What happened
On September 25, 2016, at LKMB (Mladá Boleslav), a 47-year-old female skydiver participated in a training jump from an altitude of 1500 m AGL. The jumper was performing a specific training task involving an exit against the direction of aircraft flight. Following the exit, the jumper was unable to stabilize her body position, leading to an uncontrolled rotation during freefall.
During the descent, the jumper failed to activate the main VO-03 parachute. In a state of significant stress and likely due to a lack of experience in emergency procedures, she did not attempt to manually deploy the reserve parachute. Instead, she pulled the main parachute cutaway handle. The jumper struck the ground at approximately 205 km/h, resulting in fatal injuries.
The investigation
An investigation by the ÚZPLN examined the jumper's equipment, including the VO-03 main parachute, the VO-04 COBRA 1 reserve parachute, and the VIGIL 2 automatic activation device (AAD). Investigators reviewed video footage from an aircraft-mounted camera and a ground-based industrial camera, as well as data logs from the AAD.
The investigation also scrutinized the training process and the maintenance of the parachute rig. It was noted that the jumper had returned to the sport after an 18-year hiatus and was undergoing training for the "Ž" category, but her training did not strictly follow the prescribed syllabus for category "A" proficiency.
Findings
- The primary cause of the accident was the jumper's failure to activate the main parachute, followed by the failure to manually deploy the reserve parachute, compounded by the failure of the AAD to deploy the reserve.
- The VIGIL 2 AAD's cutting unit was non-functional because the firing pin failed to ignite the pyrotechnic charge.
- The jumper was unable to stabilize her body position due to a methodologically incorrect exit technique, which led to uncontrolled rotation.
- The instructor overestimated the jumper's ability to manage the equipment and underestimated the impact of her long absence from the sport.
- Maintenance issues were identified regarding the parachute owner's equipment, including the failure to replace the AAD cutting unit in accordance with manufacturer bulletins and the use of containers without manufacturer approval.
Safety action
Following the investigation, the ÚZPLN recommended that the Civil Aviation Authority issue an alert to all owners of VIGIL 2 devices to ensure compliance with service bulletin ADV-01-2017.