Breaking the Links in the Chain

Survey information provided by members of USPA indicates that “Incident Reports” is one of the most important and widely read sections of Parachutist magazine. Apparently, we all see the value in learning from these reports in hopes of avoiding a similar situation on our own skydives. Skydivers are not unique in learning through this type of process. Airplane pilots, BASE jumpers, scuba divers and all sorts of people who participate in potentially dangerous activities study accident information. An entire government agency, the National Transportation Safety Board, is dedicated to investigating accidents in every form of transportation, all in the name of discovering their true causes and developing recommendations for avoiding them in the future. So it is not unusual at all that you would want to read “Incident Reports” for educational purposes.

Almost every skydiving fatality is a result of a series of separate but related events that ultimately combine to result in the injury or death of the skydiver. This is known as a “chain of events.” Break any one link in the chain, and you can avoid the fatality. Sometimes, these links form in quick succession on one skydive. Other times, it takes months or even years for a series of errors to develop and lead to an accident. Skydivers must learn to recognize as early as possible when these links are forming so that they can take the necessary steps to change the outcome. 

Here is just one example: A newly licensed jumper begins to downsize to smaller main parachutes in quick succession. He also continues to manifest for loads when the winds are strong and gusty. In just two months’ time he makes more than 200 jumps, but his canopy control remains questionable. Many very experienced skydivers attempt to help him improve his canopy-control and decision-making skills with coaching. While jumping a semi-elliptical 120-square-foot canopy at a wing loading of 1.3:1 in winds of approximately 20 mph, he makes a low turn that results in fatal head injuries. The fatal mistake was the low turn, but there many other links that ultimately led to his fatal mistake:

  • exhibiting poor decision-making skills throughout his short history of jumping
  • refusing to take the advice of others
  • exhibiting difficulty in applying his training
  • rapidly downsizing his canopy
  • insisting on continuing to jump in strong winds

Of course, it is always easy to look back after an accident and find the individual links of the chain. But if you pay attention, you can also see them as they develop. Who knows how many lives observant individuals have saved when they noticed a bad situation developing and stepped in to alter the course the jumper was taking? Whether it was catching a mistake on a geared-up jumper or providing canopy training that helped a jumper fly his canopy better, there are an endless number of examples of when someone could see something was wrong and acted to alter the outcome.

So, as you spend your days hanging out and jumping at the drop zone, keep your eyes and ears open and watch out for yourself and your fellow jumpers. Speak up when you see something that needs attention. And if you find yourself on the receiving end of the advice-giving, listen carefully and realize that your fellow jumpers are trying to help you see that there might be a problem that needs correcting. We should all work together to find problems early and break the links in the chain to prevent accidents. 

Jim Crouch | D-16979 | USPA Director of Safety & Training

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