Broken Riser to Double Malfunction

[BobxMarley 1]

Hey Dropzone,

I want to share my story with everyone. For learning and accountability purposes. I rented a Pilot 168 from Aerodyne and they included a set of risers with the demo. I hooked it up to my rig, and went for my first jump on it. Luckily, I decided to do a high pull in order to feel out the new canopy. I pulled sub-terminal out the door at 11,500ft. I was immediately thrown into a violent spinning malfunction on my back. I realized something was very wrong with the canopy. I cutaway and my sky-hook extracted my reserve while I was on my back. However, since the spinning malfunction was so violent, it left me with slider up line twists on the reserve. Both malfunctions took ~3000ft to fix.

After I recovered the main, I took it to the loft at Skydive Elsinore and had a master rigger inspect it. After inspection, we discovered that the right front riser was tacked with glue, but it was not sewn. On opening, the riser broke which is why the malfunction was so violent. My first and only cutaway was due to defective risers and poor inspection.

I am sharing this so that others can learn from these mistakes. I now realize that I should have inspected the risers before using them. However, I think we can all agree that we expect a certain level of quality control from equipment manufactures; which, at least in my case, this riser was not up to par.

Had this jump been a standard freefall jump, I'm not sure what condition I would be in. Or, what if the riser didn't break on opening but broke on final approach instead? These scenarios didn't happen and I feel I am honestly lucky. I'm sharing this story so that the community can learn from Aerodynes and my mistakes. Stay safe. Inspect your gear. Trust no one but your own eye.

I've attached links to the photos of the defective right front riser. I have also attached a video where the master rigger talks about what happened. I will post updates here as the story progresses. If you have any questions, feel free to ask.

Broken Riser Image: https://drive.google.com/file/d/0B-EzrYVtdPl6VFAxRmZuNDRzbmM/view?usp=sharing

Inspection Video: https://drive.google.com/file/d/0B-EzrYVtdPl6VDR2elpQNW84WXc/view?usp=sharing

Klaasic

[Quagmirian 40]

Holy shit. This trick is apparently as old as gear itself. I've heard about it happening but never seen it. Just be thankful it wasn't your harness.

Have you talked to Aerodyne yet?

[pchapman 279]

Any idea roughly about the time or altitude to deal with the reserve twists specifically, or the number of twists? Reserve line twists are usually not an serious problem even if they sometimes happen from RSL or MARD use, but very occasionally they can be bad enough to take up a lot of altitude to fix.

As for you not noticing the lack of stitching in the risers, technically you missed seeing it, but it is understandable. When you get handed a set of risers and canopy you expect them to be in jumpable condition -- it isn't as if you were sending a newly purchased canopy to your rigger for a full inspection just in case.

The lack of stitching wouldn't be that obvious in this particular case. Looks like it was on the front riser, and would be entirely or nearly entirely hidden underneath the dive loop, black stitching on navy blue risers. Not at all obvious if one lays out the canopy for to hook it up and pack it.

[BobxMarley 1]

The reserve lines had about 6 twists in it. The slider was hung up at the top and it left my head pinned to my chest for a quick minute. I recall it taking about 800-1000ft to fix the reserve. It was long enough for me to think to myself..."If I don't fix this, game over. I don't have any more handles to pull." Ironically, this was my first time I've ever had line twists as well. All in all, the reserve flew fairly stable while I was fixing the problem.

~11,000 - Pull Altitude
~8,500 - Cutaway Altitude
~7,500ft - Reserve Line Twists Fixed

It took 3,000-3,500ft for me to fix everything. I'm just glad I was doing a high pull when this happened.

Klaasic

[BobxMarley 1]

I have spoken with Aerodyne. Here is a statement they issued publicly.

Quote

We are performing an ISO 9000 audit of this incident. This analysis will establish a root cause and determine appropriate corrective actions to prevent any reoccurrence. All risers produced in this lot and batch are now being physically inspected.

They have also stated they are refunding me for the demo rental fee, jump, and reserve repack.

Klaasic

[Unstable 9]

Quote

***
We are performing an ISO 9000 audit of this incident. This analysis will establish a root cause and determine appropriate corrective actions to prevent any reoccurrence. All risers produced in this lot and batch are now being physically inspected.

