Monday, 30 April 2012

The hang-gliding fatality in Agassiz B.C.

I'm brought to comment on the hang-gliding fatality in Agassiz Saturday.

It's obviously unfortunate that this occurred, I put myself in the boyfriend's place and can't imagine how awful he must feel.  I bought a similar trip a couple years ago, a floatplane trip around Whistler for my girlfriend's birthday, I thought she would get a kick of seeing the geography of our home from high up in the air.  I got an inkling then, and know more clearly now, that this might be more of a thrill for me than it was for her, but she was game and smiled and took pictures throughout.  I never considered the possibility of anything going wrong, you have to trust that the pilot and plane owners are professionals and will have minimized the risk down to acts of god.

In this case, I wish I was confident that the hang-glider was that thorough and competent.  I hate to say it, but it does seem that very simple procedures must have been overlooked, namely, the clipping in and safety-checking of the passenger harness.

I have a few reasons to believe this.  I used to work at a popular zipline tour company in Whistler, was a lead guide during the inaugural season, and was in charge of setting protocols for launching and landing guests in a safe manner.  Most of the work had been done by the owners who had set up the infrastructure and purchased equipment that allowed for a lot of safety margins in terms of load capacity, and for redundancy in systems.  There was a load line and a safety line that were impossible to clip in improperly, for example.  The pulley wouldn't work if a guide, inconceivably, clipped them in wrongly.

My modest contribution, along with my fellow lead guide, was to draft a policy manual and train guides to these policies, and ensure that the highest level of precautions were followed.  We used a progression, where guests would first test out their harness and rig on a 'training line' that was barely a metre off the ground.  This helped to reassure the guests that their harness was quite sturdy and would support them, as well as to introduce them to the clipping procedure and commands, and to instill in them that while we would have lots of fun and opportunities to joke around, the guide was in charge on the launch platform and needed to go through that procedure and needed to be 100% certain that everything was right before they zipped away.

We were very successful in establishing our procedures and conducting our training.  We never suffered a catastrophic failure in equipment or launch procedure while I was working, and the company hasn't since I've moved on.  The owners had the right philosophy and attitude about safety, and never stinted or compromised on it.  When practical realities would intrude and some amendments were considered, I would stand firm and refuse to adapt our procedures, pointing to our success, and always managed to convince the sales team or owners that safety was primordial, and details that were skipped could be those that trip us up later.  I would repeat the motto of the rope rescue company that provided my training in the fire service: "There's a safe way, and a safer way."  We always, after discussion, deferred back to the safer way.

This is in marked contrast to a competitor who started their operation after ours, and tried to compete on the more 'extreme' experience at their site.  One of my friends who worked on their startup decided to leave eventually, because he felt they didn't put a priority on safety.  An acquaintance of mine, who runs a tour company with a similar thrill-seeker quotient and whose focus on safety needs to be unrelenting, and who had previously taken a couple of tours that I led and of which he spoke highly, told me after taking a tour with them how their guides lacked in professionalism and knowledge compared to ours, and how they even enjoined their guests to demean our company in a group cheer, which he said left a bad taste in their mouths.  Of course, this company improperly clipped in and dropped a guest from a considerable height, and she was lucky to only suffer a broken leg.  This is after another guest had also been clipped in incorrectly a few weeks before, but had enough strength to hold on for the entire ride with his arms and reach the other side safely.  And also, after one guest was launched into another guest who hadn't yet cleared the line, with both suffering serious injuries and emotional trauma.  All of these incidents were explained away by the owner, stating that they were learning from these episodes and bringing in changes so they wouldn't happen again.

One guide's remark in response was telling: "You make a million hamburgers, eventually you're going to forget the pickles on one of them."  This attitude is so inane and would have been so foreign to me and my fellow guides, that it would never have been uttered at our site.  We wouldn't have thought of our business as making hamburgers, ever.  We definitely wouldn't have thought that the safety aspect was the pickle on the burger, the condiment, a nicety you can do without.  An extraneous detail.  A peripheral concern.  We definitely wouldn't have had an acceptable, unavoidable failure rate in mind.  Our focus wasn't on pumping out widgets and dealing with the few irksome rejects later, it was on being absolutely sure, every time.  As one owner would say: "Think of your guest as your mother.  Would you let her ride this zipline?"

