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Skydiving Fatality of Kerrie Pyke, Peter Dawson and Tobias Turner image …
Skydiving Fatality of Kerrie Pyke, Peter Dawson and Tobias Turner
Figure 1: Tandem skydivers, source: Adrenaline 2019
What Happened
(Coroners Court of Queensland 2019)
Toby's parachute opened early causing him to fall at a slower speed
Kerrie and Peter collided with Toby and fell through his parachute with great speed and force
Wind conditions were considered favorable at around 10 knots
The impact has rendered all three unconscious or deceased mid air
Toby Turner was a contracted skydiver and jumped separately and after the tandem jumpers
Toby's main and reserve parachute were both deployed and appeared to tangle
Kerrie was strapped to Peter in preparation for the jump
All of the deceased landed close together in a residential area
Peter Dawson was the Tandem instructor assigned to jump with Kerri
All three died as a result of a mid air collision and not as a result of hitting the ground.
Kerrie Pyke was undertaking a tandem skydive on 13 October 2017 as a 54th Birthday present from her husband
People
Single jumperToby
Was scheduled to jump second last
Appeared not to open the chute voluntarily
Wind pressure infiltrated the pack which in turn deployed the chute (Dekker 2014)
when the chute opened his speed slowed dramatically
The tandem jumpers burst through the chute and collided with Toby causing him to become unconscious and fall uncontrolled to the ground
Tandem jumpers Kerri and Peter
Were scheduled to jump last
This free fall was compliant with the chute opening expectations
Their free fall trajectory was in line with the previous jumper
They collided with the single jumper and became unconscious causing them to fall uncontrolled to the ground
System Life-cycle
Manufacture
The Parachute that failed was a part of a two part system (Bruce, McMurphy 1998)
The appropriate storage of the system
Quality of the materials used
Adequate information provided in a way that allows for easy understanding for the system use
Engineering standard ensure failure free use
Sales
Staff training
Staff product knowledge
Staff ability to analyse the expected use and match the correct product to ensure there is redundancy built in to the system
Level of experience of the customer or proposed jumper
Sound knowledge of related legislation and skydiving processes
Compatibility of any combinations of product
Commissioning
The jumpers level of experience
The jumpers level of understanding of the instruction material provided by the manufacturer
Initial inspection of the system is compliant
HF issue : Is the user competent in their understanding
Third party inspections to ensure the correct use, packing and storage of the system
Maintenance
Regular and scheduled maintenance is carried out
Adequate records provided to ensure serviceability of the parachute
Records keeping methodology of privately owned equipment
Decommissioning
Life span of a parachute is between 300 and 2000 jumps depending on material type and storage type (Federal Aviation Administration 2005)
Workplace Factors
Skydive Australia operated the dropzone
Insufficient staff to check the suitability of customer owned rigs
Work Environment
Weather conditions were not considered a factor
The aircraft was suitable for the intended use
Management
Job Design
Profitability is needed and may have influenced practices for full flights ( Ore condition)
Decisions are made for scheduling different jump types on the same load
Packing up to 26 rigs in a day (Latent Failure)
Organisation
Administrative checks are incomplete
Rig checklists are not exhaustive
Inadequate logging of customer owned jump, use and storage data is held by the company
No defined process to identify all possible failure causes prior to the jump (Davidson, Labib 2003)
training
Staff are not trained to be able to inspect customer owned rigs
Reference List
Adrenelin 2019, Skydiving Gold Coast – Beach Tandem Skydive 12,000 Ft, Viewed 25 September 2019,
https://www.adrenaline.com.au/gold-coast/skydiving/beach-12000ft/?gclid=EAIaIQobChMI0-7VouLr5AIVRAwrCh0hDQ-aEAQYASABEgKuuPD_BwE
Bruce W, McMurphy K J 1998, "Safer by design: Reducing hazards through better designs", Professional safety, vol. 43, no. 2, pp. 29-33.
Coroners Court of Queensland 2019,Cairns, Inquest into the death of Kerrie Anne Pyke, Peter Michael Dawson and Tobias John Turner, Viewed 2 September 2019,
https://www.courts.qld.gov.au/__data/assets/pdf_file/0003/624234/cif-skydiveinquest-20190830.pdf
Davidson, G.G & Labib, A.W 2003, Learning From Failures: Design Improvements Using A Multiple Criteria Decision-Making Process’ Proceedings Of The Institution Of Mechanical Engineers- Part G: Journal Of Aerospace Engineering, vol. 217, no. 4, pp 207-216, Viewed on the 30th of August 2019,
https://journals.sagepub.com/doi/10.1243/095441003769700762
Dekker, S 2014, The field guide to understanding human error, 3rd edn, E-book, CRC Press, Boca Raton, Florida.
Federal Aviation Administration 2005, 4.7 Skydiving, viewed 25 September 2019,
https://www.faa.gov/search/?q=4.7+skydiving&bSubmit=Search
People / System Relationship
Skydive Australia
pre- jump checks (pre condition)
Determining the order of jumpers
Administrative systems- Restoring and Fatigue management
Allocating and packing equipment (Active failure)
Jump equipment
Aircraft
Altimeter worn by jumpers
Video recorder (go pro)
verification of privately owned equipment
Suitability of parachute pack to ensure effective deployment (latent failure)
Atmospheric
Wind speed was within acceptable limits at 10 knots at the time of the jump
People
Experience of jumpers
Experience of staff
Experience in packing parachutes (pre-condition)
HF Failure - This is a critical activity and if not done absolutely correctly then this will ultimately lead to a failure
Verification that parachutes have been packed correctly customer owned equipment (Latent Failure)
HF Failure - This is not possible to be confirmed by a third party when a customer owns and packs his own parachute prior to a jump
