Mishap at Big Sur 2012
Posted: Sun Dec 16, 2012 11:55 am
My apologies for posting this late entry. I did not feel it would be appropriate for me to post this until I was officially the Safety Director for the SHGA. For the record, the pilot involved submitted this to me roughly two months ago.
Here is a summary of a flight incident which occurred at Wild Cattle launch, Big Sur, CA on September 30th, 2012.
From the PILOT:
"Here are the facts and my opinions surrounding my structural failure at Big Sur.
Please use the information any way you feel will be helpful to the hang gliding community at large. I look forward to the results of your studies. I hope you will forward a copy of your accident investigation to the USHPA and to the SHGA for the benefit of other pilots.
In my mind, there's no mystery as to why this happened. Simple carelessness was almost certainly the cause, but if anyone concludes otherwise, I'd like to hear the reasoning.
The following is generally true for me and is very true for that day.
1. I often choose to accept a lot of distractions (questions from other pilots, assistance to anyone who needs it.)
2. I often choose to accept a lot of responsibilities in addition to my own flying responsibilities (guidance, instruction, public relations, etc).
3. I don't often fly the same glider twice in a row. I fly many different style gliders, including all 3 models Falcon. Of all Falcon models, this specific failure is only possible on the Falcon 3 model.
4. I'm getting older and perhaps losing some of my mental acuity.
5. I'm a very experienced pilot that is likely guilty of complacency during set up and preflight procedures.
The date was Sunday, September 28th in the early afternoon at the launch Wild Cattle launch site a few miles north of the Plaskett Creek Campground. Conditions had been blowing down in the morning but it had turned around and a couple of pilots had already launched into smooth, mostly un-soarable conditions.
I set up my glider (a Falcon 3 195) while monitoring my other responsibilities of running the trip and the student training. My harness was a knee hanger style with a 22 Free Flight 22 gore PDA reserve and a 1/2 shell helmet. I also put a video camera on the wing for this flight (unusual for me). Although I was not in a particular hurry, and I performed what for me is a normal pre-flight, it is clear that I failed to insert the base tube corner bolt through both the lower downtube bracket and the base tube, completely missing the hole in the base tube. This problem is simple to prevent simply by a quick visual inspection that the base tube is inserted all the way to the edge of the lower downtube bracket, before inserting the bolt. It is also very easy to inspect during the pre-flight, by the same simple observation.
The launch conditions were very gentle w/ light winds of around 3 of 4 mph.
After performing a hang check and hook in check, I proceeded to launch the glider, only to find the wings folding upwards a moment before I became airborne.
At the next moment, the slope of the hill steepened, the ground dropped away and I found myself several feet in the air with each down tube being pulled laterally out of my grip. At this point the glider has a massive amount of dihedral, substantially increasing the sink rate and glide ratio of the glider, and bringing it back down to the slope of the hill. Within 3 or for seconds from the moment of lift off, I settled back to the ground and was sliding smoothly down the slope, very fortunately without a scratch or a bruise.
It has been suggested by some, and I tend to agree, that the glider may have failed sooner, rather than later, due to the fact that I chose not to perform a smoothly accelerating launch run, but rather a jerky, hopping, launch. Had I chose to perform a more conventional launch run, the glider may have remained structurally intact longer, placing me much higher and much further away from the ground at the moment of the structural failure. I would argue that any significant increase of altitude beyond that attained during this accident, would have seriously increased the danger to the pilot (me), and likely require the successful deployment of the reserve system to avoid death or serious injury.
Conclusion:
I believe that the accident was caused solely by my failure to perform a proper, effective pre-flight. The reasons for my failure to perform an adequate preflight may be any one or more of the statements numbered 1 through 5 above.
Please call me if you have any questions.
Respectfully, PILOT"
WITNESS1:
Hi Steve, many of the pilots were around the glider when PILOT launched as he was waiting for it to clear a bit so he sat there awhile. When he moved into position someone was asking about how many steps they should take for the launch run. He started hopping on one foot laughing about how many feet it took. I think he made it about 3 hops, the glider was just getting into the air when the downtube broke away from the base tube
PILOT tried to grab for it but the wings folded very fast and he went down. I think he fell about 8-10 feet, maybe a bit higher because of the slope.
Others were closer to the edge than I who may have had a better view of what happened after the wings folded.
Hope that helps!"