After watching the video report from CBC News (linked above), I can't help but suspect that the pilot, while possibly being entirely professional and well-meaning, was at least distracted, maybe by the boyfriend and his video camera, and failed to run through a similar checklist.  The hang test on the ground would immediately have uncovered the problem, much as our 'training line' was meant to.  If you sat in your harness and zipped it successfully, the proof was in the pudding.  If there was a problem, either run-of-the-mill or extraordinary, it would immediately be exposed.  A strap might need to be cinched, a helmet might need to be adjusted, and then we were ready.  If this gentleman did do his hang test, maybe he subsequently allowed his guest to unclip for a reason, a final photograph or to hand her phone and keys to her boyfriend, and then he failed to go through the sequence again.

I'm saying this not to pile on the guy.  The investigation will show if there was negligence, but in the meantime I'm sure he feels awful and will need some time before he can hang-glide again.  He will probably always suffer with nightmares, having her hang on to him for dear life, and he being unable to save her.

One reason I feel moved by this story is that something similar happened to me.  My roommate Richie and I, along with a few of his friend (Tiny, Bruce, was Crash there?) went parachuting in the early 90's, it must have been 1992.  We drove all the way down to Abbottsford, and on site saw a small ramshackle building made up of portables and a connected shed, which made us chuckle on arrival and remark on what was the luxurious and glamourous headquarters of our parachute experience providers.  I still have the pictures from this.  In any case, we were excited by the prospect of jumping and might have been a handful of smart-alecks, but the instructors were very thorough and professional and kept control of the day, except at the end, when we were meant to jump.

We were supposed to do a static-line jump from three thousand feet, if I remember correctly.  This was the progression back then, you had to do a certain number of static line jumps, and if you handled yourself properly, you could then graduate to some free-fall jumps, from gradually higher and higher altitudes, with correspondingly more free-fall.  We had done all the theory and ground practice, including the procedure for stepping out of the plane, which was conducted in the fuselage of a retired airplane grown over with weeds.  When we were ready to jump, however, the winds had picked up to such a degree that we were told we may not be allowed to jump.  We made the uncomfortable mention of refunds, but the instructors tried to convince us that coming back another time might be to our advantage, and that they'd throw in an extra jump for our troubles.  Clearly, they wanted to keep our money.  So when the winds died down, they mustered us quickly and piled us in the plane.  We had rock-paper-scissored to see who would jump first and second and so on, but when we got to the plane, the instructor yelled at us in no uncertain terms to get in and never mind who went where.

Which ended up meaning that I climbed in the plane last and would have to jump first, contrary to our intended order.  In any case, we got to the desired altitude, the pilot got the okay from the ground to let us jump, and the side door an inch from my right knee was swung up and out of the way by the instructor.  I could see straight down for miles it seemed.  The instructor nodded his head toward the door, I gulped, and then, with legs stiff from having been in a kneeling position for so long, made my way onto the wing.  One foot on the foot rest, one hand on the crossbeam, the other on the crossbeam, and now I was outside the plane, hanging on under the wing, buffeted by the wind, with nothing but sky all around me.  I was pretty proud of myself for not having messed up the exit procedure, was arching my back as we were shown, and started rehearsing in my mind the next procedure while I waited for the jump signal from the instructor, when all of a sudden his face appeared in front of mine, barely two inches away.  "JUMP!!!" he shouted right in my face, as loud as anyone had ever shouted at me, and I had old-school parents, mind you, and rugby and football and hockey coaches who were perpetually disappointed in me, and even a few girlfriends who had been even more disenchanted with me.  So really, really loud.

Later, Richie told me that I was on the wing for at most a second before he leaned way out and yelled at me.  I let go immediately, he nodded appreciatively and muttered "Good boy" as he leaned back in and closed the door.  To me, it had felt really long, and I thought he was kind of mad at me for something.  Apparently, he was just used to people freezing on the wing, and he had a tactic to counteract that.

So I had let go of the beam and suddenly everything was calm, as much calm as I'd ever experienced.  No more wind noise, no roar from the engine and propeller, just blue sky and quiet.  I enjoyed it for a second, then remembered I had to count, and check my chute opening, and the state of my canopy.  So I started this sequence ("Thousand and one, thousand and two, thousand and three, check canopy, thousand and five...), and followed it until the chute billowed open, caught, and I dropped through my harness.

My fall was arrested by the leg loops of my harness, which had not been cinched up, but were at least attached.  During ground training, we were told not to touch our parachute harness, that the instructors would take care of that.  Possibly because of the rush to get us back on the plane during a period of calm winds, they failed to check my harness appropriately.  I don't remember if the leg loops could be unhooked completely, or just slackened and tightened, I didn't have a lot of experience in that area back then.

