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AAD investigation after a fatality - partial?

 

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skydiverek  (C 952)

Jan 10, 2012, 2:57 AM
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AAD investigation after a fatality - partial? Can't Post

Isn't it strange that in case of 'strange' fatality, where it is crucial to determine whether the AAD fired at the correct OR too low altitude, the AAD is investigated by the manufacturer (only)?

We have had approximately 10 fatalities in the last few years where AADs fired, but reserves failed to inflate. I believe in all cases the AAD was sent to the manufacturer to determine if it fired at the altitude it should have fired. The conclusion was that it did (in every case, from what I recall), and that it was a possible reserve PC hesitation, or speculated high freebag extraction force.

I am not saying that someone is lying here, but who would want the AAD company to be the judge in their own case? I suspect this situation is probably caused by the proprietary software that the AADs are using, and that only the manufacturer has the ability to read the data. But why no 3rd party observers, for example?

Imagine a situation - you are the manufacturer who has invested millions of dollars in your product (AAD). 'All your eggs are in one basket' so to say, you only have one product. The AAD comes back to you after a fatality, to determine whether it fired at a correct altitude, or not. You read it in the privacy of your own company and get a conclusion that it fired at 300 feet AGL, instead of approx 800 feet AGL. You conclude an obvious malfunction.

You now have a choice to:
a) admit the truth, and potentially loose the business, go bankrupt, and be unable to feed your family,
b) release the information that the AAD did its job correctly, firing at approx 800 feet AGL. You know that no one will be able to verify it anyways, the jumper is already dead and nothing can change that, and you can correct the 'bad product' quietly, in the privacy of your own R&D lab.

Again, I am not saying that it is happening, but the there is for sure room for such 'temptation', when everything is at stake ($company$ and business survival-wise).

Why do we trust partial investigations so much?

(I am taking a screenshot of this post now Wink).




realpet  (D License)

Jan 10, 2012, 4:14 AM
Post #2 of 27 (1787 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

Time to RTFM, this for example from Cypres User's Guide:
CYPRES is not able to open your reserve. It is
only intended to sever your reserve closing loop.



skydiverek  (C 952)

Jan 10, 2012, 4:22 AM
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Re: [realpet] AAD investigation after a fatality - partial? [In reply to] Can't Post

Please re-read my post, this time with understanding Unimpressed. I realize English is not your first language, but you totally missed the point. Maybe this will help?:

http://translate.google.com/#en|fi|


wolfriverjoe  (A 50013)

Jan 10, 2012, 6:13 AM
Post #4 of 27 (1708 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

Not the first time this has been brought up.

http://www.dropzone.com/...ty%20police;#3546393


RiggerLee

Jan 10, 2012, 6:24 AM
Post #5 of 27 (1695 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

 
I may dissagre with a lot of their pollicies. They certinly make a habbit of missrepresenting or at least coloring some of their statistics to place them in the best light. Number of "saves" etc. But what I can say is that I've never seen any sign of them hideing or faultsifing data in a fatality. I say this haveing been involved at least perrifrealy in a number of fatalitiy investigations.

Yes, the whole thing does seem a little strange. There is a little conflict of interest there but as far as I can tell it has never been abused.

Lee


diablopilot  (D License)

Jan 10, 2012, 7:18 AM
Post #6 of 27 (1662 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

Your entire post speaks to a mindset that you think it's acceptable to hold the AAD and it's manufacturer responsible for your/a life.

It's not. It's a tool. It's no more responsible than a screwdriver.

If you (or anyone) can't wrap their head around that, please stop using one or stop jumping completely.


skydiverek  (C 952)

Jan 10, 2012, 7:24 AM
Post #7 of 27 (1649 views)
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Re: [diablopilot] AAD investigation after a fatality - partial? [In reply to] Can't Post

In reply to:
Your entire post speaks to a mindset that you think it's acceptable to hold the AAD and it's manufacturer responsible for your/a life.

It's not. It's a tool. It's no more responsible than a screwdriver.

