The 2022 Non-Fatal Incident Summary—Part Two: Non-Landing Incidents
Safety & Training | Jun 06, 2023
The 2022 Non-Fatal Incident Summary—Part Two: Non-Landing Incidents

Ron Bell

Part one of this article (May 2023 Parachutist) analyzed 156 non-fatal-landing-incident reports and offered advice on how to avoid the most frequent landing errors. This second part examines the other 113 non-fatal incident reports received in 2022. Whether you are a novice skydiver or a seasoned pro, this information will provide valuable insights that will help make your skydiving experience safer and more fun.

The Injury Severity Index (ISI)

For this report, USPA categorized the severity of the injuries sustained during incidents by developing an Injury Severity Index (ISI) that uses a scale of 0-5.

0—No injury
1—Soft-tissue injury typically requires 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)

In the following article, we’ve categorized the non-fatal incidents by primary cause, followed by the percentage of overall incidents that category represents. Without adequate historical data on non-fatal incidents, this report compares 2022’s percentages to the average of three years, 2019-2021.

 

Equipment Problems | 43, 16% (2019—2021-10%)

This year, we decided to look at equipment problems not only by type of problem, but by whether the jumper responded to the problem appropriately and by whether they cut away. Looking at the data this way resulted in some interesting insights.  

 

Equipment Problems Followed by Successful Cutaway–23, 9% (2019-2021-Untracked)

In these incidents, the jumper encountered an equipment problem and cut away successfully at an appropriate altitude. When breaking down the successful cutaways by license, the data showed that D-licensed jumpers tended to cut away more frequently than lower-licensed jumpers when they faced a problem. This may be because the urgency of a malfunction accelerates under an experienced skydiver’s higher-loaded canopy, but could also be that those seasoned skydivers have gained wisdom from past incidents (their own or others’) and know that acting quickly and correctly can improve their chances of landing safely.

Line twists accounted for 70% of these incidents, and more than half of those involved spinning line twists. The jumpers in these cases reacted correctly, but in 2022, spinning line twists with cutaways at about 200 feet resulted in two fatalities that are not included in this report. The USPA safety campaign slogan, “Don’t delay, cut away,” is still an important message.

The other 30% of successful cutaways involved issues other than line twists. One was simply the result of a damaged canopy. Two were bridle entanglements where the container opened, the deployment bag flailed behind the jumper, the bridle tangled and when the canopy opened it was severely distorted. In another instance, a misconfigured AAD (set plus-900 feet) resulted in two canopies out, and the canopies went into a downplane. In another, a tandem instructor had an out-of-sequence deployment. All these jumpers handled their situations well at an appropriate attitude and landed safely on the ground with their reserves. Incident reports are often full of tragic stories that end in injuries. It is reassuring to see the biggest category of part two filled with success stories.

 

Equipment Problems, Other | 20, 7% (2019-2021–10%)

Premature deployments—all four of which occurred near an open door—topped this category in 2022. The jumpers had a wide range of experience. Jumpers should check their handles before approaching an open aircraft door and use caution as they climb out and set up to exit. Jumpers should also regularly review SIM section 4-C.C.1, which covers how to deal with open-container situations near an open door.

Line problems are some of the most common malfunctions a jumper will experience, and jumpers could avoid many of them by maintaining their lines according to manufacturers’ standards. The second most common problem in the equipment problems category was a toggle tangling with a loose brake line. This usually happened when the stowed brake line came out during deployment, and the canopy pilot grabbed the toggle through the brake line (making a knot, locking the brake line in place). Jumpers should check their brake lines and line keepers regularly and ensure that the brake lines are stowed properly during packing. Consider waiting until the canopy is fully deployed before reaching for the toggles; otherwise, be extremely careful if reaching for toggles or risers during the inflation stage.

Tension knots and line overs—both also line problems—were equally common on the equipment-problems list, coming in third. Tension knots can happen for various reasons but are often due to twisted brake lines. They are more likely to occur on old, worn-out lines. To avoid tension knots, untwist your brake lines regularly and follow the manufacturers’ guidelines for line maintenance. Line overs usually happen because the packer rolled the tail too much, causing the D-lines of the canopy to wrap around the nose.

Eighty-nine percent of equipment problems did not result in injury, but two had an ISI rating of 4. In one, a wingsuit flyer using a new suit deployed at 1,700 feet, had line twists and failed to unzip his arm wings. He cut away at around 750 feet, but his reserve canopy deployed in a turn. The turn continued until he hit the ground. He might have had time to deal with the malfunction and avoid the serious injuries (broken ribs, shattered femur, pelvic and spinal fractures, dislocated hip and damaged kidney) if he had deployed at an altitude consistent with the Basic Safety Requirements.

