Covering form of preliminary or final report
| Date of event : | 2020-04-18 |
| Incident number : | CZ-20-0187 |
| Report : | Final report |
| Place of event : | Forested slope below Velký Javorník |
| Registration mark : | Accident |
| Weight category MTOM: : | <2250 kg |
| Type of operation : | Recreational and sport aviation |
| Plane / SFM : | Sports flying machines |
| Type of plane / SFM : | Non-powered Paraglider PAŠA 3-42 |
| Health effects of event : | Without injury |
| PDF document : | 
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Description:
SUMMARY
Synopsis
The pilot took off without checking the female passenger’s harness and discovered only after the take-off that the passenger was sliding out of the seat because all the straps were completely unfastened. In an attempt to land as quickly as possible, the pilot activated the reserve parachute approx. after about 3 minutes of flight. During emergency landing, the parachute canopy got caught in the crowns of tall trees, and the passenger fell down from the height of about 15 meters on a slight slope. Upon hitting the ground, the passenger sustained serious injuries and was transported by the IRS helicopter to the Emergency Department in the University Hospital. The pilot was not hurt. He climbed down the tree and called the IRS unit in cooperation with tourists passing by. The canopies of the tandem paraglider and of the reserve parachute were damaged when being removed from branches of full-grown trees.
Factual Information
The pilot together took off with a passenger without checking the passenger’s harness and discovered only after take-off that the passenger was sliding out of the seat because all the straps were completely unfastened. The passenger was hanging in the harness caught under both her armpits. As it was quite painful for her, she made it clear that she would not be able to keep holding for much longer. In an attempt to land as quickly as possible, the pilot activated the reserve parachute approx. after about 3 minutes of flight. During emergency landing, the parachute canopy got caught in the crowns of tall trees, and the passenger was suspended in the air without being able to get hold of anything. A borrowed helmet with a camera, which came down over her eyes, made her spatial orientation difficult. As she was no longer able to keep hold of the harness, she fell down from the height of some 15 m onto a slight slope. Upon hitting the ground, she sustained very serious and complicated injuries of lower extremities and was transported by the IRS helicopter to the Emergency Department in the University Hospital. The pilot was not hurt. He climbed down the tree and called the IRS unit in cooperation with passers-by. The canopies of the tandem paraglider and of the reserve parachute were damaged when being removed from branches of full-grown trees.
Analyses
The paraglider pilot held appropriate competence and medical certificates. He had a lot of experience in piloting a tandem paraglider. Since 2005, he has performed approx. 250 flights on his own tandem paraglider. In 2020, it was his first flight day when he conducted three commercial flights, including the event one. He was well familiarised with the Velký Javorník take-off area and its close surroundings.
When waiting for take-off, the pilot paid hardly any attention to the passenger. He did not provide her with any basic information about the flight or any fundamental briefing, including information about emergency situation solving. He failed to perform fastening of the passenger’s seat harnesses as a comprehensive set of successive steps finalised by an overall check. The pilot pulled the seat harnesses over the passenger’s head and put them on her shoulders, then he interrupted the harnessing process and allowed the passenger to move freely around the take-off area. Several minutes later, he approached her, put a protective helmet on her head, and fastened the strap under her chin. He carried out a lax inspection of the helmet fixation on her head and then attached the outdoor camera to the mount. This was the end of passenger’s harnessing for him, and he continued preparing the paraglider for take-off. The pilot was unable to explain why he had not fastened the safety clips on the passenger’s seat harness straps. Having attached the passenger’s seat to the pilot’s harness, he lifted the canopy to the flight position and then they together started running against the wind.
The event situation occurred immediately after the take-off, when the pilot discovered that the passenger was not fastened and seated. The passenger was suspended in the shoulder seat straps under both her armpits and as it was quite painful for her, she was making it clear that she would not be able to keep holding for much longer. In an attempt to get to the ground as quickly as possible, the pilot deployed the reserve parachute, in a not very convenient place however. The parachute canopy was caught in the crown of a high-grown tree so unfortunately that the passenger hung on in the open space without support. In addition, the borrowed helmet with a camera slipped down over her eyes, so she could not see anything. During the three-minute flight, the pilot asked the passenger several times how long she could hold on, but neither gave her any meaningful advice on how to hold on in the seat straps, nor warned her about activating the reserve parachute. After making an emergency landing in the crown of a tall tree, the pilot attempted to push a tree branch towards the passenger for her to catch onto it. However, without the ability of visual perception, the passenger was so disoriented and so physically exhausted that she could no longer hold herself within the harness and fell to the ground 35 sec after the emergency landing in the tree crown.
Conclusions/Causes
The cause of the air accident was the fact that the passenger was not properly fitted into the seat harness and subsequent failure to perform the prescribed five-point pre-take-off check.
Safety Recommendations
In view of the circumstances and other findings from accident investigation, the AAII recommends that the Light Aircraft Association of the Czech Republic considers amending Rule ZL 1 Terms of operation of the Sport Flying Devices (microlights)
in the Czech Republic as follows: Paragliders, Hang Gliders in order to establish the responsibilities of the pilot in command when flying with another person with particular emphasis on the following:
- The content of the safety briefing for other persons without an aeronautical rating (passengers) before the commencement of a flight or series of flights.
- The pre-flight check of equipment.
- Actions to be carried out in an emergency.
- The active presence of an additional pilot in the take-off area for commercial tandem flights with a valid paraglider pilot licence. This pilot would assist in pre-flight preparation and with the dressing of the passenger(s) in the seat harness. The tandem pilot would remain responsible for the accuracy and checking of the equipment fitting.
Attached final report in PDF file is in original Czech language.