If you (or anyone) can't wrap their head around that, please stop using one or stop jumping completely.

You overinterpreted my post. It speaks what is says. Nothing "in between the lines".




obelixtim  (D 84)

Jan 10, 2012, 7:26 AM
Post #8 of 27 (1646 views)
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Re: [diablopilot] AAD investigation after a fatality - partial? [In reply to] Can't Post

In reply to:
Your entire post speaks to a mindset that you think it's acceptable to hold the AAD and it's manufacturer responsible for your/a life.

It's not. It's a tool. It's no more responsible than a screwdriver.

If you (or anyone) can't wrap their head around that, please stop using one or stop jumping completely.

+ 1. Anyone who voluntarily steps out of a plane, at any time, is responsible for saving their own life.

Most times an AAD fires, its a bounce that didn't happen. Anyone who experiences an AAD fire through their own failure or fault, should seriously think about taking up bowling.

End of story.


diablopilot  (D License)

Jan 10, 2012, 7:39 AM
Post #9 of 27 (1638 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

The post is ENTIRELY about assigning responsibility.

Edit:

Could it be true that the data is not impartial as it might be from a third party? Yes.

Do I think it's a problem? No.

The manufacturer should have no responsibility to hand their proprietary product to a third party. The information from the manufacturer should also be considered as just that, information from an interested source. The end user has the responsibility to consider, interpret, and discount if needed, that information.


(This post was edited by diablopilot on Jan 10, 2012, 7:48 AM)


skydiverek  (C 952)

Jan 10, 2012, 7:44 AM
Post #10 of 27 (1627 views)
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Re: [diablopilot] AAD investigation after a fatality - partial? [In reply to] Can't Post

In reply to:
The post is ENTIRELY about assigning responsibility.

My post was about who should be the investigator. That's it.


(This post was edited by skydiverek on Jan 10, 2012, 7:45 AM)


obelixtim  (D 84)

Jan 10, 2012, 7:59 AM
Post #11 of 27 (1607 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

In reply to:
In reply to:
The post is ENTIRELY about assigning responsibility.

My post was about who should be the investigator. That's it.

I'd be surprised if an AAD that has been involved in a bounce can be accurately tested by anyone.

I'd also be surprised if suitably qualified "3rd party" assessors are thick on the ground to oversee testing in a competant manner.

Also I think if an AAD manufacturer states his product will cut the loop, and it actually does so, it would be very hard to prove at exactly which point it does so, considering the variables that could affect the thing operating.

Considering that an AAD is a back up only, and not a primary component, I think it is reasonable for the manufacturer who has the expertise and technology to do the testing. If he finds a fault in a component that he prolly didn't build, then responsibility for that item rests back on the manufacturer of said component...,

BTW i have seen an AAD turned on AFTER an incident, in an attempt to cover up the fact that it wasn't on in the first place. It didn't take much to figure out what had occurred.....This was an FXC 12000.....


(This post was edited by obelixtim on Jan 10, 2012, 8:33 AM)


pchapman  (D 1014)

Jan 10, 2012, 8:31 AM
Post #12 of 27 (1584 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

In reply to:
(I am taking a screenshot of this post now Wink).

Hello, Rhys, where are you? Smile


I agree with the idea that there probably isn't real fraud going on, but there is that feeling of conflict of interest.

We can't get around the manufacturer doing some of the tests, since we don't have independent flight data recorders. If an airliner crashes, the aircraft manufacturer will assist the safety board, and the safety board can send guys to the manufacturer if certain parts are inspected there.

We lack that kind of money in skydiving, but more importantly, we have almost no process for accident investigation.

Some countries might have something, or have something in unusual circumstances. (E.g., the Polish investigation into the death of a student with an Argus -- that was surprisingly competent, coming from a government.)

What is the accident investigation process, say in the USA? Some guy on the dz scribbles up an incident form, and sends it to the USPA? Will someone with the organization follow up with a phone call? Nothing more than that? After all, we do see fatality reports where basic info is missing. If the DZ didn't supply it, tough luck. There's no money / process / authority / whatever to investigate further.

