Joe Gregor - 2006/01
SUMMARY REPORT:
2005/10/01 / approximately 14:00
Whitwell, Tennessee
52-year-old male, H-3
Wills Wing Sport 2
High Energy Tracer
Charlie Insider
SSE at 5-7 mph; nearly straight in and smooth
A new intermediate rated pilot participating in his first hang gliding competition launched from a modified cliff-launch site and became separated from the glider seconds after launching. The pilot fell approximately 300 feet into mature hardwoods and died immediately due to severe blunt-force trauma. Witnesses state that the pilot was asked by several people just prior to launching if he needed a hang check, and he responded in the negative.
Conditions: The accident flight was initiated from a SE-facing cliff-launch site. Winds were SSE at 5-7, essentially straight in and light.
Logbook: The accident pilot held a USHGA H-3 rating (obtained in March, 2005) with the following special skill signoffs: AT, FL, PL, ST, and TURB. Detailed logbook information is not available, but still the vast majority of his time and training had been obtained via aerotow. The accident pilot had reportedly just discovered mountain flying, having logged roughly 12 flights at four different sites.
Medical: There were no known preexisting physical conditions or illnesses prior to the accident flight. The accident pilot appeared to be in good spirits, although a bit nervous as it was his first hang gliding competition.
Synopsis: The accident pilot - who was reportedly eager to get into the air - carried his glider to the launch point and set it down tail to the wind. He walked out to launch to look at conditions and was told they were fine. At this point no one had yet launched. A call for wind dummies was made, and the meet director was assessing conditions while awaiting volunteer non-competition pilots to arrive and perform the first launches. The accident pilot checked his harness points (parachute handle, leg straps, hook knife, etc.) assiduously. At least one witness stated that the accident pilot appeared a bit nervous both in this situation and before, while setting up his glider. When he went to his glider to get ready, one pilot who had been talking with him said, "Be sure to do a hang check." The accident pilot spent some time under his glider while it was turned around. He then lifted it, turned 180 degrees to face the ramp, and was met by a side wire crew. At this point his team leader told the accident pilot, "Do a hang check." The wire crewman on the right side reported that, after subsequently setting the glider down, the accident pilot started adjusting his VG rope and talking to the crew about how to give him feedback.
The accident pilot picked up his glider and proceeded to the launch point. Several pilots present at the scene reported they checked his hang point and it looked like he was hooked in. Several pilots present at the scene reported that there were four or five other individuals who said, "Do a hang check," or "Have you done a hang check?" In no case was it reported that he responded directly.
Conditions were pronounced fine and the accident pilot cleared his launch. He launched using the grapevine grip and the glider dove as soon as he put weight on it. Two videos of the launch clearly show that he rotated his hands to the beer-bottle grip as soon as he started running and the glider lifted.
The glider disappeared from view but soon reappeared going nearly straight up, reached an apex, stalled, yawed to the side, and went back down nearly vertically. Witness reports and later review of two videos taken of the launch indicate that the accident pilot had lost his grip on the glider as soon as it began pulling out from the dive. He was carried on a trajectory that sent him past the trees below launch and it was estimated that he fell approximately 300 feet. He died upon impact.
Airframe: Damage to the glider is consistent with mild impact and recovery from a tree landing. Hang strap and carabiner were both found in good condition and disconnected from one another. The parachute, a PDA-22 manufactured by Free Flight, was found in good condition still inside the deployment bag.
Analysis: No electronically recorded flight information (GPS or barograph) was available for analysis in this accident. As a result we are left with eyewitness accounts and post-crash damage analysis in order to determine what likely occurred in this accident. Sadly, the probable cause in this incident seems relatively certain.
A post incident continuity check was performed on the accident pilot's harness and glider. The glider hang strap and the carabiner were both found intact with no sign of stress. A photograph, taken just before the accident pilot launched, showed that the carabiner was actually clipped to the pilot's harness under his arm. The accident pilot was flying a Sport 2 glider with a High Energy harness. The normal white Wills Wing hang strap is a non-standard length. As a result, he had a black extension strap hooked to his glider's hang strap. The black extension strap was long enough and of the proper color to make it appear, upon a cursory inspection, that the pilot was actually attached to his wing. The black colored carabiner did not stand out against the dark colored harness and could have easily been overlooked. Several pilots reported seeing him hooked in, indicating that they had mistaken the black extension strap for his harness main strap.
The accident pilot had experienced a failure-to-hook-in event two weeks prior to this accident while attempting flight from a local ramp-launch site. He was challenged at launch by another pilot who, grabbing his nose wires, saw that the accident pilot wasn't hooked in and said: "Do you want a hang check?" The accident pilot refused this and three additional increasingly emphatic offers to perform a hang check before he was told to examine his carabiner, to discover that he was not yet hooked into his glider. The accident pilot never made comment on this incident at any time after his successful ridge-soaring flight.
