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Fatality Black Nights


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#1 shorehambeach

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Posted 01 May 2017 - 10:46 PM


An experienced parachutist described as a "hero" by his son has died after a "tragic" jump in Lancashire.
Carl Marsh suffered fatal injuries at Black Knights Parachute Centre in Cockerham, near Lancaster, on Saturday.
Paramedics were called to the site but the 46-year-old from Knutsford, Cheshire, was pronounced dead.
Lancashire Police and the British Parachute Association are investigating but there are not thought to be any suspicious circumstances.
Mr Marsh's relatives released a statement paying tribute to the "much-loved" family man.
Black Knights Parachute CentreImage copyrightGOOGLE
Image caption
Experienced parachutist Carl Marsh died at Black Knights Parachute Centre near Lancaster
They added: "Carl was taken away from us so suddenly that this just doesn't feel real.
"His enormous heart was big enough for every one of us and he lived life to the full.
"He was a leader and admired by so many, and his son Craig says he was his hero."
Det Insp Simon Ball said: "Our thoughts are with the family and friends of this man and in particular those who witnessed this tragic incident yesterday.
"During our initial investigation at the scene, we saw nothing that suggested any sign of suspicious activity.
"We are working with the British Parachute Association who are now in charge of investigating the incident, and have been conducting enquiries on their behalf."
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#2 shorehambeach

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Posted 21 June 2017 - 01:10 PM



From the minutes of the British Parachute Association's Safety & Training Committee held on the 1st of June 2017:

Quote:
The Chair reported that unfortunately, there was a fatal accident at the Black Knights Parachute Centre on the 29 April. A résumé of the accident had been circulated with the Agenda:

At approximately 15.05 hours on Saturday 29 April 2017, Carl Marsh boarded a Cessna Caravan aircraft, in order to carry out a 2-way Canopy Formation (CF) coaching jump, along with 15 other parachutists. This was the 12th lift of the day.

The aircraft climbed to approximately 8,000ft AGL. A ‘jump run’ was made over the PLA. Once the aircraft was at the exit point, some of the parachutists on board exited. The first to leave was an experienced parachutist carrying out a solo free fall jump, followed a few seconds later by a group of 5 experienced parachutists carrying out a 4-way CF jump, together with an ‘in-air’ videographer recording their jump. Next to leave the aircraft was the trainee CF jumper with 407 jumps, who was being coached by Carl. They were followed by 2 Student parachutists, carrying out solo free fall jumps. These 2 students were dispatched by the Jump Master, a BPA instructor. The aircraft then proceeded to climb to the planned altitude of 15,000ft, where the remaining 6 parachutists on board intended to exit.

The main parachutes of all the parachutists who exited on the pass at 8,000ft AGL, were seen to deploy at the correct altitudes for the types of jumps they were undertaking, and all were observed to be flying correctly.

Carl and his CF trainee were seen to link their parachutes together and turn back towards the landing area. Shortly afterwards, the lower parachutist (the trainee CF jumper) was observed to cut-away from his main parachute whilst it was still attached to the higher parachutist (Carl) and deploy his reserve parachute after 3 – 4 seconds.

The trainee CF parachutist’s cut-away parachute was then seen to partially wrap around the lower part of Carl’s body. Soon after this Carl’s main parachute was observed start to rotate to the left.

Shortly after the rotation started, a small object was seen to drop away from Carl. After this, the entangled parachute detached from Carl, who then continued to rotate quickly under his parachute (approximately one rotation per second) until he impacted heavily with the ground. Once the incident had been observed, the remaining 6 parachutists on board the aircraft were instructed to descend on board the aircraft.

A BPA Board of Inquiry was immediately instigated. The members of the Board were; Tony Butler – Chief Operating Officer and Jeff Montgomery – Safety & Technical Officer.

Carl Marsh was 46 years of age. It is believed that he had completed a total of 1,150 jumps prior to the accident, as not all his jumps had been logged. Carl was also an experienced CF jumper and CF Coach.

