopy. One of these jumpers, who had 150 jumps, rented gear and didn’t realize the AAD was set to student mode. Two of these jumpers reported forgetting to change their AAD settings after switching out a wingsuiting main canopy for a high-performance canopy. (One safely cut away the main canopy, the other landed hard under an entanglement but sustained no serious injury.)

Jumpers must thoroughly understand the operating parameters of their automatic activation devices. There are many types of AADs on the market, including changeable-mode AADs, which can toggle between settings for solo students, tandem skydivers, licensed jumpers and high-performance canopy pilots. There are also AADs specifically meant for wingsuit flyers. Jumpers need to refer to their owner’s manuals and learn the speeds and altitudes at which their specific AADs will activate or even disarm.

Two of the AAD activation reports were of jumpers who had problems with finding the main deployment handle. One was a wingsuit flyer who borrowed a rig that they knew was too small and could not reach the main deployment handle once the wingsuit inflated. The other was a student who partially extracted the main deployment handle on the first attempt to deploy and could not find it on the second attempt because it was trailing about three inches behind the bottom-of-container pilot chute pocket. Both jumpers activated their reserves but at an altitude low enough for the AAD to fire during the reserve deployment. Jumpers must stay altitude aware when having deployment issues and resort to their emergency procedures at appropriate altitudes.

Hard Openings

In late 2019, the Parachute Industry Association started research into hard openings. Coincidentally, USPA received no reports of hard openings that year, but received nine in 2020 (7.2% of total reports) and 19 in 2021 (29% of equipment problems and 7.5% of the total). Ten of the hard-opening incidents in 2021 resulted in minor to moderate bruising and stiffness, but nine resulted in more serious injuries. In the worst case, the jumper lost control of all four limbs on opening, steered back to the landing area with harness input and landed into the wind with no flare or PLF and both brakes stowed. (The jumper regained the use of their limbs but was diagnosed with three broken vertebrae, three bulged discs and swelling of the spinal cord and needed to use a body brace for months.)

USPA passed along the hard-opening incident information it received to PIA for its research project. If you have a hard opening, please visit uspa.org/ir to report it. If you are willing to let PIA contact you for more information, provide your email address in the incident description.

Cutaways

USPA received 29 incident reports of cutaways in 2021. Though this is an insignificant number compared to the estimated 6,200 cutaways (based on member polling) that occurred during the year, it is still the highest number of reports that USPA has received in any given year. Almost 70% of the cutaways reported were related to the lines of the parachute, with the most common cause being line twists and over half of those spinning line twists. (Don’t delay, cut away!)

The second most reported line problem was a toggle entangling with excess stowed brake line. Typically, these incidents occurred when the excess brake line came loose during deployment or when the canopy pilot accidentally reached through the excess brake line when grabbing the toggle (creating a knot at the guide ring and locking the toggle in place). Jumpers should regularly inspect their brake lines and line keepers, as well as check that the brake lines are properly stowed during each pack job. Consider waiting for the canopy to fully deploy before reaching for toggles, and take extra care if reaching for toggles or risers during the inflation stage.

Tension knots and line overs tied for third on the equipment problems list. Tension knots occur for many reasons, including twisted brake lines, and are more common on old, fuzzy lines. To prevent tension knots, regularly untwist your brakes lines and maintain your lines according to the manufacturers’ recommendations.

Line overs generally occur because the person who packed the parachute rolled the tail excessively, pulling the D-lines of the canopy around to the nose. This is a common packing error that can avoided by following your main parachute manufacturer’s recommendations.

It’s encouraging to see incident reporting numbers slowly growing, not because we are having more incidents but because the USPA membership is seeing the importance of these non-fatal reports. But we still have a long way to go. From our member survey in early 2021, we estimate a reportable event happens at least every 570 jumps, which would mean 6,200-plus reports annually. This means we are getting reports less than 10% of the time! It’s a huge improvement over the 0.4% of reports we received in 2018, so we are headed full steam in the right direction, but we encourage the membership to support USPA’s effort by reporting non-fatal incidents and providing complete information. Take advantage of the resources available to you! Together we can continue to strive for a year with zero fatalities.