Sometimes the USPA web site accident report has more info than what's scattered among all the posts on dz.com, sometimes not. The USPA online reports don't carry the identifying details to make searching easy. (E.g., no searchable database where one can type in date and state or name of the deceased and get the output. The US NTSB for aircraft at least provides a searchable database, and unique identifying codes for each accident.)

Since we don't have any 'officials' or 'official process' involved, it might be hard to get access to equipment -- one can't just go borrow dead people's stuff. And if someone says they aren't releasing data because of a pending court case, we don't have any higher authority to get it.

Just about the only reports that I've seen from the US that was a little more detailed were Kirk Smith's San Marcos Argus report, and his "What's Going on with AADs?" report (not specific to any one accident). He did the latter report presumably on his own initiative, and the former because he was asked by Argus (A.A.D.) as a dealer to assist. That report does actually show a little 'cooperation' between different groups, at least to get together to talk -- There was a meeting that was attended in person by Kirk, the FAA, the jumper who had an AAD issue, a rigger involved with packing the rig, an experienced rigger from the DZ, and a representative from Argus (by phone).

It isn't clear to me to what degree the FAA wanted to be there or was involved. You know how they are, it's not their job if we die, they just want to make sure the reserve was in date, and no air regs were broken. (Having more FAA involvement would have its down sides.)

Even if the US has very little formal process to investigate a skydiving fatality, other countries may have more.

I imagine the BPA in the UK could be more rigorous -- they go through great detail even without an accident. If one reads their minutes, they haul instructors and riggers up in front of their meetings to account for themselves if errors were discovered, to determine whether sanctions should be applied. They clearly have some sort of investigative process.

An issue at least in North America is cops etc. sometimes grabbing gear, tossing it in the trunk, and making off with it for a couple months, ruining chances at careful, timely inspection. Occasionally cops at an accident are OK, but if I were around a fatality early, I'd be documenting everything I could and try to get data before any damn cops got close. Clearly trying to sweet talk them might be more productive than getting in their faces, but if I were ever hauled off by cops for obstructing them, that would be the place.

For AAD's how many times have we ever actually seen graphs from the data readout for an incident? I've only ever seen a couple on dz.com, and those were from Vigil. I don't recall what the circumstances were, or who was able to access the data and post them.

Seeing some graphs would offer some peace of mind to help confirm what a manufacturer says. They still wouldn't be revealing algorithms and such.

There is the little issue that with a single pressure sensor to determine altitude with, we have no independent confirmation of altitude. Yeah, we know, the AAD says it fired at 750' right on the button, but how do we know it really was at 750' when it thought it was? (Or at least, it fired at, say, 1050' pressure altitude which would be 750' belly to earth with a burble or 1050' back to earth.)

Well, off the top of my head, there are ways to infer altimeter correctness to some degree, but it can still get tricky. One can check that it recorded jump run correctly against other devices, and ground level, but that still leaves questions about burbles and body position down around AAD firing altitude. That's where one would be analyzing the pressure vs. time trace carefully, trying to calculate fall rates and accelerations, applying smoothing calculations, to see if one can tease any useful info out of it.

I don't know on whose authority the data would be released, but it would be nice to see a few of those graphs in case of fatalities. We might not be qualified to fully interpret it, but it would be a little more satisfying than just hearing the manufacturer say, yes it fired at the right height.

In the sport of skydiving we don't have good answers yet on why people go in after their AAD fired. Sure we have plenty of ideas, but no clear proof. Being presented with evidence about how the AAD performed would help us better understand the situation.

I wonder if, say Cypres would even provide a data readout, if one sent in one's own AAD and offered to pay for their time. (Since it is your own AAD, while you are alive, there's no issue like after an accident over who has authority.) Vigil in contrast offers for sale their download box to interface with the Vigil and record jump graph data. I don't know who has them, maybe some distributors or dealers, but at least the idea is that one can get an output graph.



