skydiving fatality case study - asasi process of a recent... · skydiving fatality case study...
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Skydiving Fatality Case StudyRichard McCooey
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Presentation Overview
1. Introduction
2. Role of the APF
3. Overview of parachute equipment
4. Case Study of a recent fatality
5. Conclusion
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Safety & Training ManagerRichard McCooey
• Business background
• 35 years skydiving experience
• 30 years flying experience (CPL)
• Cert IV Lead Auditor & Workplace Health and Safety
• ATSB Investigation Fundamentals training
• Lead investigator on 11 previous skydiving fatalities
About the Speaker
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Safety & Training ManagerRichard McCooey
• 60 training operations around Australia
• Fleet of 90 modern aircraft (turbine)
• 400,000 jumps pa
• Chief Instructors accountable for safety
• SMS in place at all operations
• Winning multiple tourism awards
Skydiving Has Changed!
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Safety & Training ManagerRichard McCooey
Role of the APF
• Deed of Agreement with CASA
• Administer skydiving in Australia
• Jump Pilot training & authorisation
• Investigate incidents
• Annual safety audit of all operations
• Power to discipline members
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Safety & Training ManagerRichard McCooey
Overview of Equipment
Standard Parachute Equipment:
• Harness/Container
• Main Canopy
• Reserve Canopy
Backup Devices:
• Automatic Activation Device (AAD)
• Wrist altimeter
• Audible altimeter
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Safety & Training ManagerRichard McCooey
Post Incident Actions
• Emergency services called promptly
• First Aid clearly not required
• Equipment not disturbed
• Victoria Police/Coroner and APF investigation launched
• Media and Workcover interest low
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Safety & Training ManagerRichard McCooey
Preliminary Facts
• 44 year old male
• 35 Jumps experience
• Solo jump from 14,000 feet
• Impact with ground, part parachute open
• No witnesses
• Equipped with altimeter, audible altimeter and AAD
• No obvious cause
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Safety & Training ManagerRichard McCooey
Initial Evidence
• Main parachute not activated
• Reserve handle still in place
• Reserve parachute activated but not fully open
• AAD activated
• Three Reserve lines under deceased left armpit
• Still no obvious cause
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Safety & Training ManagerRichard McCooey
History of Deceased
• 35 Jumps over 16 years
• Intermittent pattern of activity
• Different equipment at different locations
• Some history of freefall instability
• No obvious cause but some human factors emerging
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Safety & Training ManagerRichard McCooey
Later Evidence of Interest
• Recent training video located
• AAD data recovered from German manufacturer
• First jump on new jumpsuit (3 months old)
• Marriage issues, living good life with mates
• Recent wind tunnel experience
• All equipment found to be operational
• Autopsy/Toxicology found non-contributory
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Safety & Training ManagerRichard McCooey
Past Training Jump
Training Jump
(Note the stability)
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Safety & Training ManagerRichard McCooey
AAD Data Review
AAD data download
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5,000 ft
750 ft
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Safety & Training ManagerRichard McCooey
The Pieces Come Together
Whilst all equipment found to be operational……
• Video/log evidence: stability issues at deployment
• AAD: supports instability at deployment height
• Lifestyle: marriage issues, living good life
• Jumpsuit: too tight due10Kg weight gain
• Wind tunnel: lack of height awareness
• Poor Currency: contributes to slow reaction times
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Safety & Training ManagerRichard McCooey
Likely Sequence of Events
• Normal freefall from 14,000 ft
• Trouble reaching main deployment handle
• Jumpsuit/weight gain possible contributing factor
• Bent at waist causing instability (rolled onto back)
• Failed to revert to emergency procedure (reserve)
• Lost height/time awareness (200 kph or 12,000 ft/min)
• AAD activated reserve at 750 ft
• Reserve pilot chute under armpit
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Safety & Training ManagerRichard McCooey
Coroner’s Findings
• Finding without Inquest (14 months later)
• Satisfied equipment was NOT deficient
• Adopted APF scenario of events
• Left APF to make any recommendations
Note:
• APF has directed more focus on currency
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Safety & Training ManagerRichard McCooey
Close
• 2 fatalities per year and declining
• Back-up devices have really assisted safety
• New challenges with high performance canopies
• Remains an adventure sport – potential danger
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Safety & Training ManagerRichard McCooey
Thank You