The Board were able to examine the equipment used by both jumpers involved, which was CF equipment belonging to the Centre; PD Lightning 160 main parachutes. It had been noted at the scene of the accident that the right hand steering toggle of Carl’s main parachute was located against the keeper and that the left hand steering toggle had been found with some slack line and resting on the ground. Carl’s knife was also located close to his position on the ground.

Carl’s reserve parachute had not been activated and it was still inside its container. Both the cutaway pad and reserve handles were in place. It was also noted that the Carl’s left training shoe was missing. This is what had been seen to fall away from him whilst he was rotating under his main parachute. The Board members could not find anything that would indicate a fault with any of Carl’s parachute equipment, and there was no reason to suggest that either the main or reserve canopies were not in an airworthy condition.

The Members of the Board also examined the main parachute jumped by the other parachutist involved and noted that the left hand steering toggle was missing and not attached to the end of the left steering line. The right hand steering toggle was attached. The left steering had detached when the jumper had taken hold of the toggles after deployment. Neither set of equipment was fitted with an AAD.

The Conclusions of the Board are that Carl and the other parachutist involved exited the aircraft at approximately 8,000ft AGL to carry out CF training jump. They deployed their parachutes within approximately 3 seconds of leaving the aircraft. Carl’s main parachute deployed without problem. However, upon deployment, the other parachutist involved encountered a problem; his left steering toggle detached, making it difficult to control the parachute.

He informed Carl of the problem and that he intended to carry out his emergency procedures, which would be to cut-away his main parachute and deploy his reserve parachute. Carl then informed the other parachutist that, notwithstanding this problem, he would continue with the manoeuvre to link the parachutes together, so that he could guide them through some cloud which was in the area.

This decision goes against correct training on emergency procedures. If there is an emergency problem with the main parachute, such as a malfunctioned parachute, the planned CF jump should not continue and the relevant emergency procedures should be carried out.

Carl proceeded to link the two parachutes together and turn the pair back to the PLA, briefly going through some cloud. Once they were out of cloud, Carl informed the other parachutist that it was clear to cut-away and deploy his reserve parachute. However, the other parachutist observed two more parachutes below him and decided to wait until they had vacated the area. He informed Carl of his decision.

Once the area below was clear, Carl advised the other parachutist involved to cut-away his main parachute. This other parachutist did this, whilst Carl was still attached to the other parachutist’s main parachute. This also goes against training on emergency procedures, as Carl should first have released his link on the other parachutist’s parachute and moved a safe distance away from him before the other parachutist cut-away his main parachute, to allow space for the cut-away parachute to come away safely.

The other parachutist involved cut-away his main parachute and deployed his reserve parachute without further problem. However, as he cut-away his main parachute it entangled around the lower half of Carl’s body.

At this stage, Carl attempted to release the entangled parachute. In the process, his left training shoe came off or was kicked off in an effort to release the parachute. Carl then used his knife, located on his chest strap, to cut entangled rigging lines to release the parachute. In order to do this, he had to release control of the parachute, by taking his right hand out of his steering toggle, and take hold of his knife. It is possible that he either forgot also to release the left steering toggle at the same time, or the toggle may have caught on his wrist-mounted altimeter, obstructing its release.

Not releasing the left steering toggle is the probable cause of the parachute’s rotation to the left. As Carl was concentrating on releasing the entangled parachute, which he eventually did, he may not have realised that his parachute was rotating at the time.

It is likely that the entangled parachute was released between 2 - 3,000ft AGL, which should have enabled Carl either to rectify the rotation or carry out his emergency procedures. The Board do not know why he did not rectify the situation, but it is possible that he became disorientated, or he may perhaps have lost consciousness as the parachute was rotating so quickly.

The Panel therefore concludes that both Carl and the other parachutist, for whatever reasons, did not follow their training regarding the actions that should have been taken in the emergency situation in which they found themselves. However, the Board believe that it is understandable that the trainee CF jumper would take his lead from his coach.

