My tandem malfunction- drogue in tow due to mis-rigged 3-ring (Stong tandem)

[VTmotoMike08 0]

Alright, now that the incident report has been submitted to Strong Enterprises and I know the student won't be suing me, I will post here about my first tandem malfunction- a drogue in tow due to a mis-rigged 3-ring drogue release on the strong tandem system. Below is a copy of the report I submitted to Strong:
______________________________________
Date: 8/14/10
Equipment: Strong Dual Hawk Tandem with SET 400 and Master 425 reserve
TI # of jumps: 606 total, 41 tandems
Injuries: None

After a normal exit, drogue throw and initial freefall, the student pulled the primary ripcord when prompted at 6,000 feet AGL. I observed a good pull to full arm extension but immediately noticed that the drogue was not released and we continued in free fall. I immediately pulled the instructor’s (secondary ripcord) and the drogue still did not release. I initiated emergency procedures and pulled the cutaway pud and reserve handle, and the reserve pilot chute launched clear of the drogue and the reserve inflated.

After a visual check of the reserve and handing both handles to the student, I felt the main bag fall out of the container, hit my foot, and then begin to inflate behind me. I immediately reached over each shoulder with the opposite hand and cleared each riser (which had been successfully cutaway) off of the large harness ring, and the main detached. I finished a control ability check on the reserve above 3500 feet. I had an uneventful landing with no injuries under the reserve.

I was able to inspect the high resolution still photos from the jump to determine the cause, which was a misassembled 3-ring drogue release that I failed to catch on my pre-jump inspection, which was performed. The small ring seems to have been routed through the middle ring and the big ring, and the three rings hung up on each other and did not release until after pressure was released by the opening reserve. The photos clearly show both ripcords were pulled. However, the conditions were just right for the rings to hang on each other and not release.

The solution to make sure this never happens again will be for me to perform a more thorough pre-jump inspection and to retrain the packer who misassembled the drogue release.
______________________________________

Video: http://www.youtube.com/watch?v=GPjctnA6Os0

Anyway, this malfunction has undoubtedly happened before, but the real point of this post is to share the amazing photos of an actual 3-ring hang up in mid-air. After the student ripcord pull, she really dropped her knees and this rotated us 180 degrees so the camera guy got a perfect shot of the rings hung up with both ripcords pulled. I doubt there has ever been a photo like this in such high resolution before. Contact me if you are a tandem I or IE and you want a full size photo for training purposes, these shrunk ones really do not do it justice. I also have several stills of the ripcords being pulled and a high res video. See attached.

A few other points:
-The student only knew we were under a reserve because she asked me if she could help steer and I had to tell her no, because there are no student toggles on the reserve. Later, she commented "it felt like it took a while for something to happen after I pulled the ripcord!"
-We tried to re-create the malfunction on the ground. We could rig the rings in the same way, but we could not get it to "catch" and it would always release with even a slight tug. As best as I can tell, it was just a freak occurrence.
-I'll be pretty happy if I never have to land a Master 425 canopy again... it just sucks to fly and land
-Gotta get back up, I did 7 more tandems that weekend.
-And finally, yes, FUCK ME! for not catching it on my pre-flight check. I put this on here so others could learn from it, and I really don't need 100 posts of people telling me how stupid I was.

[liftedtitan 0]

man watching that reserve pilot chute skim by that drougue is a little nerve wracking to watch huh? glad you made it out ok, have you heard anything from strong?

Moriuntur omnes, sed non omnes vixerunt.

[theonlyski 8]

It looks like the webbing helped wedge the middle ring inside the large one. The more pressure you put on it, the tighter it wedges in, and once you drop pressure, the ring would move through it.

Maybe slightly larger big ring, or slightly smaller middle ring may have been able to prevent it from happening? (Yes, I realize it should have been caught on a gear check, but one more safety against it happening is always better)


Either way, good job man!

"I may be a dirty pirate hooker...but I'm not about to go stand on the corner." iluvtofly
DPH -7, TDS 578, Muff 5153, SCR 14890
I'm an asshole, and I approve this message

[VTmotoMike08 0]

Yes, the webbing probably had something to do with the failure to release... that is part of what makes me think it was a freak occurrence and not a malfunction that could easily happen again. When we re-created it on the ground, it would still release when the ripcord was pulled even with the rings assembled wrong. It's a very strange situation. I have not heard anything from Strong yet.

Also, I wanted to add that I'm sure glad I initiated the pull at 6,000 feet, and I did not take it down to 4,500 like some TIs do. If I had taken it down to 4,500 then had that mal and taken slightly longer to react, I would have been flirting with AAD fire. I forget whether this rig had a cypress or vigil.