They have also stated they are refunding me for the demo rental fee, jump, and reserve repack.


As a Quality Manager myself (former Aerospace, now medical world), I can already see a few concerns with the statement. A very good documented corrective action is the right response. However, it takes multiple process breakdowns to allow a failure like this to go out the door. This is not a 'our associate didn't follow the print' type issue. I would be very interested if they post the results of their internal investigations and what corrections and corrective actions are put into place.

=========Shaun ==========

[irishrigger 32]

Glad to hear you are OK after this nasty incident. although it is rare is not unheard off that something like this comes from a manufacturer. i had a case where i found the leg straps of a new rig, which i was assembling that did not have any stitching on them.
i had another customers canopy that came back from a reline from the manufacturer that had lines routed incorrectly though the stabilizer tabs. so it does happen on the very odd occasion and i am sure that other riggers have also come across other things
but one must always remember "assumption is the mother of all fuck ups". i would say that 99% of jumpers would not have caught this. that it is why it is so important for a person to know their gear and what to look out for. the best way to do that is ask your local rigger to show you these things while you are getting a reserve repack and how to do a correct inspection on the basic need to know.
when i get a set of gear to repack i will try show the customer the important part of where the important stitching should be and what to look out for. granted it is not always possible to do that.
i would love for USPA to make it mandatory in their A and B license application that they went through this inspection process with a rigger and to have the rigger to sign that off.
knowledge about ones gear is a very valuable and really necessary skill that everyone should have!

but at the end of the day i am glad you walked away from this incident and thank you for sharing this valuable lessons with us here on Dropzone.

you now have a "no shit their i was" story to tell over a couple beers with friends and new jumper

enjoy your few drinks!

[BobxMarley 1]

I plan on following up with them in regards to what changes are being made to insure this sort of oversight doesn't happen again. Hopefully this audit will allow for that.

Klaasic

[riggerrob 643]

The last time CSPA revised their A certificate gear knowledge requirements, I suggested progressively more complex gear tasks.
For example, an A certificate holder needs to know how to pack a main and do pre-flight checks.
B should know how do monthly inspections and re-assemble 3-Rings, replace main closing loop, etc.
C should know enough to assemble a main canopy from a pile of risers, d-bags, etc.

[chuckakers 425]

BobxMarley

All risers produced in this lot and batch are now being physically inspected....

Wait a minute. Are we to assume by the above statement that there are components that are NOT physically inspected as a matter of routine?

If there is someone in the manufacturing world following this thread, please address this. Given the nature of the product, I assumed - hopefully correctly - that EVERY component on EVERY parachute system built by EVERY manufacturer is physically inspected.

Chuck Akers
D-10855
Houston, TX

[stayhigh 2]

I've seen two cases where the closing pin on the bridal wasn't stitched on, that little square portion was just glued on, resulting in a inflated PC in tow/container lock.

Ever seen a missing bartack on a reserve? It happens.

Bernie Sanders for President 2016

[RiggerLee 61]

I'm trying to figure out how they built that. Do all of the bar tacks go through all three layers of webbing? Both layers of riser and the dive loop? Are they all done at once? If they fold and sew the end of the riser then sew the dive loop then that means they actually missed two steps in the process on the same riser.

Lee

Lee
lee@velocitysportswear.com
www.velocitysportswear.com

[mxk 1]

I'm guessing they mean "re-inspected." My brand new Vector had Louie loops sewn to the wrong side of the front risers despite having a "QC" number on the riser label. Someone did inspect them, but didn't see anything wrong.

[chuckakers 425]

stayhigh

I've seen two cases where the closing pin on the bridal wasn't stitched on, that little square portion was just glued on, resulting in a inflated PC in tow/container lock.

Ever seen a missing bartack on a reserve? It happens.

I understand mistakes happen. My question was specifically about the statement made by the manufacturer that makes it sound like not everything is physically inspected and that's hard to believe.

Chuck Akers
D-10855
Houston, TX

[Quagmirian 40]

Yeah, sometimes when you inspect something you see what you expect/want to see. It's very easy to miss seemingly obvious things.