Edit:
Regarding some other posts, for *uck's sake, why is it that whenever someone asks a question about an AAD's functioning, someone has to chip in with "But they only cut loops!"

Sorry, is there something wrong with trying to stay alive, to improve the sport? When a student asks me as an instructor about something, should I just laugh at them and walk off, saying "There are no guarantees in skydiving, stupid!" The no guarantees stuff may be a useful concept for a newbie to understand, but it doesn't do anything to enhance a discussion of how things actually work.


(This post was edited by pchapman on Jan 10, 2012, 8:39 AM)


obelixtim  (D 84)

Jan 10, 2012, 8:57 AM
Post #13 of 27 (1560 views)
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Re: [pchapman] AAD investigation after a fatality - partial? [In reply to] Can't Post

 

Quote:
An issue at least in North America is cops etc. sometimes grabbing gear, tossing it in the trunk, and making off with it for a couple months, ruining chances at careful, timely inspection. Occasionally cops at an accident are OK, but if I were around a fatality early, I'd be documenting everything I could and try to get data before any damn cops got close. Clearly trying to sweet talk them might be more productive than getting in their faces, but if I were ever hauled off by cops for obstructing them, that would be the place.

OK, a lttle off toopic here....

In NZ, an accident investigator has precedence over the cops when it comes to a scene examination, for the simple reason the cops know jack about skydiving. The cops are used purely to protect the scene and are happy to do just that, even though in law, they have authority to do whatever they want. In practice, they defer to the experts.

In the event a cop was being overly officious I would advise him firstly that he was at risk of destroying/ damaging evidence, and get his superior on the phone ASAP to set him straight. Only after the investigator gives the all clear can the body, and then gear, be removed from the scene.

Thus the investigator has all the time he needs to do a thorough, detailed investigation.

The investigator then secures the gear and hands it to the cops for safekeeping or further analysis.... At any point he can ask the cops to render assistance in the investigation.

The cops, in NZ at least, are not a problem. I'm surprised they would be in the US. Would this be common?.


Anvilbrother  (C 39168)

Jan 10, 2012, 9:58 AM
Post #14 of 27 (1523 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

I see where you are coming from. Checks and balances, if it has to go back to the MFG because they are the only persons able to read the data, have a third party with knowledge of whats going on and knows a cover up when they see it present.


councilman24  (D 8631)

Jan 10, 2012, 1:43 PM
Post #15 of 27 (1435 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

The software and products are proprietary. Only the manufacturers (for the most part) can analyze their products. There is no regulation, testing standards, performance standards (in the US) or standardization of recorded data.

Who else do you want to analyze the AAD's?

All of the comments about its only a tool reflects that there is none of the above items.

The other issue was the data can say if it fired. Not if the loop was cut or the reserve was extracted.

I think your looking for stuff that isn't possible now. Until and unless AAD's (as well as skydiving in general) is regulated in the large markets to the level of Airline transport independent investigation is not reasonable.

And no PIA isn't in a position to try to take on this role. PIA IS the manufacturers and doesn't have the resources to become an investigative body.


Genego  (D 10375)

Jan 10, 2012, 2:52 PM
Post #16 of 27 (1388 views)
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Re: [obelixtim] AAD investigation after a fatality - partial? [In reply to] Can't Post

In reply to:

Quote:
An issue at least in North America is cops etc. sometimes grabbing gear, tossing it in the trunk, and making off with it for a couple months, ruining chances at careful, timely inspection. Occasionally cops at an accident are OK, but if I were around a fatality early, I'd be documenting everything I could and try to get data before any damn cops got close. Clearly trying to sweet talk them might be more productive than getting in their faces, but if I were ever hauled off by cops for obstructing them, that would be the place.