[aykay 0]

Nice save I guess :) Whats the camera dude doing all the way up there to get the view from above?

[VTmotoMike08 0]

He was actually plenty far away, I zoomed in on that photo to get it within the size limits for posting here. The camera guy is also a very experienced TI, I have no problem with him being up there.

[Canadianfella 0]

Quote

Yes, the webbing probably had something to do with the failure to release...

Every once in a while when returning my Sigma tandem rig to the packing mat, I notice that the medium and small rings are the wrong way through the big ring...

To fix the problem, it often requires 2 hands and some pressure to push the smaller rings back through... If that were ever loaded in such a way, I bet it would stick exactly the same way yours did on the drogue release... until it had enough slack or was squished enough to come back through.

[crashtested 0]

Good job in staying with us...

help me out here... I'm somehwat worried that you don't check out your three ring system every jump... but you've stated you'll be more thorough it the future so we'll move on..

The body positon of your self and the studnet looks really strange, both of you have your knees cocked downards in a knee flying type of config.. and then on roatation, it looks like your laterals are not done up properly, and your bottom connectors are loose. the movement she gets seems to be massive.

Am I missing something here!! i'm new to TI work myself only 610 jumps, its more of a question than a dig at you..

Thanks

[koppel 4]

there is a technique that requires no effort or force to rotate the rings back into orientation. It is hard to describe but if you send me an email I will put a little clip together for you to show you.

:)

I like my canopy...


...it lets me down.

[riggerrob 643]

Push the (cutaway cable) housing and the middle ring together to reduce the pressure needed to re-orient them.

But straightening out "flipped" main risers is really a separate debate.

[riggerrob 643]

" ...

The body position of yourself and the student looks really strange, both of you have your knees cocked downwards in a knee flying type of config.. and then on rotation, it looks like your laterals are not done up properly, and your bottom connectors are loose. the movement she gets seems to be massive.

...

Thanks

[VTmotoMike08 0]

Ya, she half way tried to knee fly on me, especially after the first ripcord pull. I'm a pretty big guy and I've noticed on the smaller people that it is pretty hard, almost impossible, to get zero "washing around" with the student when they are significantly shorter and smaller than me. The difference in the width of our hips contributes to this. That being said, I assure you that I cranked down those laterals as tight as I could and I feel that any motion is due to her body position.

In this attached pic, you can see that the laterals are pretty tight but she is actually bending at the stomach in a severely de-arched position and pulling her hips away from mine. In any event... the laterals didn't cause any problems on this jump.

Also, I did check the 3-ring before putting on the rig. I just "saw what I expected to see" and failed to look closely enough to spot the missassembly. Stupid me!

[bill.m 0]

Thank you for your post of your drogue in tow. You hung your neck out, I wish more folks had your spine because the tandem community needs this kind of information.
As you say, you already know where the problem lies.
Your posting, in the interest of safety and of pointing out potential problems to the mfg. and other Tandem Instructors, is to be commended. Hopefully everyone will see that the problem started with whomever assembled the drogue release.

Addressing these incidents in this public forum helps to keep us all informed and aware. History has a way of becoming foggy and we forget that many of todays incidents had
occurred before. One example occurred in 1993, when there was a tandem fatality involving a misassembled drogue 3-ring assembly. It was on a different system, but a 3-ring is a 3-ring. Basically a similar scenario, the Tandem Master didn’t see it, for one reason or another. On that one, the loop put extreme pressure on the drogue release cable and it was impossible to pull the ripcord. Unfortunately that Tandem Master wasn’t as fast with his emergency procedures as you were. So, congratulations on being focused and following your procedures. Another pat on your back.

As for the Incident Report, I can’t find it in-house. It can be faxed to: 407 850 6978, or fill in the Form from the website: www.strongparachutes.com. under Information Central/Forms/Dual Hawk Incident Form.

I have seen a thread on the subject of Incident Report Forms that suggests that the mfg. uses them to place blame on the Tandem Instructor. Not so! We created those forms so that we could learn of any problems with the gear or how the gear was being used. I can attest to Incident Report Forms having indeed resulted in life saving changes to both gear and procedures.

[skydivingchad 0]

One thing I noticed in the last picture that you posted and in the video is the separation between the two of you at the laterals. To me it looks like the harness is fitted a little short on her. Where the articulation ring would be on the harness, if it were articulated, seems to sit higher than her hip bone.
Ideally if it is on the students hip bone then they can't fold in half as much and it will be a tighter hook up.

Just a thought.

Good job on the handling the situation.

