Non-Incident analysis

[fcajump 153]

I recently reviewed the Cypres-Save report at:
https://www.cypres.aero/the-day-cypres-saved-my-life/
(video is there too)
and had some thoughts/questions on it...

Note: Please understand, I am NOT interested in calling out the individual... our (re)actions when things go south are not always what we would prefer, but also different training and philosophy leads us into different actions. My first reserve ride could have also gone better. My point with this is to analyse, discuss and learn... just as with an incident, I think there is much for everyone (especially our newer jumpers) to learn with this dive. Fortunately, the individual is still around to learn as well.

Selected Details:

Quote

He had 307 jumps at the time.
4-way
“At my planned time of 1000 meters, my hand-deploy was not findable,” “I couldn’t feel it. It was possibly hidden by wind pushing the bottom edge of my freefly-jacket over it, but the fact was that it wasn’t tactile.”

Note: ~3,280ft for us 'mericns...
Lesson 1 - make sure your clothing selection can not impede your access to your handles or block your vision.

Quote

“There were a lot of things running through my mind as I was trying to find that hand-deploy,” he says, wryly. “First: ‘Oh sh*t, this has never happened to me before!’ Secondly, ‘Keep calm! Go on feeling around for it…strike against the container…the reserve-pull isn’t needed quite yet.’ The third thing, of course: ‘Try to get it right.’”

To the good Dr: yep... sounds like a very familiar internal dialog at that point...

Quote

altitude had dropped to just 750 meters. He imagines now that he had sped up his descent rate as he was fumbling for the hackey. He’s sure that he lost strict belly-to-earth orientation and had begun accelerating beyond the 125 mph descent rate he was used to. His hackey was still missing.

Note: 2,460ft
Lesson 2: Work to maintain body position, but deployment before hard deck is primary goal. Increased speed would not be unusual, nor the time used pursing the desired goal (main deployment), but don't loose track of ALTITUDE. (I don't say "time" here, as really its the altitude that matters and with both varying speed and mental time dilation during a crisis, its hard to keep that meaningful.)

Quote

When he reached his decision altitude of 500 meters, he realized the time had come. “I thought, ‘No longer! Time to cut away!

Pause here...
Note: ~1640ft, not an unusual hard-deck.
Note: "cutaway" was the thought despite nothing out on the main.
This is not a PC-in-tow or beyond, this is a no-pull, high speed situation.
It IS consistent with the "always use one procedure" method, though it takes a little more time, the training is to then ALWAYS pull the reserve handle as well...
Roll tape...

Quote

Reserve!,’” he says. “I changed my body position to sitfly in order to see handles in front of me, so I’m certain I accelerated even more. I pulled the cutaway handle but I did not pull the reserve right away. The canopy didn’t leave the tray, so it didn’t trigger the SkyHook. I already had the experience of successful SkyHook reserve deployment last year, so I was expecting to see a canopy after I cut away. I looked up and thereby lost one precious second of time.”

Lesson 3: yep, your post/self-analysis is good. Because there is no main, the cutaway is not going to activate the skyhook based deployment and time has now been spent both pulling the cutaway handle AND in the split second to realize that still nothing is happening and why.
Question #1: Does anyone teach going into a sit when deploying the reserve? If so, why? On the one hand I could see that it clears the burble so as to (maybe) have a cleaner launch of the PC, but it also speeds you up, may put you on your back (shouldn't.. but...) and in this case may actually cause the jacket to cover these handles as well due to the relative wind shift. Finally, as John Sherman has pointed out, some rigs have increased deployment forces getting the freebag out of the container from that angle.
Lesson #4 (from the video) some precious time appears to be wasted at this point trying to decide which hand should hold the (already deployed) cut-away handle and which should reach for the reserve. If you're going to pull it, clear it and THROW IT. Not worth holding on to for the time spent and the distraction.

Quote

When the altitude reached a 300 meters, still in a sitfly position, and time had pretty much run out.“I reached to my left,” he explains, “And in this last moment, my CYPRES fired.”