The second incident with an ISI rating of 4 happened when a ring from a removable deployment system tangled with a brake line. The jumper attempted to land using the rear risers only. However, the entangled brake line interfered, and the jumper landed in a turn and fractured vertebrae in his lower spine. SIM section 4-A.D.3 states that jumpers should check their canopies after deployment and make sure they can steer and flare them.

Lower-experience jumpers made up a larger percentage of this equipment problems category (60%) than the successful-cutaways category (30%). This data suggests that jumpers with less experience are more likely to struggle with problems longer or handle problems poorly. In two instances—one a brake-line knot, the other a step-through—the jumper did not take any action and landed with the malfunction. Both were injured (ISI of 2) during their landings. Skydiver’s Information Manual Section 4-3.F.1 states, “The most important skill a skydiver must develop is the ability to cope with and respond to emergency situations. A student should review emergency procedures at the start of every jump day.” Although the SIM makes no recommendations regarding regular emergency-procedure reviews for licensed jumpers, it’s clear that it is beneficial, especially for those with less experience.

 

Incorrect Emergency Procedures | 13, 4.8% (2019-2021–5%)

This category is filled exclusively with less-experienced jumpers. Here are some tips to help jumpers gain experience safely:

  • Start with the basics. Learn skydiving theories and concepts from the SIM, in courses or from mentors.
  • Apply what you learn. Practice your skills in simulated situations. Seek feedback and improve your performance.
  • Learn from your own and others’ mistakes and successes. Ask questions. Parachutist’s incident reports are a great resource.
  • Keep learning.  Expand your knowledge and skills by exploring new areas like rigging, meteorology and aviation. Learn about concepts such as cognitive bias, normalization of deviance and the Dunning-Kruger effect, to name a few.

There’s an old skydiving adage that goes, “There are old jumpers and there are bold jumpers, but there are no old, bold jumpers.” This is a way of saying that skydiving is a risky sport that requires caution and wisdom. It implies that young skydivers who are too bold or reckless may not live long enough to become old skydivers. On the other hand, old skydivers who have survived many jumps have learned to be careful and prudent. 

 

Hard Openings | 12, 4.5% (2019-2021-2.4%)

We have seen an increase in the number of hard openings reported by jumpers over the years as more people are willing to share their experiences. Jumpers reported one hard opening per nearly 500,000 skydives in 2022, but it is likely that far more went unreported.

Five of those who reported a hard opening in 2022 experienced nothing more than discomfort. Four others reported visible bruising after their hard openings. One jumper’s hard opening caused several broken lines, and the jumper suffered a facial cut with swelling and severe back pain. One jumper reported dislocating a shoulder, which required surgery, during a hard opening. Another jumper suffered a dislocated shoulder, as well as a concussion and spinal compression from their hard opening.

USPA urges any jumper who experiences a hard opening to fill out a detailed incident report and provide contact information for follow-up (Online incident reports come through anonymously, so you must provide contact information or we won’t be able to reach you.). USPA shares these reports with the Parachute Industry Association, which is gathering data on this issue for the purpose of understanding and hopefully finding a solution to the problem.

 

AAD Activations

In addition to tracking the causes of non-fatal incidents, USPA also tracks automatic activation device activations. In 2022, USPA received 26 reports of AAD activations, 14 of which likely saved the life of the jumper. Sixty-five percent of these incidents involved no-pull or low-pull scenarios. All the no-pull situations involved students who had stability problems at pull time. The low pulls were mostly experienced jumpers.

Deploying a parachute is the most important freefall task. SIM Section 4-A.C.6 explains the pull priorities, starting with, “You must deploy the parachute,” and ending with, “Never sacrifice altitude for stability.” Jumpers need to keep track of their altitude and deploy at their assigned altitudes no matter what chaos they face in freefall.

 Nineteen percent of the reported AAD activations involved students or A-licensed jumpers incorrectly performing emergency procedures when confronting a hard-pull or being unable to find the main-deployment handle. Jumpers must prioritize getting a canopy out instead of fixating on their main pilot chute. SIM section 5-1.E says: “If altitude permits, the jumper should make no more than two attempts to solve the problem,” then deploy the reserve.

The 2022 reports describe 14 AAD saves. Seventy-nine percent were students or A-licensed jumpers with stability issues who didn’t deploy a canopy. One was a B-licensed jumper who had difficulty reaching their deployment handle. Two were D-licensed jumpers who were knocked unconscious (one from striking the aircraft, the other from a freefall collision). Both jumpers remained incapacitated though landing and although their injuries were severe, they are both expected to make full recoveries.   

 

 

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 USPA 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.

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