Probable Cause: Failure to hook into the glider prior to launch. Failure to complete a full and complete hang check just prior to launching.
Discussion: Launching is one of the most dangerous phases of flight for a hang glider pilot. This is doubly true if the glider is mis-assembled prior to flight. For a hang glider, the harness serves the same function as the cockpit and fuselage of a conventional aircraft. Ensuring that the glider is airworthy requires a preflight check that cannot be completely performed while the glider is still partially assembled. Until the harness is attached to the wing, the glider is still only partially assembled. Performing a final hang check just prior to flight is the only way to ensure that the glider is completely assembled and airworthy. The final hang check must therefore be performed meticulously and religiously. Pilots who, for whatever reason, delay assembly or partially disassemble their glider (unhooking and remaining in the harness) while waiting at launch are at increased risk for launching a non-airworthy aircraft.
Having and maintaining a strict routine is of extreme importance to any pilot. The accident pilot may have been nervous due to his inexperience with mountain launches and his relative lack of competition experience. The latter is an important point because competition has a tendency to increase the tension and the distraction level (even though this was a low key "fun" meet.) Additionally this was a new site to this pilot, and he was flying with some new and less-than-familiar electronic equipment. All of these factors can serve to break a pilot's routine. Pilots flying under conditions that break their normal routine must exercise vigilance to ensure that all required checks are successfully completed prior to flight.
The accident pilot had trained and flown primarily via aerotow. He was relatively new to mountain flying and his background may have been a factor in this accident. The routine developed for performing a pre-flight safety check is different when launching from a dolly via aerotow vs. launching from a mountain site - increasing the potential for the pilot to make a serious oversight impacting safety of flight. Pilots experienced and confident in one launch method or maneuver should be cognizant of the fact that their skills and abilities may not be at the same level when performing a new launch method or maneuver.
Recommendation: Always perform a full and complete hang check just prior to launching. Pilots should make full use of their wire crew, when available, to assist in evaluating their aircraft (glider and harness) for airworthiness prior to launching.
Techniques, such as the so-called "Aussie technique" of completely assembling the glider before pre-flight and not removing the harness until flight is complete, can be used to eliminate one common failure mode - that of unhooking from the glider and failing to properly hook back in prior to launching.
Another technique that can be used to eliminate critical errors is the religious use of checklists and standardized procedures. Over the century-long course of manned-aviation history, maintaining a strict routine and standardized procedure has proven a potent safety multiplier. Hang glider pilots experience a much wider range of conditions during take-off, approach, and landing than do most pilots of conventional aircraft. Additionally, the individualist nature of our sport does not lend well to efforts at standardization. This puts hang glider pilots at significantly increased risk compared to their fixed-wing brethren, and this risk must be managed intelligently and professionally. Since our aircraft are so simple, use of a written checklist has proven unnecessary for most pilots. This, unfortunately, makes us vulnerable to making critical omissions when conditions cause a break in our individual routine. Alarm bells should go off in our heads when we note a break in our routine. One way to manage this risk is to limit changes to equipment, flying sites, venue, and flying tasks to one element at a time. If you decide to fly a new site, for instance, avoid doing so with a brand-new harness or wing.
One important technique for managing risk at launch is to always make efficient use of any available ground crew. The pilot in command bears sole responsibility for the safe conduct of his or her flight. Thus, performing a full and complete hang check just prior to flight is the sole responsibility of the pilot in command. In discharging this responsibility, pilots should make maximum use of available ground crew to help ensure that whatever checks they routinely perform have been successfully completed prior to flight.
Recommendation: Event organizers should encourage all pilots involved in an event to demonstrate that their aircraft is airworthy just prior to flight as a condition for launching during the event.
While the pilot in command bears sole responsibility for performing all required checks, accurately judging conditions, and conducting a safe flight, it behooves everyone to do what they can to help fellow pilots achieve these goals. The wide range of operating conditions and flying equipment, the self-imposed lack of standardized operating practices, and the understandable pre-occupation we all have ensuring the safe conduct of our
own flight, makes this an extremely difficult task for the community. Organized events, however, provide a more controlled and constrained environment, one where procedures could be implemented that would significantly enhance safety. While several people reportedly challenged the pilot to confirm that he had performed a hang check, and had glanced at his equipment to see if everything looked OK, no one demanded to observe a full and complete hang check as a condition of helping him launch. Had such a demand been made, and the accident pilot complied, this accident would never have occurred.
Photos: Dean Funk
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