WITNESS2:
I read through PILOT's accident report and I feel like he covered everything. One way that I may have contributed to his glider falling apart sooner was that I gave PILOT a piece of advice just before launch and he humored me by doing the opposite of what I suggested. I advised him to launch very smoothly so his camera mount wouldn't shake or hit the ground. Had he done what I said his control bar may have jiggled apart later in the flight. I was on PILOT's wires before he launched and watched in horror as the wing fell apart. It looked a lot scarier than what PILOT experienced since he only felt to be a few feet from the ground the entire time. To everyone watching from launch it appeared that he was falling vertically nearly 100 feet to the ground. I'm not sure what else to add. It happened so quickly. I hope this helps.
FINDINGS:
The cause of structural failure was an incorrect assembly at the downtube/control bar juncture of the Falcon 3 glider. The control bar was only PARTIALLY inserted into the downtube bracket. Therefore, when the pilot pushed in the keeper bolt, it was not inserted into the control bar, and a false assembly was accomplished. To an untrained or less than critical eye, this false assembly can appear to be correct, and this presents a critical danger to the assembly of the Falcon 3 model glider.
During my investigation into this incident, other pilots revealed that they had made the same mistake in the past. In one instance a pilot stated that he had missed the bracket on BOTH SIDES of the control bar. The glider simply came apart in his hands as he was standing on launch.
This incorrect assembly did not happen by accident but rather by omission. The PILOT clearly states that he found himself in an environment where his attention was being pulled in many different directions at once, both during assembly and afterwards during his pre-flight.
RECOMMENDATIONS:
This incident resulted in several posts on the club Forum, discussing possible remedies to this potentially fatal FALSE ASSEMBLY of the Falcon 3 downtube/control bar juncture. This investigation is being forwarded to the vendor for further consideration.
One recommendation on the forum was to wrap a ring of red electrical tape around the control bar marking the correct position of the base tube/downtube juncture, making it easier to spot when the assembly is incorrect. Another was to etch the control bar, marking the correct location.
The more important and obvious recommendation is to perform a thorough pre-flight EACH AND EVERY TIME you fly, no matter how many hours of flying you have under your belt. If distractions arise that require you to walk away from your gilder during pre-flight, start from the very beginning when you come back. Are two extra minutes worth your life? Absolutely!
END OF REPORT
Here is a summary of a flight incident which occurred at Wild Cattle launch, Big Sur, CA on September 30th, 2012.
From the PILOT:
"Here are the facts and my opinions surrounding my structural failure at Big Sur.
Please use the information any way you feel will be helpful to the hang gliding community at large. I look forward to the results of your studies. I hope you will forward a copy of your accident investigation to the USHPA and to the SHGA for the benefit of other pilots.
In my mind, there's no mystery as to why this happened. Simple carelessness was almost certainly the cause, but if anyone concludes otherwise, I'd like to hear the reasoning.
The following is generally true for me and is very true for that day.
1. I often choose to accept a lot of distractions (questions from other pilots, assistance to anyone who needs it.)
2. I often choose to accept a lot of responsibilities in addition to my own flying responsibilities (guidance, instruction, public relations, etc).
3. I don't often fly the same glider twice in a row. I fly many different style gliders, including all 3 models Falcon. Of all Falcon models, this specific failure is only possible on the Falcon 3 model.
4. I'm getting older and perhaps losing some of my mental acuity.
5. I'm a very experienced pilot that is likely guilty of complacency during set up and preflight procedures.
The date was Sunday, September 28th in the early afternoon at the launch Wild Cattle launch site a few miles north of the Plaskett Creek Campground. Conditions had been blowing down in the morning but it had turned around and a couple of pilots had already launched into smooth, mostly un-soarable conditions.
I set up my glider (a Falcon 3 195) while monitoring my other responsibilities of running the trip and the student training. My harness was a knee hanger style with a 22 Free Flight 22 gore PDA reserve and a 1/2 shell helmet. I also put a video camera on the wing for this flight (unusual for me). Although I was not in a particular hurry, and I performed what for me is a normal pre-flight, it is clear that I failed to insert the base tube corner bolt through both the lower downtube bracket and the base tube, completely missing the hole in the base tube. This problem is simple to prevent simply by a quick visual inspection that the base tube is inserted all the way to the edge of the lower downtube bracket, before inserting the bolt. It is also very easy to inspect during the pre-flight, by the same simple observation.