As a cop, jumper and rigger, I feel at least a little qualified to comment. The first thing we need to remember is that officers will treat the area as a crime scene. I would personally question the motives of anyone trying to "get data" before the "damn cops" get close, it creates the appearance of impropriety even if none exists. Not dissimilar to the original idea that an ADD manufacturer might not report a fault in an ADD as it could be against their vested interest. It is difficult for anyone on a drop zone to be an impartial witness to a fatality, the decedent is our friend, husband, wife, father, mother, son, daughter. The DZ operator has business concerns in addition to the personal concerns. The police, for good or ill, are neither emotionally nor fiscally involved in the situation. Therefore the odds that they will make impartial decisions, especially at the initial scene, are much greater than those who are directly and emotionally involved in a fatality. That includes properly recovering any and all evidence and maintaining the chain of custody for everything recovered. As for careful, timely inspection, I'm not going to let you "inspect" anything at a crime scene. I don't know you, I don't know your connection, I don't know your "expertise" , I don't know your self interests. My responsibility is not to the bystanders regardless of how vocal or upset they might become, it is to the victim and subsequently to their family.


pchapman  (D 1014)

Jan 10, 2012, 3:40 PM
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Re: [Genego] AAD investigation after a fatality - partial? [In reply to] Can't Post

All that you said seems reasonable.

In reply to:
As for careful, timely inspection, I'm not going to let you "inspect" anything at a crime scene. I don't know you, I don't know your connection, I don't know your "expertise" , I don't know your self interests.

Just like I don't know the cops or whether they'll mess things up.

The cops may be interested in knowing whether it is a crime and have some sort of duty to check that out, even if it seems laughably improbable to a skydiver.

(Maybe it is a terminology issue. If it were an incident scene or investigation scene, that sounds reasonable. Maybe terms like those are actually formally used, but when everyone just calls it a "crime scene" when 99+% of the time there's no crime, it just looks really stupid and leads to misunderstanding.)

Although having some duties, cops may have no duty towards the furthering of skydiving aviation safety.

Quite possibly there's a reporting & recall bias, that over 20 years, I've heard more about & remembered more clearly a 'few' or 'some' cases where the cops seemed not to care. Maybe they call the FAA or NTSB and hear back that those groups aren't all that interested, so who else do they know who can investigate? They can't be sure if we can't be sure what procedure to follow either. Who is independent enough or knowledgeable enough to collect data? How much supervision is needed when there are issues of conflict of interest, as there often is even if at a minor or perceived level? No simple answers.


obelixtim  (D 84)

Jan 10, 2012, 4:17 PM
Post #18 of 27 (1332 views)
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Re: [Genego] AAD investigation after a fatality - partial? [In reply to] Can't Post

In reply to:
In reply to:

Quote:
An issue at least in North America is cops etc. sometimes grabbing gear, tossing it in the trunk, and making off with it for a couple months, ruining chances at careful, timely inspection. Occasionally cops at an accident are OK, but if I were around a fatality early, I'd be documenting everything I could and try to get data before any damn cops got close. Clearly trying to sweet talk them might be more productive than getting in their faces, but if I were ever hauled off by cops for obstructing them, that would be the place.

As a cop, jumper and rigger, I feel at least a little qualified to comment. The first thing we need to remember is that officers will treat the area as a crime scene. I would personally question the motives of anyone trying to "get data" before the "damn cops" get close, it creates the appearance of impropriety even if none exists. Not dissimilar to the original idea that an ADD manufacturer might not report a fault in an ADD as it could be against their vested interest. It is difficult for anyone on a drop zone to be an impartial witness to a fatality, the decedent is our friend, husband, wife, father, mother, son, daughter. The DZ operator has business concerns in addition to the personal concerns. The police, for good or ill, are neither emotionally nor fiscally involved in the situation. Therefore the odds that they will make impartial decisions, especially at the initial scene, are much greater than those who are directly and emotionally involved in a fatality. That includes properly recovering any and all evidence and maintaining the chain of custody for everything recovered. As for careful, timely inspection, I'm not going to let you "inspect" anything at a crime scene. I don't know you, I don't know your connection, I don't know your "expertise" , I don't know your self interests. My responsibility is not to the bystanders regardless of how vocal or upset they might become, it is to the victim and subsequently to their family.

