Safety is more than not having accidents. It is more than doing things right, or of not doing things wrong. Safety, as a culture, is derived from an understanding of how accidents happen, and from a conscientious effort to eliminate the root causes of all accidents.
It would be easy to develop a "safe" culture if we could anticipate each accident and control the specific causes in advance. Yet there is a randomness to accidents that makes it difficult to apply resources in a focused manor that will address just a single anticipated event. Rather than struggle to identify and correct a specific problem, we should be looking at safety as a broad collection of issues that can be identified and corrected, thus reducing the probability of a serious or fatal accident. It is this broad based approach that defines a safety culture.
Often the same skydiving behavior or situation will result in different outcomes, sometimes passing unnoticed, and sometimes generating a fatal accident. Our objective should be to proactively identify and correct risk behaviors, rather than focus on only those cases that result in serious injury.
Every accident is different, yet many share common causes. It is reasonable, then, to create a fictional accident, and to examine pre-accident behavior so we can analyze an event divorced from the emotion that follows injury to a friend.
A Fictional Accident
Joey Jumper is not real, but the problems discussed here are all very real, and each has been identified in the past as a component of accident cause. See how many potential problems you can identify in his story, and try to determine what the cause(s) of Joey's accident might be.
Joey Jumper has made 1,050 skydives over a 20 year career. He has made 30 jumps in the last year, and just two in the last 90 days. Joey's jumping career has been sluggish over the past few years because he wants to spend time with his new wife and two small children, but he still tries to jump whenever he can get away from his busy home life. Joey weighs 240 pounds and is jumping a Stilletto120 His reserve is a PD 193. The rig is an old Mirage and it appears the container has been modified to hold the small Stiletto. He has a Cypres AAD, and his rig is equipped with an RSL that has been disconnected and attached to the reserve cable housing. The reserve is sealed, but the packing data card shows the reserve hasn't been packed in more than a year, and the Cypres battery is six months past the replacement date. Joey isn't wearing a helmet, but does have a new jumpsuit, and he is equipped with a chest and wrist mount altimeter.
The bridle of the kill-line collapsible pilot chute is old and no longer shows a mark to indicate that it has been set for deployment. Joey gives the rig to a packer who has been packing other jumpers mains for many years but lacks a rigger certificate. The packer is rushed and forgets to set the pilot chute. Many of the rigs that are handled by the packer lack bridle markings, so the missing marking on Joey's equipment doesn't attract the packers attention, and his failure to set the pilot chute goes unnoticed.
Joey is invited on a eight-way freefly jump, and although he has done some freefly, he has never been in anything bigger than a three way. He is nervous about the jump when he picks up his rig from the packer, and is rushed to the airplane because he didn't hear early calls on the drop zone PA system. He quickly glances at the wind sock and recognizes there is a strong wind from the west, but he thinks his main will handle landing in the high winds. He knows that while the spot will probably be far from the DZ, he has jumped in stronger winds in the past, and there are plenty of "outs" if the spot turns out to be too long.
Joey throws the rig on his back while running out to the airplane, and just barely gets both leg straps on while moving into the Twin Otter. The climb to altitude is a blur as Joey thinks about the dive, and tries to remember the names of his new jump buddies. The airplane is carrying Joey's group and just four tandem jumpers because the rest of the load scratched at the last minute due to increasing winds. The airplane reaches 14,000 feet quickly and Joey exits last in his group.
As the dive progresses Joey corks and looses sight of the others. He catches a quick glimpse of one or two of the jumpers at several points, but can't keep track of where the rest are. He knows a mid-air collision could be a problem so he moves to his belly and continues searching until the ground begins to rush through his field of vision. Joey quickly checks his altimeter, finds himself at 2,000 feet, and then tosses his pilot chute in a near panic.
The pilot chute streamers. It pulls the main pin and lifts the bag, releasing most of the lines, but doesn't have enough drag to free the last two line stows that are held by double rubber bands. Joey is confused by the bag lock malfunction and waffles between cutting away and just pulling his reserve. Finally, the Cypres fires and deploys the reserve pilot chute between the main risers. The reserve bridle clears the risers but wraps around the main bridle, and then drags the main deployment bag free of the double rubber banded line stows.
