Covering form of preliminary or final report

Date of event:	2023.10.16
Incident number:	CZ-23-1248
Report:	Final report
Place of event:	ATZ LKST
Registration mark:	Accident
Weight category MTOM::	<2250 kg
Type of operation:	Recreational and sport aviation
Plane / SFM:	Para
Type of plane / SFM:	Jalbert Parafoil 2000
Health effects of event:	The fatal injuries
PDF document:

Description:

SUMMARY

Synopsis

On 16 October 2023, the AAII was notified of a parachuting air accident at LKST ATZ. The parachutist made a parachute jump from the Cessna 172 aircraft from the altitude of 1,000 m above the ground. After a short time in a stabilised belly flying position, he rolled over his head to the back flying position. In this position, he was in free fall with no apparent attempt to regain a stabilised belly flying position. Low above the ground, he activated the main parachute, which slowed down the free fall velocity, but did not prevent the parachutist from falling hard to the ground. The parachutist had suffered injuries to which he succumbed on the spot.

 

Factual Information

The parachutist was performing his third jump for precision landing training from the Cessna 172 aircraft from the altitude of 1,000 m above the ground. He left the aircraft as the second parachutist with about a two-second interval after the first parachutist. After jumping out of the aircraft, he maintained a stabilized belly flying position in free fall for 2 to 3 sec. He then rolled over his head onto his back. He was on his back with his arms and legs outstretched in a slight rotation, falling to the ground without any apparent effort to resolve the situation. He activated the main parachute too low above the ground and hit the ground hard. The main parachute canopy remained spread out on the ground near the parachutist’s body. The parachutist succumbed to his injuries on the spot.

 

Analyses
Parachuting Equipment

The parachute set was fully functional for the jump and no malfunction or reduction in the parachute functionality or controllability was identified that would affect the course of the jump. The condition of the used parachute equipment was good. The parachute set was suitable for skydiving. The slider braking blanket was damaged due to the main parachute opening after a long free fall.

Both the parachute documentation and the condition of the parachute equipment showed the parachutist’s due diligence as he took exemplary care of his parachute set. The size of the parachute, the size of the surface load and the size of the reserve parachute corresponded to the parachutist’s training and weight.

The reserve parachute was in a condition caused by impact with the ground. The reasons for the reinstallation of the automatic activation device from the reserve parachute could not be determined by the Commission.

The parachute equipment used, its technical condition, size or method of use did not affect the parachutist’s fatal injury and there was no causal relationship between them.

Meteorological Conditions

The meteorological conditions were adequate for performing parachute jumps, the wind speed limit for the parafoil types of parachutes did not exceed the 9 m∙s-1 value.

Operation Organisation

The organisation of the paradrops was controlled by the DZM and the operation staff. The members of the staff in the shift had no influence on the history of the parachuting incident and could not prevent it from happening. The DZM organised and managed the parachute operation, including the search operation in accordance with the regulations for parachute jumps in the Czech Republic.

The Parachutist and the Critical Jump History

According to the parachute documentation, the parachutist was an experienced parachutist with a valid category C skydiving licence. According to his skydiving logbook, he made 570 parachute jumps as at 1 October 2023. For the last three years, he had been fully engaged in the parachuting discipline and performing of precision landings. He participated in training jumps, training camps, and competitions, including Czech Republic championships.

He performed his practical parachute jumps systematically without longer breaks that could affect his training skills. Over the period, when he was making parachute jumps, no case was known of his having a difficulty during activation of the main parachute. He had practical experience with a malfunction of the main parachute, which he solved correctly by cut-away and subsequent timely activation of the reserve parachute, on which he landed safely.

On the critical day before the start of the activity, the parachutist discussed the planned activity with his team members. Subsequently, by signing the list of participants in the parachuting operation, he confirmed that he was able to perform the jump. He had the full parachute set on in the standard way, and his equipment was fully in compliance with valid regulations. The parachutist was experienced and qualified to perform precision landing jumps. It was his third jump that day. The two previous jumps were made under the same conditions and took place without any problems.

Critical Situation

The critical situation occurred when the parachutist, after about 3 sec of falling in a stabilised belly flying position, probably because of his searching for the first member of the group, rolled over his head to the back flying position. He probably “froze” in this position, because during the next 10 sec, he did nothing to safely resolve the abnormal situation by resuming the stabilised belly flying position. He was probably under such high mental and physical stress, as confirmed by the high tension in his upper and lower limb muscles, that he probably “lost track of time and space” and realised too late that the situation was critical.

Well below the prescribed altitude of 600 m above the ground, the parachutist did not solve the critical situation by immediate activation of the reserve parachute, but low above the ground, he did the first thing he was used to, and that was the activation of the main parachute, whose canopy did not fill with air sufficiently enough so that the speed of impact would be compatible with survival.

 

Conclusions/Causes

The cause of the parachuting accident was a free fall after a properly executed jump from the aircraft and the activation of the main parachute too low above the ground.

Attached final report in PDF file is in original Czech language.