The launch conditions were very gentle w/ light winds of around 3 of 4 mph.
After performing a hang check and hook in check, I proceeded to launch the glider, only to find the wings folding upwards a moment before I became airborne.
At the next moment, the slope of the hill steepened, the ground dropped away and I found myself several feet in the air with each down tube being pulled laterally out of my grip. At this point the glider has a massive amount of dihedral, substantially increasing the sink rate and glide ratio of the glider, and bringing it back down to the slope of the hill. Within 3 or for seconds from the moment of lift off, I settled back to the ground and was sliding smoothly down the slope, very fortunately without a scratch or a bruise.
It has been suggested by some, and I tend to agree, that the glider may have failed sooner, rather than later, due to the fact that I chose not to perform a smoothly accelerating launch run, but rather a jerky, hopping, launch. Had I chose to perform a more conventional launch run, the glider may have remained structurally intact longer, placing me much higher and much further away from the ground at the moment of the structural failure. I would argue that any significant increase of altitude beyond that attained during this accident, would have seriously increased the danger to the pilot (me), and likely require the successful deployment of the reserve system to avoid death or serious injury.
Conclusion:
I believe that the accident was caused solely by my failure to perform a proper, effective pre-flight. The reasons for my failure to perform an adequate preflight may be any one or more of the statements numbered 1 through 5 above.
Please call me if you have any questions.
Respectfully, PILOT"
WITNESS1:
Hi Steve, many of the pilots were around the glider when PILOT launched as he was waiting for it to clear a bit so he sat there awhile. When he moved into position someone was asking about how many steps they should take for the launch run. He started hopping on one foot laughing about how many feet it took. I think he made it about 3 hops, the glider was just getting into the air when the downtube broke away from the base tube
PILOT tried to grab for it but the wings folded very fast and he went down. I think he fell about 8-10 feet, maybe a bit higher because of the slope.
Others were closer to the edge than I who may have had a better view of what happened after the wings folded.
Hope that helps!"
WITNESS2:
I read through PILOT's accident report and I feel like he covered everything. One way that I may have contributed to his glider falling apart sooner was that I gave PILOT a piece of advice just before launch and he humored me by doing the opposite of what I suggested. I advised him to launch very smoothly so his camera mount wouldn't shake or hit the ground. Had he done what I said his control bar may have jiggled apart later in the flight. I was on PILOT's wires before he launched and watched in horror as the wing fell apart. It looked a lot scarier than what PILOT experienced since he only felt to be a few feet from the ground the entire time. To everyone watching from launch it appeared that he was falling vertically nearly 100 feet to the ground. I'm not sure what else to add. It happened so quickly. I hope this helps.
FINDINGS:
The cause of structural failure was an incorrect assembly at the downtube/control bar juncture of the Falcon 3 glider. The control bar was only PARTIALLY inserted into the downtube bracket. Therefore, when the pilot pushed in the keeper bolt, it was not inserted into the control bar, and a false assembly was accomplished. To an untrained or less than critical eye, this false assembly can appear to be correct, and this presents a critical danger to the assembly of the Falcon 3 model glider.
During my investigation into this incident, other pilots revealed that they had made the same mistake in the past. In one instance a pilot stated that he had missed the bracket on BOTH SIDES of the control bar. The glider simply came apart in his hands as he was standing on launch.
This incorrect assembly did not happen by accident but rather by omission. The PILOT clearly states that he found himself in an environment where his attention was being pulled in many different directions at once, both during assembly and afterwards during his pre-flight.
RECOMMENDATIONS:
This incident resulted in several posts on the club Forum, discussing possible remedies to this potentially fatal FALSE ASSEMBLY of the Falcon 3 downtube/control bar juncture. This investigation is being forwarded to the vendor for further consideration.
One recommendation on the forum was to wrap a ring of red electrical tape around the control bar marking the correct position of the base tube/downtube juncture, making it easier to spot when the assembly is incorrect. Another was to etch the control bar, marking the correct location.
The more important and obvious recommendation is to perform a thorough pre-flight EACH AND EVERY TIME you fly, no matter how many hours of flying you have under your belt. If distractions arise that require you to walk away from your gilder during pre-flight, start from the very beginning when you come back. Are two extra minutes worth your life? Absolutely!
END OF REPORT