Both the main and the reserve parachute open side by just 500 feet above a small field far from the drop zone. Joey aggressively tries to steer his main parachute into the open field so he will not land in the surrounding trees. As he pulls down hard on the right steering toggle the main parachute quickly turns, and then collapses. Joey frantically pulls on both steering lines and the main re-inflates behind him in a spin. The Main chokes the reserve lines, then both parachutes spin and collapse almost completely.
Joey slams into the small field below him, but nobody saw his low opening, or watched his frantic efforts to steer the two parachutes. Joey isn't reported missing, but two hours later another jumper happens to see his parachutes in the open field while he is flying back from another load.
The other jumper lands at the drop zone and then drives to the field to check on what he thought was a cutaway main. When he reaches the field he finds Joey, still alive and struggling to breath. The second jumper runs back to the road and stops a passing car, asking the driver to call 911. He then returns to Joey and quickly removes his rig so the ambulance crew won't cut the harness. Joey stops breathing seconds later, and ambulance workers are unable to revive him when they arrive shortly thereafter.
Analyzing The Chain
In the above accident there were plenty of problems. Some of those problems had no direct bearing on the accident, but several were clearly serious, and if corrected could have prevented the demise of Joey Jumper. The problems that relate to this specific accident form a chain, and correcting any one of those "links" could prevent the accident from occurring. For example, if the pilot chute bridle was properly marked the packer might have noticed it had not been set, and might have had a chance to correct the error before Joey put on the rig. If Joey was more current he might have responded faster to the bag lock malfunction and might have cutaway sooner, preventing the dual deployment. If other jumpers had noticed Joey was missing they could have sent help sooner, and rescue personnel might have been on the scene when Joey stopped breathing.
It quickly becomes apparent that serious accidents have many causes, but that accidents are often easy to prevent if we can identify and correct even a few problems before the jump happens. Take a few minutes and review the above story to identify the links in the chain that could have made a difference in this fictional accident.
Three Kinds of Causes
In the above accident there are several things that are obviously serious enough to cause a problem by themselves. Other elements combine to create additional risk, and still others are fostered through bigger issues of culture. The key elements are considered "direct causes." Secondary elements are considered "contributing causes." The larger cultural issues are considered "root causes." In this case the direct causes might be the failure to set the pilot chute bridle, and Joey's failure to properly respond to the pilot chute in tow. Contributing causes might include such things as Joey's lack of currency, lack of altitude awareness, or the failure to identify the pilot chute problem prior to the jump. Root causes are generally related to culture, and might include such things as the failure of rig owners and packers to have a standard of equipment maintenance and inspection, a willingness of jumpers to overload themselves and each other with excessively challenging dives, or the failure of anybody on the drop zone to quickly identify and respond to a missing jumper.
Correcting the direct causes would have prevented this specific accident, and possibly others. Correcting the contributing causes would have had a greater effect by changing many risk elements that might cause additional accidents. Correcting the root causes would change the culture, and in turn, would significantly reduce the occurrence of direct and contributing causes that might lead to future accidents. Together these three types of causes form the chain discussed earlier.
Take a few additional minutes and try to determine which of the specific problems in the Joey Jumper story might be direct causes, contributing causes, and root causes. Keep in mind that many of the problems in the story did not have a direct relationship to the actual cause of the accident, but they may illustrate root causes such as a lack of oversight, or a limited program of risk management. Consider how changes in culture might eliminate some of the root causes, and how those changes might reduce the probability of future accidents.
As we have seen, isolated problems can combine through a chain to cause an accident. Likewise, problems that are direct causes of one accident may be contributing causes of other accidents, and both direct and contributing causes can often be corrected through analysis of the root causes. Identifying and correcting root causes within the culture of an organization will have the greatest potential to drive change across multiple problem areas, and will thus have the greatest effect on operational safety.