I would think the cops have also got a responsibility to other jumpers who jump the same system when they go full on and disturb an accident scene and possibly destroy evidence that may save lives in the future.

There is no rush in these situations to get the job done. Most skydiving experts are in fact skydivers. Who do the cops expect to do a thorough investigation?. In NZ the investigation has to be done by a jumper with no connection to the DZ in question, but the initial investigation is usually initiated by the people on the spot, and that is usually only a visual and photographic recording of the scene... Why would the cops have a problem with that?, especially as they are there to supervise....


RiggerLee

Jan 10, 2012, 6:39 PM
Post #19 of 27 (1279 views)
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Re: [obelixtim] AAD investigation after a fatality - partial? [In reply to] Can't Post

I've seen both ends of the spectrom.

Example one: Quincy. I worked in the rigging trailor for jeff Wagner for... I think it was nine years. I guess we bounced about one jumper a year on adverage. I'm not talking straight up landing accedents or silly shit like the floater in the kiddy pool. On adverage we had one "interesting" fatality a year. It was a unique inviroment in that the staff police, FAA and all the manufactorers were there, knew each other, and were used to working with each other. Wag is the one that was normally called out to deal with them. I would generally make my self scarce in the sewing room. Don't really like looking at bodies, don't drink dont do drugs and have way to good a memory. Scott Chue was also an old friend of Wags, He was the doctor on sight for a number of years and we would all hang out in the trailor in the evenings as they drank beer. Needless o say we got full unedited reports on all the accedents and incedents of the day. fastest most therogh investigations ou could ever have. Cops to control the scene. FAA to take charge. Under them all the experts you could ask for on site. Done in a day. Evrey thing was examined in place. No access issues. Total trasparency. I loved having the FAA there on site. It made every thing so much easier. And a lot of those guys are a lot cooler then you would think.

Now lets take the opposit end of spectrom. Or all most. I used to hang out at Dallas. There they took the exact opposit attude. There was kind of this atmosphere of fear and paranoia. The first thught in every ones mind was littigation. The first thing the staff would do is to try to keep every one away from the scene. Not a bad thing on the whole. The para medics would generaly cut through any thing they could wether it was nessasary or not. The local police would take over the scene gathering up ad seazing every thing in sight destroying any evedence that might have exested on site. A coulpe of the staff would go around takeing statements for there "private files" We had a couple of really pompus ones that got a huge power trip out of this. But it was all about controling infomation. The FAA would be notified. Now as it happions we ad a guy around there named Giene Bland. Old sky diver, rigger, dropzone owner from way back. He could be a real pain in the ass turning mole hills into mountians. But there were times that I think we were lucky to have him. This is one of them. He was actually interested. He would actually show up. It was a cance for him to get out of the office he hated and force his boss to pay for him to fly his POS 182 up there. So we would get the gear back in a pile wrapped in a white sheet. It would go up in the loft under the table And Bland would fly up in his plane. I was usually working in the loft. Bland would come in and we'd all unwrap the bundle and start going through it. Or depending on where the gear wound up they might do it down in dallas. In which case he might call a coulple of riggers down like Stanford for there oppions. Bland had been out of the loop for a long time and wasn't real current. The bottom line is that if it wasn't for him there probbable wouldn't have been any tecnical investigation at all. If t hadbeen up to the drop zone manager it probable never would have happioned. He once tryed to keep me from answerng Blands questions. He didn't quite cross the line and tell me to lie to the FAA but he basicaly said that he wanted to be in control of every thing that bland learned. The point is that it was the exact opposit of how it was run at Quincy.

And as for the USPA. To the best of my knowlage they do not do any form of investigation at all. If an interested party, An S&TA for example should take it upon them selves to make some observations, take notes on gear, etc they will publish a write up of it in what ever detale is reported in parachutest. At least this has been my impression. If they have a more formal proceadure then that please correct me. I have never met a picked team of investigators flown in from around the country by the USPA at the sceen of a fatallity.

