Irish Hang Gliding & Paragliding Association Ltd

Investigation into serious accident

30th May 2010 - 14:30hrs
involving paraglider pilot Krzysztof Zak

(AAIU State File No. IRL00910037)



Date of Accident: 30th May 2010

Location: Mt. Leinster (Black Banks) Co. Carlow.

Synopsis: A single paraglider entered an uncontrolled spin while attempting to thermal at low altitude and impacted the hillside resulting in spinal injury and paralysis.

Weather Reports: Witness statements and weather reports from various meteorological services all agree that the weather conditions on the day, and at the time of the accident were light, fair and entirely suitable for paragliding activity.

The Met Eireann station at Oak Park in Carlow reported a 5kt Northerly wind and fair weather, with an air temperature of 16°C. The ICOCARLOW2 weather station, located on Mt. Leinster reported a West-North-West wind of 7kts, with an air temperature of 12.7°C. The temperature difference between the two stations, at different altitudes, suggests a environmental lapse rate conducive to the formation of light thermals. Other paraglider pilots who were present (on the ground and in the air) reported similar wind conditions with light thermal activity ideal for the sport.

Equipment: The pilot was flying a Mentor M paraglider glider manufactured by Nova in 2009 (serial no. 37222.) This glider model is classified DHV 1-2  GH (DHV certification no. GS-01-1719-07) and is suitable for pilots with a all-up weight of between 95Kg and 110Kg in flight.

The harness used was an Up Pamir, manufactured by Up Europe GmbH.
Flight instrument used was a Brauniger IQ Basic variometer / altimeter / GPS.

The glider had been recently inspected (under its original warranty) and recertified as being safe for flight by Aero Sport Beskidy, Poland, a licensed inspection agent approved by both the manufacturer and the Polish National Governing Body for the sport. The inspection report shows that no issues were found with the glider and a certificate was issued on 9 March 2010 by Aero Sport Beskidy stating that the glider was "fit for flight."

Witness Statements: Although a number of qualified paraglider pilots were present, both on the ground and in the air, none were in a position to give a clear description of how the accident occurred or what the pilot was doing at the time, only that the pilot had been flying and thermalling safely and successfully for about an hour before the accident and that he appeared to be thermalling at the time of the accident.

Details of Accident and Emergency Care: At approximately 14:30hrs the pilot was observed to be turning in a thermal close to the hillside when his wing spun and he impacted the ground. Other pilots in the air and on the ground were able to alert each other and coordinate their activity using 2m-band radios on a common frequency. The first pilot on the ground to reach the injured pilot, who had impacted the hill high up on the Black Banks, took steps to prevent the glider from dragging the casualty. Paul Eustace landed immediately lower down the hill and called 999, asking for the Air Search & Rescue helicopter to be dispatched to the scene.

With the assistance of other pilots now reaching the scene, the injured pilot was made as comfortable as possible without allowing him to move, and his glider was detached from the harness and secured to prevent it inflating once the helicopter arrived some twenty minutes later. The casualty was air-lifted to Wexford Regional Hospital.

Following the removal of the injured pilot from the hill, his glider, harness and instruments were handed over to Garda Peter Sortle (name to be checked) of the Borris Garda Station, who attended the scene.

Interview with the Injured Pilot: Dara Hogan (IHPA Chairman) and Philip Lardner (IHPA Training & Flight Safety) interviewed the injured pilot on Sunday 4th July 2010 at the National Rehabilitation Hospital, Dun Laoghaire, with the assistance of Gregorz Pelikan (IHPA member) who acted as an interpreter.

In a detailed interview the following information was gleaned from Krzysztof Zak regarding his accident:

  • The pilot's all-up weight was approximately 105kg (within  the 95 - 110kg weight range for his wing.)  
  • The glider was purchased new and had seen approximately 50 hours of air  time.  
  • The pilot experienced light winds and gentle thermals on the day of the accident, and the glider was flying and handling normally, with nothing out of the ordinary.  
  • The pilot had been thermalling close to the hill when he flew out of the thermal. He turned, increasing the amount of brake applied to one side of the glider to try and re-enter the thermal when the glider entered a spin (spinning at least twice) twisting the risers.
  • The pilot reacted by releasing both brakes, but was not sure what effect this had, if any, as the risers were twisted more  than once. The pilot estimates that he was perhaps 150 feet directly above the ground (but close to the steep hill) when the glider entered the spin.  
  • The pilot had approximately 100 hours of (un-logged) air time experience - about 50 hours of which was flying the glider involved in the accident.   
  • The pilot did not hold any pilot rating or national licence and had been taught to fly paragliders by a friend.


Inspection of Glider and Harness: On Monday 21st June 2010 Dara Hogan and Philip Lardner, assisted by David Bullard (IHPA member ; ex-BHPA PG Instructor), carried out an inspection of the glider and harness at the Department of Transport Air Accident Investigation Unit's (AAIU) depot at Gormanstown Military Camp in the presence of Paul Farrell (AAIU Accident Inspector.)

After finding no material defects in the wing itself, a number of lines were selected, on each side of the glider, and their measurements compared to the technical data published by the glider's manufacturer, Nova.  Significant discrepancies were observed between the measured line lengths (not measured under flight-tension) and the published data. One line was also observed to have a broken or damaged core, with just the outer sheath providing any strength to the line.