[marde 0]

I guess as long as the stitching has the same color as the webbing it is rather easy to miss.
It would be really easy to make it obvious by just using a contrast color for the stitching.

For climbing harnesses this is a standard for quite some time.
UIAA requirement:
"...at least 50 % of the visible area of the stitching shall contrast with the background colour"
http://www.theuiaa.org/upload_area/News/2014/UIAA-105-Harnesses_11_June_2014.doc1.pdf

[traffic 0]

Here is my Aerodyne reply to Bob's Facebook post

Quote

On September 1, 2015 Aerodyne was contacted by Bob Klaas regarding this incident. We called Bob and he explained the situation, that a riser had been assembled to an Aerodyne demo canopy without having the bar tacks creating the line attachment in place. He had the riser separate on opening, resulting in a cutaway and safe landing under a reserve.
Upon inspection by the rigger at Elsinore, it was discovered that the riser was held in place only by the tacking glue which secures it prior to sewing. This then separated on deployment.
Aerodyne owns this failure. Our people, processes and systems did not work as designed. We put risers through all the quality inspections prior to shipment and the last inspection is by the user or rigger who performs the final assembly. In this case all inspections failed and an unsafe item made it onto an airplane.
We are performing an ISO 9000 audit of this incident. This analysis will establish a root cause and determine appropriate corrective actions to prevent any reoccurrence. All risers produced in this lot and batch are now being physically inspected.
We regret that this incident took place and want to assure our loyal customers that Aerodyne is committed to continuously improving our processes and our products. Please address any further questions to Aerodyne Research, 1407 Flightline Blvd, Unit 14, DeLand FL 32724 or by email to bill@flyaerodyne.com

to clarify a question from Chuck further on, we are physically re inspecting all risers that were produced in this batch. They had gone through the multiple standard inspection processes prior to and after installation. As I stated, our systems and people and processes failed in this instance.

[betzilla 56]

Quote

Yeah, sometimes when you inspect something you see what you expect/want to see. It's very easy to miss seemingly obvious things.

EXACTLY.

It's easy to inspect what is there. It's also relatively easy to miss what isn't there. This is a good lesson for all of us who inspect... ANYTHING.

A couple years ago I inspected a reserve that was missing a bartack on one center A line. It had been inspected and packed that way by three other riggers before me. Thankfully there was a well-equipped loft and master rigger nearby who could make it right without the customer having to wait any extra length of time.

Any of us are capable of a mistake at any moment. Let's just keep trying not to make them, and let's watch out for each other!

[fcajump 164]

Thanks for your posting this... good reminder to us all that manufacturers and riggers are people who can make mistakes. The person with the most vested interest in the gear is the one putting it on their back, so it helps all of us if the owner/jumper knows their gear. Yes, gear straight from the mfg should be 100%, but you're the one about to hang your butt under it.

FWIW - when I first get new gear, I assume that there is a mistake in how it was made and my job is to find it. Failing that, I then do a series of break-in jumps (higher alt pull, focusing on the gear rather than the jump). Sub terminal first, and increasing the delay/forces on it in subsequent jumps. That way, as in your case, the early QC issues are found with ample altitude/time to resolve.

JW

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

[Joellercoaster 6]

betzilla

Quote

Yeah, sometimes when you inspect something you see what you expect/want to see. It's very easy to miss seemingly obvious things.

EXACTLY.

It's easy to inspect what is there. It's also relatively easy to miss what isn't there. This is a good lesson for all of us who inspect... ANYTHING.

This.

My first thought about this was "would I have noticed?"

I can't honestly say the answer would be yes.

(I have friends who I am sure would have noticed, but... not many.)

We can all get better. And we should.

--
"I'll tell you how all skydivers are judged, . They are judged by the laws of physics." - kkeenan

"You jump out, pull the string and either live or die. What's there to be good at?

[yoink 321]

Joellercoaster

My first thought about this was "would I have noticed?"

I can't honestly say the answer would be yes.

I'll go one further and say that (without blind luck) there's no chance I'd have caught this on a preflight inspection.