Sometimes you're the windshield, sometimes you're the bug.
Pelt Head #3

[davelepka 4]

Quote

In this attached pic, you can see that the laterals are pretty tight but she is actually bending at the stomach in a severely de-arched position and pulling her hips away from mine. In any event... the laterals didn't cause any problems on this jump

Not the laterals, but possibly the location of the lower attachment point. It appears to be too far up her torso, above the pelvis, allowing the bend in the stomach to cause a seperation between you two.

If you could adjust the harness so the lower attachment point is lower, it will pull her pelvis up toward yours when you tighten the lowers and limit the washing around to only her legs.

I see this problem all the time, and it does look very similar to loose laterals.

[crashtested 0]

great post rob,

but hold your ponys here...

I'm guessing your drunk, or i've taken the hah!! hah!! aspect of your post the wrong way

the girl was not fat..

having a poorly adjusted harness, (be it laterals, or as mentioned student harness) is not really an acceptable excuse when you side spin it into the ground.

maybe you should think about going over the exit just before leaving the plane, maybe after 4300 jumps you have gotten lazy.... your student having a poor body position does not really mean that you should mimmick it.

Your post is worthless, and thats my opinion after only 100 tandem jumps.

[crashtested 0]

Thanks for the post dave, I've been looking at the way i adjust my harness and have found a simular thing with regards to the lowers attachment point, and the more control you have, if the harness is adjusted correctly.

Still learning every day!!

And thanks for the video to the poster, its cool to see somone show stuff when it does not go to plan so the newer (maybe older aswell) TI's can learn something new

[crashtested 0]

Hey mike, i had a cool tip from my Chief instructor, but its only relavent if your on a bench set up, try bringing your knees back along the bench so your farthest point fwd is your pelivs from the hip down, i have found this to work a lot better in getting the laterels super tight. (maybe too much so) but it works for me..

[VTmotoMike08 0]

I use that technique when the student has larger legs and hips and mine would be smashed against the side of the plane if I had them in front of me. I have not found it to be useful with average or smaller students but YRMV. Anyway, lets keep this thread on track and start another one to discuss lateral tightening techniques if you want. Thanks.

[koppel 4]

eloquent... thanks

I like my canopy...


...it lets me down.

[Rover 11]

I too wish to commend you on this post. We all make mistakes but there are few that step up to the plate and admit them. It is easy to see what you expect to see and there are now alot more people out there more aware because of this thread.

2 wrongs don't make a right - but 3 lefts do.

[tandemwench 0]

Quote

Alright, now that the incident report has been submitted to Strong Enterprises and I know the student won't be suing me, I will post here about my first tandem malfunction- a drogue in tow due to a mis-rigged 3-ring drogue release on the strong tandem system. Below is a copy of the report I submitted to Strong:

ok - I know it isn't really pertinent to the whole discussion, but why on earth would you even mention anything about a student suing you? I found this slightly odd.... You did everything right...and did it well, I might add (other than your pre-flight, but you already know that) I'm just afraid comments like those are what puts it into peoples mind in the first place. Well that and this country is sue happy....but your description of the events doesn't make me think...wow he should be sued. Just curious what made you even consider it?

[jimjumper 25]

I consider being sued every time I take anybody out of the norm. Overweight, unfit, aged, or handicapped passengers/students are a risk that may result in a lawsuit. If you think that students or their relatives won't sue because they signed a waiver, you just haven't been sued yet. The reality is that as a TI you get to make the choice to take someone or not. The first rule of doing tandems is to not let your student be injured.

[VTmotoMike08 0]

Well, like I said, she didn't realize we were under a reserve until she asked to steer and I had to tell her no because there are no toggles for the student on the reserve. We had talked about her flying the canopy earlier. On the ground, she seemed a little nervous that she had the reserve ride. She asked why we were under the reserve and actually wanted a real explanation but at the time I didn't know about the mis-rigged rings, I had to look at the photos later.

She did email me (looked up on facebook) a few days later and said basically "did you ever find out what caused it and thanks for handling it. I'm OK with the whole thing.". I gave her the best layman's terms answer I could so I'm not worried about getting sued. I suppose I was a little paranoid, but she could have tried to claim emotional damage (?) or something. Yes, I know thats a stretch but you never know what some people will go to.

[dninness 4]

I showed the video and photos to one of our TMs this weekend (we're a Strong DZ) and he was like "Whoa!" and immediately gathered all the other TMs to see the pics and vid.

I noted a slightly increased interest in the drogue releases during preflight this weekend. :)

If that's the result of saying "hey, here's what happened," then good on ya, man. You may have just helped someone else avoid a potentially fatal accident.

NIN
D-19617, AFF-I '19