In light of these discoveries the IHPA recommended to Paul Farrell (AAIU) that the glider be sent to an independent professional service agent for a more thorough inspection.

The AAIU sent the glider to the UK for a detailed inspection by an approved inspection agent. While the IHPA was not given access to the detailed report and findings of this inspection we are assured that, initial line length and damage anomalies notwithstanding, "the wing was serviceable and not a contributory factor in the cause of the accident."

IHPA Analysis and Findings: Having considered the facts and evidence of this accident the IHPA Tribunal of Inquiry find that:

  • The glider and harness were in a fit state to be flown.   
  • The pilot's 'all-up' weight (wing loading) was within the weight range for the wing he was flying.   
  • The pilot, despite his experience, was not formally trained and not adequately qualified to fly paragliders. While we cannot say with certainty that this would have made any difference to the situation, it  remains a possibility that a formally trained pilot with full understanding  of glider control may not have  placed themselves in a similar situation.  
  • There is no evidence of the pilot having correctly employed a combination of weight-shift and outside  brake to control the rate of turn while attempting to re-enter the  thermal.  
  • Given the pilot's altitude and proximity to terrain at the time of the spin, it is unlikely that he could have done anything to effect a safe recovery  and return the glider to normal flight before impacting the  hill.  
  • Notwithstanding point 5, above, the pilot did not react correctly to recover from the spin as per the Owner's  Manual for his Nova Mentor M glider, which  states:  
    • "Spin (or negative spin): During a spin the canopy turns relatively fast around the centre section of the canopy while the inner wing flies backwards (hence the term negative spin.) There are two usual reasons for an unintentional  spin:  
      • One brake line is being pulled down too far and too fast (e.g. when inducing a spiral dive)   
      • When flying at low speed one side is being braked too hard (e.g. when  thermalling.)
      • To recover from an unintentional spin, the pulled down brake line should be immediately  released as soon as a spin is suspected. The canopy will accelerate and return to its normal straight and stable flying position, without losing  too much height.  
      • In case the spin is allowed to develop for some time, the NOVA MENTOR surges forward on one side and a  dynamic asymmetric collapse or a line over can occur. If so, brake gently to stop canopy surging and correct any collapse: See "collapses".  
      • NEVER DO AN INTENTIONAL SPIN OVER LAND OR IF YOU DON'T HAVE SUFFICIENT  EXPERIENCE."
  • The other pilots on the ground and in the air acted quickly and correctly to stabilise the casualty and alert the emergency  services.  
  • 2m-band radio communication was an important factor in coordinating the response and  actions of other pilots in the area.


IHPA Recommendations: The IHPA Tribunal of Inquiry would like to highlight a number of important lessons to be drawn from this very serious and unfortunate accident:

  • Pilots must complete a full course of formal training with an NGB approved or licensed school and hold a minimum pilot rating of Para Pro 3 (or equivalent) before they fly outside the  controlled supervision of the training school environment.  
  • Pilots must be fully aware of the correct remedial action to take in the event of a stall, collapse, spin or other departure from normal flight specific to the wing they are flying. Different wing manufacturers recommend subtly different pilot inputs to correct for various situations. BE  FAMILIAR WITH YOUR WING'S OPERATING PROCEDURES.  
  • Pilots must be especially mindful of their airspeed when flying in or through thermals close  to terrain. It is safer to fly out of a thermal than to risk a stall, collapse or spin by tightening the turn rate in an attempt to stay in a thermal.  
  • Pilots should avoid turning full 360s in thermals while close to terrain and below hill-top height. Doing so significantly increases the risk of an accident and puts the pilot and glider flying down-wind directly towards the  hill. When flying the down-wind arc in a thermal, air-speed often decreases while ground-speed increases  dramatically, leading to reduced control authority, less reaction time and  placing the wing closer to the stall point.
  • PILOTS ARE STRONGLY RECOMMENDED TO FLY A SERIES OF FIGURE-OF-8 MANOEUVRES THROUGH THE THERMAL COLUMN UNTIL THEY  HAVE CLEARED THE TOP OF THE HILL AND LOCAL TERRAIN BEFORE DEVELOPING THEIR  TURNS INTO FULL 360s.
  • In order to ensure that only suitably-qualified pilots fly hang gliders and paragliders in Ireland, IAA should delegate responsibility for licensing hang glider and paraglider pilots to IHPA which is the National Governing Body recognised by the Irish Sports Council and by Fédération Aéronautique Internationale (the World Air Sports Federation) in Switzerland.

The IHPA Tribunal of Inquiry would like to thank Krzysztof Zak for his willingness to participate in this investigation and in helping IHPA to understand the sequence of events which led up to his accident.

IHPA would also like to thank all those who assisted in any way at the scene of the accident, in stabilising Krzysztof and calling the emergency services as well as in providing witness statements, photographic and video evidence.

_________________________
Dara Hogan
Former Chairman IHPA

Philip Lardner
IHPA Training & Flight Safety

Frank Cronin
Senior PG Pilot & IHPA Member