Note: just under 1000ft
Yep... that's what should happen, because at this point you are below your hard deck... the time spent awaiting the skyhook went just like that... As to it not being 750', I would suggest that in a sitfly position, the Cypres would likely read a little lower and may fire a little higher... But at that speed/altitude, the difference is slight if any...

Quote

estimates that his canopy time was about five seconds–”just long enough to take [his] toggles”–but he landed safely on the dropzone.

Note: actually 12 seconds, but definitely a very short time to analyse your canopy, location, direction, landing options and fly a canopy you may have never flown before to a safe landing. Which he did VERY well. The final turn didn't go as far as he might have on his main, but he did correct that too.

Quote

“If I could do it again, I wouldn’t hesitate to go for my reserve handle,” he adds. “And not to rely on my SkyHook. Just as it’s taught in Skydive-education! But I am full of thankfulness that my CYPRES saved my life. That’s the most important thing!”

Note: And here he shows that he did learn better and the why of it. One set of good decisions (getting a good reserve and AAD, and turning the AAD on before the jump) means that he gets to learn and try again.

Some will point out that he was finally on his way to pulling silver...
Would he have been quick enough and survived? Dunno... but at that point, the AAD did what it was designed to do.

Finally - I commend this jumper for his gear choice, his review of the jump, actions, outcome and video. Had my first reserve ride been on video, I don't think it would review any better. Glad to be discussing this here, rather than on the incidents page.

JW

Always remember that some clouds are harder than others...

[Quagmirian 40]

Sorry I got lost when he started talking about expecting the skyhook to actually do something after cutting away.

[gowlerk 1,911]

All too human and just about what the average AAD save really is. Most of us say that we have them because we may take a hit on a jump and it could save us. But the reality is that we are human, time is short in freefall, and all of us could screw up. I've personally been on the scene of only a few AAD fires. All of them caused by a single person's error. None involving anyone taking a hit.

And almost all come with much less honesty than this report.

[obelixtim 100]

I wouldn't call that a non incident. A non fatality would be more apt.

There is some truth in the saying that an AAD save is a bounce that did not happen, and should be investigated in the same way as a bounce. The bonus being the primary witness is there to give their version.

His analysis is very good, but really it all boils down to dithering when he should be reacting.

The big lesson is to keep your EPs current, and be ready for anything. It seems he allowed himself to forget the drill for total malfunction.

When the ants look like people.....

My computer beat me at chess, It was no match for me at kickboxing....

[GoGoGadget 0]

It is important to learn from your mistakes. Even better to learn vicariously from the mistakes of others. Life is too short to make them all yourself.

[CrashProne 4]

If you're only going to pull ONE handle during an emergency, it had better be the reserve and you had better have nothing else out. When he puts both hands on the cutaway handle/cable, it's him trying to bundle it up for storage inside his suit, he believes he's DONE with his EP's at this point. Uh, NO...

[gowlerk 1,911]

Before AADs were in common use fatalities involving people cutting away then failing to pull the other handle, or waiting too long before remembering were fairly common. This scenario accounts for the largest proportion of AAD saves.

[dthames 0]

I am not an instructor but it seems really weird that some people (not specifically this jumper) would insist on a plan that you would pull the cutaway handle 100% of the time before deploying the reserve.

This thinking would suggest that some jumpers don't have a good understand of what was the proper course of action during a given situation. That is troubling to me. We all need to be very aware of what is going and what needs to be done under these conditions. If you know the pilot chute is still in the pouch and you have no reason to think the pin is out, then just deploy your reserve when you need to.

Instructor quote, “What's weird is that you're older than my dad!”

[fcajump 153]

dthames

I am not an instructor but it seems really weird that some people (not specifically this jumper) would insist on a plan that you would pull the cutaway handle 100% of the time before deploying the reserve.

This thinking would suggest that some jumpers don't have a good understand of what was the proper course of action during a given situation. That is troubling to me. We all need to be very aware of what is going and what needs to be done under these conditions. If you know the pilot chute is still in the pouch and you have no reason to think the pin is out, then just deploy your reserve when you need to.

I agree that a cutaway in this situation is not a useful step and wastes time.