Any USPA member can file an incident report. You can find more information in the Skydiver’s Information Manual Section 5-8. An easy-to-fill-out, mobile-friendly online report form is available at USPA.org/ir.


A Closer Look at AAD Activations

AAD activations make an appearance in seven of the non-fatal incident report categories, often partnered with a loss of altitude awareness.Students are heavily represented, but the Basic Safety Requirements require instructors to report any AAD activation on a student jump, so USPA is likely capturing a lower percentage of AAD activations from licensed jumpers.

Ten reports of AAD activations involved unstable students who either didn’t deploy because they were preoccupied with trying to get stable or because they couldn’t find their main deployment handle while unstable. Nine out of 10 of the AAD-initiated reserve deployments saved the student’s life; in the tenth instance, the instructor deployed the student’s main canopy (but at an altitude that the AAD fired during inflation of the main).

In four cases, the jumper lost altitude awareness and deployed their main parachute low enough for their AAD to activate during inflation. In three of these instances, the two open canopies went into a downplane, and the jumper was able to successfully cut away the main canopy and land safely under their reserve. In the fourth instance, the jumper safely landed the two canopies, which were flying in a side-by-side configuration.

Jumpers must maintain altitude awareness, especially when faced with problems near deployment altitude. Jumpers can get fixated on a problem (commonly called “tunnel vision”), which can cause them to lose altitude awareness during this critical part of the skydive. They must remind themselves that the first priority is to pull, the second is to pull at the assigned altitude and the third is to pull stable. In reality, though, it may be best for jumpers to look at pulling stable as simply preferable and not truly a priority at all. 

Other notable AAD activations reports included:

  • A tandem instructor who forgot to set the drogue after exit. Although the instructor did eventually pull the reserve handle, the pair was at a low enough altitude for the AAD to activate.  
  • A jumper who performed emergency procedures but did not extract the reserve handle far enough to release the reserve canopy. The AAD then fired and deployed the reserve. The jumper landed safely under their reserve, unaware that the AAD had initiated the deployment. 
  • A freefall collision due to a lack of situational awareness rendered one of the jumpers unconscious. This jumper landed under the reserve canopy while still unconscious and sustained serious injuries but is expected to make a full recovery.
  • A main pilot chute wrapped around a jumper’s ankle after a weak throw, which resulted in a horseshoe malfunction. The jumper struggled to clear the horseshow until the AAD initiated reserve deployment. The reserve deployed normally, and the jumper cleared the entangled main pilot chute, which led to the main deploying. The two canopies went into a downplane at approximately 450 feet. The jumper landed the downplane, which resulted in several severe injuries.

Although USPA requires the use of AADs only on student equipment, it has become an option that most jumpers elect to use. Since their introduction, AADs have consistently saved lives. They have almost eliminated fatalities in the low-deployment and no-pull categories, in which there had not been a fatality since 2015 (and that jumper did not have an AAD installed). 

Of the 27 reported AAD activations in 2019, nine occurred from exceeding the AAD’s firing parameters (the eight covered in the equipment problems section and one in which a student rode the plane down and the AAD fired during the descent). Of the 18 remaining AAD activations, eight (45%) involved the jumper pulling their main canopy dangerously low and 10 (55%) involved the jumper not deploying the main at all. That means that in at least 10 cases in 2021, a jumper’s life was saved by the AAD. Our fatality statistics would undoubtedly be a lot worse without them.

Peregrine

Rate this article:
4.9
Print

Number of views (10991)/Comments (0)

Leave a comment

This form collects your name, email, IP address and content so that we can keep track of the comments placed on the website. For more info check our Privacy Policy and Terms Of Use where you will get more info on where, how and why we store your data.
Add comment