Because of the speed of the rotation of Carl’s main parachute, had the equipment been fitted with an Automatic Activation Device (AAD), it may have activated and deployed or partially deployed his reserve parachute, which may have slowed the descent rate enough to possibly lower his speed on impact with the ground.

The Recommendations of the Board are that parachutists should be reminded that:

a. if their main parachute does not deploy correctly, they must immediately follow correct emergency procedures and deal with the problem and not continue with a planned Canopy Formation descent unless it becomes safe to do so. The emergency procedure is a plan of action to be conducted in a certain order or manner, in response to an emergency situation, and has been developed to be likely to result in the most positive outcomes;

b. if carrying out a Canopy Formation descent and one or more parachutists need to cutaway their main parachutes, they should follow correct emergency procedure and first separate (unless they are already entangled together and therefore unable to do so);

c. CF jumpers consider the benefits of fitting their equipment with AADs, as this is not mandatory.

It was proposed by Matty Holford and seconded by Kieran Brady that the Board of Inquiry Report including the Conclusions and Recommendations of the Board be accepted.

For: 9 Against: 0 Abstention: 1 (Paul Yeoman)

Carried

The Chair stated that as is BPA policy, a Panel of Inquiry would be convened to consider any peripheral aspects of the Board of Inquiry.

Paul Yeoman wished to record his thanks to Matt Denton and Sharon Beeson for their help and assistance following the fatal accident.


Skydiving Fatalities - Cease not to learn 'til thou cease to live
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#3 BlueSkyBri

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Posted 27 June 2017 - 05:01 PM

Thanks for posting. I'm never quite sure how to handle the reporting of major incidents like this, in a public forum. 

 

Kudos to the UK Skydiver community for not speculating and waiting for the report to come in. 

 

Our love and thoughts are with Carl's family and friends. 


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#4 shorehambeach

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Posted 28 June 2017 - 07:18 PM

I think dz .com shows the best way to handle incidents.

Publish.

Discuss them.

Learn from them.

Move on.
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#5 BlueSkyBri

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Posted 28 June 2017 - 07:43 PM

I think dz .com shows the best way to handle incidents.

Publish.

Discuss them.

Learn from them.

Move on.

 

It's the discussion part that can cause issues. Too many media types looking for a juicy quote. too much speculation, too early, can be damaging. People not writing like their speculation is fact. It can escalate v quickly when emotions are high and the moderating needs grow too. We're trying to keep this a light touch site. 

 

I think it was Craig that said that he liked UKS over DZ.com cause it was a bit more sensible here than there. I guess, due to the smaller community in the UK.


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#6 shorehambeach

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Posted 28 June 2017 - 09:50 PM

I think we can learn a lot by discussing fatalities and accidents - of course there is some speculation which is to be expected - but the dz . com incident thread is used as a learning tool and a good one in my opinion.
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#7 BlueSkyBri

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Posted 29 June 2017 - 11:23 AM

I think we can learn a lot by discussing fatalities and accidents - of course there is some speculation which is to be expected - but the dz . com incident thread is used as a learning tool and a good one in my opinion.

 

Oh don't get me wrong, it's an incredibly valuable tool and I use it too. I'm relieved there is a way to honour the fallen by learning from their mistakes. I'm just glad I don't have to moderate that particular forum. And if there is a solution already, does UKS need to replicate it? Hmmm.


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#8 Kel

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Posted 12 July 2017 - 10:43 AM

Thanks for posting this, I have been interested to read. I think I'll be ever curious as to the reasons behind some of these decisions and actions.

I met Carl at various CF events over the years and he was a really lovely guy so it was very sad to hear this. 


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#9 100%GravityFeed

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Posted 29 August 2017 - 10:49 AM

This is so incredibaly sad. We sometimes get things like this on the moto forum I belong to....

Thanks for posting the BPA report.


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