The USPA SIM agrees with you as well (5-1-E. Total Malfunctions 2.a specifies to go straight to reserve). It is only in 2.b (PC in tow) that the SIM gives options to either cut-away or not, as both have their risks.

However, in an emergency conscious decisions are slower than practiced responses (e.g. low bailouts where jumpers deploy their main vs reserve).

That alone would not have been a significant (if inappropriate) problem here EXCEPT that the practiced behavior appears to have been cutaway and wait, rather than cutaway and deploy reserve. To go down that rabbit-hole a little further, we have been trying to get people to ensure the cutaway was successful before pulling silver (i.e. ensure one side didn't get hung-up)... in this case (or in the case of actual PC-in-tow) you would wait a long time to see the risers clear...

All of which leads me back to your notion...
Correct situational awareness (total, due to inability to initiate main deployment) should have lead to correct response (reserve NOW).

And this is one of the reasons I posted this... to get folks (including myself) to think through their decision tree on the ground and then practice for each branch of that tree.

His outcome was successful (thanks at least to the AAD), though I can agree with those that suggest that this IS actually a no-injury "Incident".

JW

Always remember that some clouds are harder than others...

[billvon 2,398]

>Does anyone teach going into a sit when deploying the reserve?

No; the risk of instability and further loss of time is too great IMO. But I do teach to check behind after deployment by twisting hard at the waist - which both allows you to see if the canopy is deploying and breaks the burble.

>I am not an instructor but it seems really weird that some people (not specifically this jumper)
>would insist on a plan that you would pull the cutaway handle 100% of the time before deploying
>the reserve.

>This thinking would suggest that some jumpers don't have a good understand of what was
>the proper course of action during a given situation. That is troubling to me.

But common; people vary in their reaction to stress, and some people get narrowed concentration (i.e. concentrate on finding the handle to exclusion of all else.) There is value in having a single procedure that always works.

[fcajump 153]

billvon

>But common; people vary in their reaction to stress, and some people get narrowed concentration (i.e. concentrate on finding the handle to exclusion of all else.)

Reminds me of the poor guy that got so focused/freaked-out when he realized his chest-strap was not fastened in freefall* that he was still working to fasten it up after landing... stress of the situation can make you act less rationally than you would hope. Pre-thought and repetitive training/practice will better enable one to handle the emergencies that arise.

*mind you - I'd be pretty damn focused on the chest strap in that case too... and after landing I'd be focused on changing my shorts...


JW

Always remember that some clouds are harder than others...

[wolfriverjoe 1,340]

dthames

I am not an instructor but it seems really weird that some people (not specifically this jumper) would insist on a plan that you would pull the cutaway handle 100% of the time before deploying the reserve.

This thinking would suggest that some jumpers don't have a good understand of what was the proper course of action during a given situation. That is troubling to me. We all need to be very aware of what is going and what needs to be done under these conditions. If you know the pilot chute is still in the pouch and you have no reason to think the pin is out, then just deploy your reserve when you need to.

Well, the question on this would be something like:

Will it take more time to pull the cutaway, then the reserve, no matter the situation?

Or will it take more time to evaluate the situation, decide on a course of action (whether or not to pull the cutaway handle), and execute that action?

Generally, in the case of procedures that are not actually executed on a regular basis, and will be needed very quickly, and under very high stress, simple is better.

"There are NO situations which do not call for a French Maid outfit." Lucky McSwervy

"~ya don't GET old by being weak & stupid!" - Airtwardo

[grimmie 173]

We have a serious problem in our sport with a lack of continuing education.

It is not uncommon to have very experienced jumpers perform very poorly in emergency situations. You can go thousands and thousands of jumps without encountering an issue, thus leading to a severe case of complacency in many long time jumpers.

We also have an entire new generation of jumpers that don't know an AAD from a skyhook. Their gear knowledge is minimal.

We need to do a much better job of continually training ALL jumpers on ALL aspects of our sport that continually change, and keep them on their toes for emergency situations. IMHO

[gowlerk 1,911]

Skydivers are the least disciplined of all aviators.

