To Err Is Human: Mistakes and slips in skydiving and other disciplines
blueskiesmag.com
blueskiesmag.com
Take skydiving, for example. As a beginner, you're keenly aware that every time you toss yourself out of a plane, you're committing suicide, and every time, the parachute saves your life. Quite quickly, it can be easy to equate "wearing a parachute" to "nothing will go wrong".
A skydive rig is an incredible feat of engineering. Each fold and stitch has a history, a reason and a purpose. It's a thing of beauty. However, in a skydive rig, half the system is a black box: You're not allowed to touch or handle the reserve part. This can foster a complacency, or a shift of responsibility: It doesn't matter if my pack was terrible, I've got my reserve..
Checklists do exist: In theory you'll check your AAD (Automatic Activation Device - it basically fires your reserve if you haven't opened by a certain altitude), your pins (reserve and main), your handles (pilot chute / main handle, cut-away handle, reserve handle), straps (leg straps, chest strap), ring system (RSL and three ring system), and then your own gear (helmet, goggles, alti).
However, expectation of performance (IE, every time you've worn your chute it's worked, leads to complacency), peer pressure (it's totally 'not cool' for experienced jumpers to ask for a gear check) - rushing - and the 'laid back' environment of dropzones erode the seriousness of the task and the importance of stringent checking.
Wow. What I'd do after I check my gear, is ask a buddy to check mine and I check his. With a checklist.
In reality, most new jumpers will ask for a gear check for the first few jumps after finishing the training and then stop.
There really isn't a need for a checklist, it isn't hard to remember what to check. The problem is that people are either too lazy, too embarrassed, too complacent, or just too stupid to do the checks (and practice emergency procedures).
Recently, at 10,000 feet up (on the way to 13,000) I asked a 15 jump beginner in a friendly way if she was going to check her handles and practice emergency procedures. She answered that she already did. I sat behind her and watched all the way up, and she had not done these things in the plane which is common safety procedure. I then said, no, I mean in the plane. She ignored me and then went on to jump without checking anything. This is actually pretty common. People don't like to be told what to do.
As a student, all your gear is double checked on the ground and just before exit. Even when you're jumping solo - if you don't open your parachute, your reserve will automatically deploy (there's a little computer that will fire the reserve if you're not open by a certain altitude)
Once you're a licenced jumper and have shaken off the 'student' label (meaning noone insists for a gear-check) - you could choose not to enable your AAD (automatic altitude deployer) and kill yourself.
To get to that stage, you've probably invested $3000+ and a lot of time. Not the most efficient way to suicide.
He has described that there is a whole group of people who want to die, but do not want to kill themselves. They often aren't (fully) aware of this nature of themselves.
These people often are very attracted to risky behaviour, and are seen pushing boundaries in extreme sports - skydiving, motorcycling, etc.
But, of course, that doesn't mean that everyone - or even a large number - in these sports are like this.
In the plane, no gearcheck - but he did take a stack of selfies. About 10 seconds into the jump, his helmet flew up - it hadn't been attached. Instead of breaking away and pulling, he deathgripped me and tried to reseat his helmet over and over.
We broke off and tracked away from the guy - when he deployed - he'd obviously been unstable - and had about 15 line twists, which he proceeded to slowly undo - while drifting up the jump run, before finally getting a flying canopy well below the hard-deck.
I tried to be as kind as possible to the guy, suggesting less selfies, more gear-checks and revisit some of the basics, but he just shrugged it off.
There were also 2 coaches in the plane that said nothing about the phone on the run up - wtf.
I'm really really surprised by these comments. Maybe it's a cultural thing but for sure where I live everyone checks at the very least themselves before jumping.
For me it's like saying "sure you won't remember to fasten the seatbelt on your car, ride after ride, once you are an experience driver?". Well, you can be damn sure I will ;)
For me, its simple. I want to live. Checking my gear/wearing my seatbelt increases my chances for survival if something goes wrong.
If it takes 5 minutes to make sure you'll live another day, would you not take these 5 minutes?
Some people like risky activities because they don't want to live. It's a cultural thing.
What I am surprised at is the fact that the parent literally says "I don't believe you" regarding something that I experience myself all the time.
It's like they internalized that doing so is not only rare -which it might be in their country- but just not at all possible!!
> Seatbelts are the perfect example - in my experience, a lot of experienced drivers don't bother
See that's quite my point. I don't doubt that people might not use the seatbelt where you live. But if you told me you "don't believe" that the vast majority of people use it here when I see it with my own eyes every day... Then I'd be indeed very surprised.
(As a side note seatbelt usage here in Switzerland is reported to be ~94% by the European transport safety council)
I'm not sure about this example. All around the world tons of people don't fasten the seatbelt (and many more wouldn't do it if there weren't fines).
I wonder if there are really a lot of people who are sensitive to the risk of a fine but not the risk of injury or death.
A popular accessory in some countries is a seat-belt "buckle" without the belt. You use it to silence the "seat belt unfastened" beepers.
Consider my upbringing. I'm not a pilot, but my father flew combat in WW2 and Korea. He was a stickler for always following the safety procedures to the letter - and flew for 20 years without a scratch. In 1963 he had seatbelts installed in the family car, and we wouldn't move an inch until the belts were on everybody. I'm the same way, and seatbelts have saved both my life and others in my family.