Lee


obelixtim  (D 84)

Jan 10, 2012, 7:14 PM
Post #20 of 27 (1261 views)
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Re: [RiggerLee] AAD investigation after a fatality - partial? [In reply to] Can't Post

 A big part of our Instructor rating involves accident investigation techniques and standard procedures.

Every DZ has an ops manual that contains a checklist of the procedure to follow in the event of a serious accident or fatality. This can be handed straight to the cops on the scene, so it puts them completely in the picture as to what is going on. They seem very happy to let us do our job.

If a cop was ever obstructive I would make sure the coroner knows about it, and would expect him to be severely censured.....never had that happen though.

You can't bring a dead person back, so the priority is determining the cause as accurately as possible, because of the implications of equipment problems, especially for jumpers still jumping that gear., or procedural problems if it is a training issue.

Of course in NZ we don't have the litigation culture, so the need to cover up isn't there, full stop.

The one attempt to do so in the early 80's was almost immediately exposed, the culprits IMO should have done serious jail time for manslaughter, but the system wasn't in place back then.

Funnily enough it was the police who led that investigation, and screwed it up completely because of their own ignorance. By the time an experienced investigator got to see the gear, most of the evidence that could have been used in a prosecution was contaminated or destroyed. The pricks involved got away scot free.....

But it provoked a serious change to the way investigations were carried out. I've been called in to investigate several fatalities at other DZ's, and even though the senior personnel involved were close friends, it had to be approached with a completely impartial mindset.

And that is understood and accepted by everyone as just the way it has to be, whatever the findings.

IMO it has led to a cleaning up of shoddy practices, and skydiving is definitely safer as a result.


dorbie

Jan 11, 2012, 8:47 PM
Post #21 of 27 (1073 views)
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Re: [councilman24] AAD investigation after a fatality - partial? [In reply to] Can't Post

In reply to:
The software and products are proprietary. Only the manufacturers (for the most part) can analyze their products. There is no regulation, testing standards, performance standards (in the US) or standardization of recorded data.

I'm sure you could do all that if you want to pay $5k for an AAD.

In reply to:
The other issue was the data can say if it fired. Not if the loop was cut or the reserve was extracted.

.... and not whether the data feed was correct and more active testing after a bounce will always be suspect.


dorbie

Jan 11, 2012, 8:50 PM
Post #22 of 27 (1071 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

In reply to:
in case of 'strange' fatality,

Nothing strange about skydiving fatalities. It'd be strange if jumpers stopped dying.


Skydivesg  (D 10938)

Jan 11, 2012, 9:08 PM
Post #23 of 27 (1063 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

As mentioned up thread, anyone can buy the I.R. reader and print the graphs of information that is contained in the unit.

I don't believe they are trying to hide anything.

http://www.vigil.aero/ir-download-box


skywombat  (D 31874)

Jan 12, 2012, 12:13 AM
Post #24 of 27 (1015 views)
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Re: [skydiverek] AAD investigation after a fatality - partial? [In reply to] Can't Post

Even completely sincere and honest AAD analysis may not always reach accurate conclusions with certainty, and the manufacturers are probably well aware of this. For instance, a plausible failure mode would be the AAD pressure sensor reporting an incorrect altitude value, in which case the AAD might both record and fire at what it believes to be the correct altitude, regardless of the actual altitude at the time. The failure might be transient, and not reproducible in a chamber after the fact. How might one even conclusively detect such a failure (without an independent secondary sensor or some other recording mechanism), or be certain it did not occur?


skydiverek  (C 952)

Jan 12, 2012, 2:11 AM
Post #25 of 27 (990 views)
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Re: [Skydivesg] AAD investigation after a fatality - partial? [In reply to] Can't Post

In reply to:
As mentioned up thread, anyone can buy the I.R. reader and print the graphs of information that is contained in the unit.

I don't believe they are trying to hide anything.

http://www.vigil.aero/ir-download-box

For Vigil: yes. For Cypres: no.


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