[JerryBaumchen 1,048]

Hi Rich,

Quote

a lack of continuing education

You can lead a horse to water but you cannot make him drink.

Way too many jumpers simply do not want to learn.

Jerry Baumchen

[obelixtim 100]

Quote

Way too many jumpers simply do not want to learn.

Its a bit more than that.

Many "Instructors" do not know how to teach, and make things way more complicated than they need to be.

And a lot of times people are made to pay for advice which back in the day used to come for free.

Then there are time constraints on people at busy dropzones.

So there are barriers in place, but that in no way excuses individuals from the obligation (and I use the word deliberately) to find out as much as possible about the equipment and techniques they need, to be the best and safest skydivers they can be. All the information they need is out there.

And to help those less experienced learn and progress.

My computer beat me at chess, It was no match for me at kickboxing....

[rmarshall234 13]

>Skydivers are the least disciplined of all aviators.

I think I would agree with the premise but not sure I would state it that way.

When I was taking my primary flight training in 1997 I had already been jumping for two decades. When the weekend would roll around after a week of flight training / preparation, I would say to those that would listen...."I can't wait to go make a mindless skydive". I don't think that is because I had already mastered (Ha!) the act of skydiving and flying was still relatively new to me, I think it is because there is so much less involved and so fewer things to think about and manage when making a skydive as opposed to flying.

I think this ties into Grimmie's comment as well. We don't do a very good job with the educational side of the sport. Especially continuing education. If there were more markers that we needed to study for, and standards that had to be met along the way in order to progress in the sport, we would have a more disciplined group.

[grimmie 173]

JerryBaumchen

Hi Rich,

Quote

a lack of continuing education

You can lead a horse to water but you cannot make him drink.

Way too many jumpers simply do not want to learn.

Jerry Baumchen

When I had the drop zone, I tried to educate the jumpers on as many issues as i could. Most listened.

Even at my exotic boogies I still try to educate the jumpers on safety issues.

And I myself never try to stop learning or keeping up with the new ways, gear, and issues of our sport.

I think all new jumpers want to learn, but it's all in the way we present it to them these days.

I always have a harder time getting through to the 1,000 jump plus people.

[pchapman 261]

grimmie

I always have a harder time getting through to the 1,000 jump plus people.

I'm curious. Was that about adding new things in skydiving? Or changing things?

Because would have thought experienced jumpers would be interested in new gear and new styles of flying.

For example, "So tell me about these new MARDs -- I just know the traditional Skyhook." or "So what procedures are people using for safety in angle flying, now that it is becoming popular?"

Versus:
" You're telling me I should strongly consider an RSL? Use a freaking AAD for EVERY jump? Pull way up high? We never needed that shit before and were fine!"

[billvon 2,398]

>Many "Instructors" do not know how to teach, and make things way more complicated than
> they need to be.

I think Rich is talking about something past instruction. There is AFF training, which is pretty good overall I think. There is the ISP, which is used sporadically and good in places it is used. But that only gets someone to 20-30 jumps, and after that they are pretty much on their own. From then on it's pretty elective - you only get the training you seek out, and much of it is completely incidental.

There is some good training available out there, from formal programs (canopy flight and bigway camps) to less formal education (seminars, safety day, demo programs) to specific people at specific times (getting a bottle of good whiskey and finding Bryan Burke after the last load lands.) But it's easy to get to a certain level of competence and think "I'm good; rather spend the day jumping than in a canopy program." And in general, the people who feel that way the strongest are the people who need additional training the most.

[grimmie 173]

Some people have 1000 jumps, some people have the same jump 1000 times.

It is often hard to get through and teach an old dog new tricks.

Old school habits die hard. Some never do. That can lead to dangerous situations.

But that isn't a blanket statement. I know a lot of old school jumpers that have been taking canopy courses. They are learning about their gear and are flying new disciplines.

I have also encountered some young jumpers that could care less what I, or anyone else, has to say. A few have finally come around after their helicopter ride.

Other than safety day, which not a lot of people that need it attend, we really don't do much to keep people continually learning and ready to handle the worst.