Building a Pyramid
Not every problem will cause an accident, nor will every accident result in a fatality, even if the same direct cause underlies many jumps. In fact, a problem may go unrecognized until an accident occurs, and even then it may remain uncorrected until an actual fatality occurs. Yet, we do not need to wait for a fatality to identify safety issues or to correct known problems. In the case of an unmarked pilot chute bridle it is possible (indeed likely) that there will not be any accident at all. Likewise, the unmarked bridle may result in a failure to identify an unset a pilot chute, and may then result in an otherwise uneventful slow opening. The same basic problem could also result in a frightening bag lock malfunction followed by a cutaway and successful reserve deployment, or perhaps even an accident with minor injuries. The result of jumping with the unmarked bridle could have a variety of outcomes. The actual outcome of a jump is often determined by the development of a chain, and by chance.
Take another moment and review the Joey Jumper accident again. You should already have a clear list of problems and their role in causing the accident. Next, identify each of the causes and determine if another jump could have been made under different circumstances without the problem being identified or even becoming an issue. Determine if the each problem might have the potential to cause a close call without injury, minor injury, major injury, or death. For example, a jumper who is not current with his emergency procedures could make a jump without ever needing those skills, and thus the problem would never be noticed. Likewise, the problem could cause the jumper to panic, but he may still react correctly within the given time and no injury would result. The same problem could result in a minor injury accident, a major injury accident, or even a fatality. Often a specific identified cause will have the potential to create an accident in any or all outcome categories.
Creating a Culture To Destroy Chains and Pyramids
It is helpful to think of all direct and contributing causes placed in a pyramid, with the base labeled as Unknown or Undiscovered issues, the next level up marked as Known Issues Ignored, the third level marked as Close Call with No Injury, the fourth level is Minor Injury, the fifth level is Serious Injury, and the top is a tiny space marked Fatal.
Preventing serious injuries and fatalities would be easy if we could identify specific causes and outcomes in advance, and then concentrate on elements in the top of the pyramid. Yet the actual outcome of a single problem or issue is often determined by chance, coupled with a chain of events that links contributing causes. Thus, the same specific problem could result in death, or it could remain unnoticed for thousands of jumps.
Most safety issues will probably be concentrated at the bottom of the pyramid, and will either be unrecognized, or will already have been identified and not mitigated. In fact, the best means of reducing risk is by concentrating on the bottom sections of the pyramid. A solid safety culture will drive improvements that force examination of simple issues and problems at the bottom of the pyramid. If we can build a culture that actively identifies and corrects minor problems, we can prevent the construction of a chain of cause, and thus prevent serious and fatal accidents that reside at the top of the pyramid.
It can be argued, although not successfully, that the culture of a drop zone is irrelevant in a sport of individuals. Yet, any serious or fatal accident has a profound effect on the drop zone, the surviving jumpers, and the family of the injured jumper. In the case of fictional Joey Jumper, he leaves behind a widow and two small children who will need to face life without him. His death will shake up the close-knit community of jumpers. It will probably generate unwelcome negative publicity that could threaten the reputation, and perhaps the very existence, of the drop zone. The packer who failed to notice that the pilot chute was not set will be faced with lifelong self-guilt, as will many of the jumpers who participated in the overly ambitious jump. The death could generate significant legal and financial liability for the drop zone, USPA, and the equipment manufacturer. While the death of Joey Jumper will be a singular and private event, it will have a wide impact that will affect many lives. A safety culture can help to prevent accidents, and can mitigate the negative outcomes associated with risk.
Applying A Safety Culture
Let's return to the Joey Jumper story one final time. Try to identify all the issues and problems in the Joey story that you have also seen at The Ranch, or have experienced on your own skydives. Next, think of ways that you as a club member or jumper can eliminate those problems. As an example, a quick inspection of your own rig prior to jumping will identify many simple problems, each of which could cause a fatality. Finally, take a moment to think about how a community of jumpers at The Ranch can create a culture that will aggressively identify and correct problems before they have a chance to build a chain and cause a serious accident. For example, consider ways that we can reduce equipment failures through improved inspection or maintenance standards.
We each have a profound affect on the safety of the drop zone, and as a group we can work to build a culture that identifies and corrects problems before they have a chance to form into an accident chain. Safety is our responsibility, and supporting a personal and club culture that manages risk will help to prevent serious accidents that can injure or kill us, or our friends.
- Tom Buchanan S&TA