I'm not dying to look cool. And my family sure wasn't cool in the 60's with the seatbelts.
I've also worked on flight critical designs for Boeing. There one learns a lot about arrogance and complacency causing disasters.
I've never done sky diving (why jump out of a perfectly fine plane? :-) ), but the culture & attitudes you describe sound scary. Well, at least people have fun and selfies (and, unlike a careless pilot, they (most likely) only endanger themselves). /s
My pilot father recounted a story once where he was going through the landing checklist. He was interrupted by the controller on the radio, then continued with the checklist. He'd skipped lowering the landing gear, which is a deadly mistake (he was informed of this by the ground).
Thereafter, whenever he was interrupted while doing the checklist, he started it over.
There's a relatively common personality type where telling people to do something is the best, most consistent way to get that person to do the exact opposite thing. The more you try to nag at such people, the more obstinately they resist, even doing counterproductive actions out of spite.
If they want to be safe they will. If they have a death wish, I'm not getting on a plane with them. I'm more than happy I've never encountered this sort of behaviour.
I'm not an experienced skydiver (only dove twice) but from what I've seen gear checks are common. Might this be regional?
I do know that the US had a reputation for being significantly more... trusting of everyone to sort out their own arrangements.
I do know that in fifty-odd jumps, I checked my gear and had someone else do a check for me once I was wearing it, every time. Good habits learned early stick.
Yeah, that mentality will get someone killed. Literally one of the first 3 things to do in any dropzone I've been in is a gear check, and I don't jump without it (duh?). I think it's an extremely reckless thing to suggest.
>it's totally 'not cool' for experienced jumpers to ask for a gear check
is not completely accurate. The reason why inside the plane gear checks are not done often anymore except on students is mostly because of the changes in skydiving gear. Typically the only inside the plane things you can't check yourself and need to ask for someone else are the main and reserve parachute pins. These pins keep the container locked, and it's very important that they are not dislodged since they prevent premature parachute openings which can be disastrous. Older rigs had exposed pilot chute bridles, huge pin flaps, and larger canopies/dbags that all made it easier for the pin to wiggle. So it was standard procedure to check the pins 3 times: after packing, before putting on and inside the plane. However jumpers downsize canopies soon as they gain the necessary experience these days, and the modern skydiving container comes free-fly ready with no bridle exposed, pilot chute handle tucked tight, all of which make it harder for the pin to dislodge. This makes most experienced jumpers comfortable checking the pins only in the first 2 steps, packing and before putting the rig on. The risk associated with having someone else mess with the flaps and the pins inside the plane is deemed greater than the risk of pins dislodging between the time they put on the rig and opening the parachute.
Students however do not have the experience to evaluate a properly positioned pin, so having an inside the plane pin/gear check is required.
To be honest, for me, as someone who's neve skydived and never will, it sounds like the mistake is to "toss yourself out of a plane" in the first place.
I can imagine myself preparing to jump and feeling every muscle fibre in my body saying "no, you idiot". Sometimes you should just listen to your base, animal urges- they know what's best. When it comes to knowing what it feels like to hit the ground at anything more than a couple of km/h, your body has a much better imagination than your brain.
For reference, an article he also wrote with that title, discussing design and human error in major transportation accidents:
However it's stupidly easy as a jumper to forget completely about your altitude because you're concentrating on something else. Hard to believe that you're able to easily ignore 'certain death' after a few times - but that's the case.
According to CYPRES documentation, they've had thousands of fires - so in theory - saved thousands of lives - including the ones in this video. Pretty impressive.
I'm being cynical. The occasional misfire is worth every life saved. I suppose that AAD systems are like airbags. An occasional false positive is better than even a single false negative.
When you're falling? What else is there to concentrate on, than how frigging high you are?
https://www.atlasobscura.com/articles/pointing-and-calling-j...
Someone linked this article in a thread related to worker safety or hazards.
There always seems to be ways to improve safety or reduce failure rate. But the problem is lack of incentive or motivation to make those improvements.
After reading the actual article. The point and call aims to eliminate the "slip" error. By keeping the human awareness focused and engaged in the activity.
A couple of years ago I changed how our work checked the tyre pressures on company vehicles. It used to be a sheet with the tyre pressure stated at the top then a checklist of if each tyre was OK. I changed it to the checker having to write down each individual pressure.
This had two positive effects. Firstly it helped ensure they actually took the measurement and secondly we could identify slow punctures better.
I think it's extremely important, because the case of aviation shows that highly trained professionals make mistakes all the time. Now, bad mistakes in aviation are very visible (hard to ignore a crashed passenger jet). However, bad mistakes in surgery result may result in the death of one person that was sick already. So, it's very easy to "overlook" them.
I feel much more comfortable in a hospital that uses checklists and CRM.
I wonder if exaggerated gestures and pointing with the finger, like the Japanese railway operators do would help. I'm going to start doing this myself during my checks (beginner paraglider).
Ex: When landing the plane: GUMPS (gas, undercarriage, mixture,prop,seatbelts ) say them all while pointing to each item.