If we started requiring Bi Annuals like in flying, people would scream about over regulation and the man keeping their freedoms down.

It's a fine line we walk in skydiving. I prefer to give my input in an honest, non threatening way. Hopefully I have made some jumpers a better rounded skydiver in relation to safety issues.

And I love getting input from guys with way more experience on issues that affect us.

We should never stop learning in this sport.

[dthames 0]

wolfriverjoe

***I am not an instructor but it seems really weird that some people (not specifically this jumper) would insist on a plan that you would pull the cutaway handle 100% of the time before deploying the reserve.

This thinking would suggest that some jumpers don't have a good understand of what was the proper course of action during a given situation. That is troubling to me. We all need to be very aware of what is going and what needs to be done under these conditions. If you know the pilot chute is still in the pouch and you have no reason to think the pin is out, then just deploy your reserve when you need to.

Well, the question on this would be something like:

Will it take more time to pull the cutaway, then the reserve, no matter the situation?

Or will it take more time to evaluate the situation, decide on a course of action (whether or not to pull the cutaway handle), and execute that action?

Generally, in the case of procedures that are not actually executed on a regular basis, and will be needed very quickly, and under very high stress, simple is better.

I fly wingsuits and the altitude goes away much slower. I am sure that my perception of this situation would be different if I was going 120 mph down.

Early in my WS days I had a PC in tow (bridle tied around PC). I shook it until the pin came out and all was well. If the pin had not came out, I can't say for sure what I would have done when I needed to give up on the main canopy deployment, cutaway or reserve.

Instructor quote, “What's weird is that you're older than my dad!”

[skyderrill66 15]

Who ever this jumper is he needs to buy a lottery ticket as he is the luckiest man around.

[DHemer 0]

Not everyone can thick quick enough in a stressful situation to safely choose between full EP procedures and going straight to reserve.

Students: Do what you were trained. Always.

My club had a student with a PIT go straight to reserve because he read on the internet that if there is no main out this is the correct choice. He ended up in a down plane when the main came out at 500ft and managed to cut away the main at a low altitude and walk away. Correct EP would have avoided this.

Experienced jumpers: Be sure you are sure you have nothing out before going straight to reserve.

You don't want the risk of an entanglement with a bag lock or PIT.

I have been in the situation where I was fighting to get a PC out and on my 3rd/last attempt I got it. At the same time the thought in my mind was if this does not work I am going straight to reserve.
You need to have thought these situations through before because at 2000ft you don't have time to weight the pros and cons.

[obelixtim 100]

DHemer

Not everyone can thick quick enough in a stressful situation to safely choose between full EP procedures and going straight to reserve.

Students: Do what you were trained. Always.

My club had a student with a PIT go straight to reserve because he read on the internet that if there is no main out this is the correct choice. He ended up in a down plane when the main came out at 500ft and managed to cut away the main at a low altitude and walk away. Correct EP would have avoided this.

Experienced jumpers: Be sure you are sure you have nothing out before going straight to reserve.

You don't want the risk of an entanglement with a bag lock or PIT.

I have been in the situation where I was fighting to get a PC out and on my 3rd/last attempt I got it. At the same time the thought in my mind was if this does not work I am going straight to reserve.
You need to have thought these situations through before because at 2000ft you don't have time to weight the pros and cons.

EPs need to be ingrained to the point of being instinctive, and really there are only two scenarios to plan for.

I think your example shows that the student did, in fact, do the right thing.

In freefall, with a problem, the first thing to do is STOP the freefall. He did that successfully. What happened after that is incidental to the main problem. It should never be a factor when reacting to the initial problem. That is not the time to be thinking "what ifs".

This is skydiving, nothing is guaranteed, and one scenario you survive today, can kill you tomorrow, even if you do everything right.

Basically, the drills for each scenario are pretty simple, and those need to be ingrained in every skydiver. If everything is done correctly there is much more chance of it being your lucky day. History proves that to be true.

If anyone reading this do not have EPS ingrained to the point of instinct, best they get back to the hanging harness.

My computer beat me at chess, It was no match for me at kickboxing....