I'm not a rigger. I'm not immediately familiar with what should and shouldn't be sewn on a rig, or which types of sewing patterns should be used. If something looks obviously wrong then there's a chance I'd catch it by comparing it to the opposite side, but this? No chance.

And for the manufacturer - the solution is simple. Don't tack stuff with glue before sewing. If you eliminated that step it is pretty much 100% certain that this defect would not have made it passed inspection.

As I said earlier - I'm not a rigger, but I'm pretty certain the glue isn't necessary. It may make the life of the manufacturer easier, but that's a different concern. Maybe a rigger could let me know if I'm wrong on that assumption.

[BobxMarley 1]

I'm not going to lie. I am not happy I received a faulty piece of equipment. The reason I did not catch the stitching issue is in fact because I've never inspected risers before. It wasn't part of my gear check process. Three ring system...yes, stitching...no. I think there are a couple important take away's from this situation.

1. Manufactures need to understand that mistakes like this can kill. Newer skydivers are generally overwhelmed with the amount of information they receive. Many of us don't know that we should be inspecting the stitching on our risers. The broken riser obviously missed proper inspection. This now creates a situation where the last person to perform the check (the jumper) may or may not know what he/she is looking for.

2. Knowing that our own lives are on the line, it is our responsibility to not leave these things in other peoples hands. Pointing fingers after you are dead or seriously injured won't do you any good. So, we should take responsibility and learn as much as possible about our life saving gear.

I think you have an interesting point about the glue. It can give the riser a false appearance of completion. I like the comment above where @marde suggested having a larger color contrast in the riser and the stitching. This would at least make it a little easier to identify.

Klaasic

[betzilla 56]

When you are dealing with a symmetrical piece of equipment (like a pair of risers, leg straps, steering lines, whatever), it's actually pretty easy to look at both sides of it and verify that they're the same. Then, if they aren't the same (maybe one side has a bunch of rows of stitching, but the other side doesn't), you can think about why they aren't (maybe one side has rsl stuff, and that's why there is more stitching), and decide whether it's a defect.

I'm actually really surprised that whoever assembled the main didn't notice those stitches weren't there when he/she hand tacked the soft links. Your eyes are pointed right at the missing stitches at that point.

Just goes to show how easy it is to not notice something is missing that isn't there to notice. I might have missed it too, but I sure hope not!

[chuckakers 425]

traffic

Here is my Aerodyne reply to Bob's Facebook post

Quote

On September 1, 2015 Aerodyne was contacted by Bob Klaas regarding this incident. We called Bob and he explained the situation, that a riser had been assembled to an Aerodyne demo canopy without having the bar tacks creating the line attachment in place. He had the riser separate on opening, resulting in a cutaway and safe landing under a reserve.
Upon inspection by the rigger at Elsinore, it was discovered that the riser was held in place only by the tacking glue which secures it prior to sewing. This then separated on deployment.
Aerodyne owns this failure. Our people, processes and systems did not work as designed. We put risers through all the quality inspections prior to shipment and the last inspection is by the user or rigger who performs the final assembly. In this case all inspections failed and an unsafe item made it onto an airplane.
We are performing an ISO 9000 audit of this incident. This analysis will establish a root cause and determine appropriate corrective actions to prevent any reoccurrence. All risers produced in this lot and batch are now being physically inspected.
We regret that this incident took place and want to assure our loyal customers that Aerodyne is committed to continuously improving our processes and our products. Please address any further questions to Aerodyne Research, 1407 Flightline Blvd, Unit 14, DeLand FL 32724 or by email to bill@flyaerodyne.com

to clarify a question from Chuck further on, we are physically re inspecting all risers that were produced in this batch. They had gone through the multiple standard inspection processes prior to and after installation. As I stated, our systems and people and processes failed in this instance.

Thanks for the clarification! Always great to hear positive reactions to issues!!

Chuck Akers
D-10855
Houston, TX

[format 1]

chuckakers

Always great to hear positive reactions to issues!!

To me, positive is: "What ever happened - we'll fix it in no time"

and this: "As I stated, our systems and people and processes failed in this instance."
is a rare gem (aka Honesty)