USAF Parachutist Fatally Extracted Through Ventilation Door (Shorts Skyvan N46LH)
On 21 February 2014, a US Air Force (USAF) Tactical Air Control Party Jumpmaster died during an inadvertent parachute extraction from a contracted Short SC-7 Skyvan N46LH, operated at SkyDive Arizona over Eloy, AZ.
Skydive Arizona Short Skyvan 3A-100 N46LH (Credit: Alan Wilson CC BY-SA 2.0)
The fatally injured “mishap jumper” (MJ) was wearing an MC-4 ram-wing parachute. He was a member of the 17th Special Tactics Squadron, Air Force Special Operations Command (AFSOC), assigned to Fort Benning, GA. According to the USAF Accident Investigation Board (AIB) report:
En route to the drop zone with the mishap aircraft approaching 9,700 feet mean sea level, the MJ stood and gave the “10 minute” warning and winds call, followed by the “don equipment (rucksack)” command. The MJ opened the Plexiglas ventilation door between the aft cargo door and aircraft floor and sat down on the seat next to the door to don his own rucksack.
Skyvan Door Configuration (Credit: USAF AIB)
[It is not clear if he] inadvertently attached his rucksack to the ripcord handle, snagged it on equipment, or inadvertently grabbed [the handle]. [Shortly after] the MJ leaned forward, the spring-loaded pilot chute popped up and fell directly through the open ventilation door taking the reserve parachute with it. In roughly two seconds, the MJ was extracted though the ventilation door opening-tearing off his rucksack, damaging the aft cargo door, and killing him instantly. The MJ landed under a fully inflated reserve parachute …southeast of Eloy, AZ.
The investigation concluded that the MJ inadvertently pulling his reserve parachute ripcord while donning his rucksack. The open ventilation door, was of “sufficient size for a parachute to pass through, but not large enough for safe passage of a person”. Opening the ventilation door without also opening the cargo door “did not violate either military or civilian guidance” but was considered contributory.
…testimony varied on whether the hazard of an inadvertently deployed pilot chute departing through the ventilation door was briefed as a safety hazard, it appears the personnel interviewed largely failed to identify or underestimated the risk of opening the ventilation door…
Investigators also noted that:
The characteristics of the MC-4 equipment attachment D-rings, which are similar in appearance, feel, and location to the lower portion of the ripcord handles, make it relatively easy to either (1) attach equipment inadvertently to a ripcord handle instead of the D-ring, or (2) catch equipment inadvertently on ripcord handle while attempting to attach equipment to the D-ring.
Not the Proximity of Handle and D-Rings (Credit: USAF AIB)
Safety Resources
- James Reason’s 12 Principles of Error Management
- Back to the Future: Error Management
- AC-130J Prototype Written-Off After Flight Test LOC-I Overstress
- C-130 Fireball Due to Modification Error
- USAF RC-135V Rivet Joint Oxygen Fire: A military accident investigation has paradoxically determined that a $62.4mn fire was due to a maintenance error but that no human factors were involved.
- Inadequate Maintenance, An Engine Failure and Mishandling: Crash of a USAF WC-130H
- Inadequate Maintenance at a USAF Depot Featured in Fatal USMC KC-130T Accident
- USAF F-16C Crash at Joint Base Andrews: Engine Maintenance Error
- USAF Engine Shop in “Disarray” with a “Method of the Madness”: F-16CM Engine Fire
- MC-12W Loss of Control Orbiting Over Afghanistan: Lessons in Training and Urgent Operational Requirements
- UPDATE 30 March 2019: Contaminated Oxygen on ‘Air Force One’ Poor standards at a Boeing maintenance facility resulted in contamination of two oxygen systems on a USAF Presidential VC-25 (B747).
- UPDATE 30 October 2019: ‘Crazy’ KC-10 Boom Loss: Informal Maintenance Shift Handovers and Skipped Tasks
Also see our review of The Field Guide to Understanding Human Error by Sidney Dekker presented to the Royal Aeronautical Society (RAeS): The Field Guide to Understanding Human Error – A Review Aerossurance is pleased to be both sponsoring and presenting at a Royal Aeronautical Society (RAeS) Human Factors Group: Engineering seminar Maintenance Error: Are we learning? to be held on 9 May 2019 at Cranfield University. 
We also wrote:
- MC-12W Loss of Control Orbiting Over Afghanistan: Lessons in Training and Urgent Operational Requirements
- UPDATE 22 February 2019: What a Difference a Hole Makes: E-8C JSTARS $7.35 million Radar Mishap
- UPDATE 30 March 2019: Contaminated Oxygen on ‘Air Force One’ Poor standards at a Boeing maintenance facility resulted in contamination of two oxygen systems on a USAF Presidential VC-25 (B747).
Recent Comments