In any case, my position was now problematic.  I had fallen so far down in my harness that my helmeted head was trapped between the shoulder straps, their highpoint probably being above the top of my head.  My nose was being abraded by the chest strap.  As I was falling I was supposed to be on the lookout for a giant red arrow on the ground, which would indicate what direction I should turn to by pulling on the brake handles, but I couldn't look down in my condition, the shoulder and chest straps under tension prevented me from moving my head.  I had let go of the brake handles early on, and my hands found my hip belt, which was under my armpits at this point.  I pushed myself up using this, as if I was doing a triceps dip on it, and searched for the red arrow.  It took me a while to find it, I'd drifted quite a bit, and by the time I did, and managed to grab the brake handles again, which meant letting go of the hip belt and dropping down again in my harness, I was off course considerably.  After a while, I did my triceps dip again, saw that I was pointed in the wrong direction again, yanked on a brake handle, and reassessed.  I was now kind of pointed in the right direction but would land three or four fields away from my intended spot.  I saw the instructor on the ground stalk away from the giant rotary red arrow in disgust.

When I finally had walked back to the landing site, having had to jump over fences and trudge through some cow pastures, I was met with a sneering instructor who asked me why I choked in the air, why I didn't follow the arrow, or basic instructions.  I explained what happened and showed him my loose leg loops.  He at first refused to believe that they had failed to tighten them, he kept asking me, in disbelief, whether I had loosened them once on the ground and forgotten about it.  Once I had him convinced, he kind of grew quiet and had a couple of whispering conversations with his colleagues.  He didn't talk to me about what was said, and I was a young punk, and didn't really understand what had happened and didn't make a fuss, there were beers to be drunked.  Amazingly, I wasn't the one who had to buy the first round for being the farthest away from the target, so I took some consolation from that.

A sad epilogue to this tale is that a few years later, a groom fell to his death during a bachelor party at this same operator's site.  His first chute failed to deploy properly, and he for some reason didn't deploy his secondary chute.  Lots of debate ensued about automatic activation devices for secondary chutes, the pros and cons, but to me, I always wondered if the same instructor who failed to harness me up properly was the one who mispacked the groom's chute.

So when I reflect on my close call, on the rush to get us in the air to avoid having to refund our money, on the insistence on not letting us touch our harness or even know anything about them, that it was safer to let instructors handle such matters, and on the emphasis on safety or lack thereof at competing zipline operators in Whistler, I have a strong suspicion on what may have occurred in the hang-gliding accident.  Well-meant procedures were overlooked or ignored.

A final point I want to bring up is that redundancy in safety systems is sometimes a hazard.  Often, because of that redundancy, we'll overlook one system being inoperative because there are two other backups.  We start to rely on the backups to play the primary role.

An example is that of an author who wrote of his travels in the Arctic on a Russian icebreaker along with other tourists.  He mixed in the story of historic polar explorers along with his personal experiences on the ship and while retracing their steps.  He described how there was on board a confusing number of systems for keeping track of all the passengers.  They would sign up for day excursions on board the main ship.  The leader of the excursion would make his own list previously, or on the launch itself.  There was supposed to be a 'buddy system', but this was not policed, so it was ineffective and unreliable.  People would drop out at the last minute, and latecomers were common, without any amendments to the plethora of lists.  Finally, there was a 'Checkin-Checkout' board on the ship, which was meant to be the master, final authority on this matter.

The author one day found himself, while on such a day trip, returning from a solo hike on an island relatively late, but in plenty of time to make the announced departure time of the launch.  Sure enough, as he approached the final rise and looked down on the beach where they were to meet, he observed it leaving.  He ran down and shouted at it, waved like a madman, but was left behind.  He tried to remember which list his name was on, and felt sure there would be a conflict between them.  Further, he was alone in his cabin, with no spouse or companion to signal his absence.  He feared the worst.

If I remember correctly, another launch came to the beach on an unplanned, unscheduled trip, and the author, while relieved to be saved thus, was dressed down by the crew for missing his own boat.  The author didn't protest, only too glad to be safely back on his way to the ship, and not stranded in the high Arctic, destined to a quick death.

Once back on board, he went to check himself back in on the Checkin-Checkout board, a procedure he had been scrupulous about during the voyage and which he had hoped would be his salvation during the anxious couple hours he spent marooned on the island.  To his surprise, he found that his marker had been moved to the 'In' position by someone else, in strict contravention of the rules, which stipulated that each passenger be responsible for their own markers, for obvious reasons.  Had the second launch not accidentally visited the island, no one would have had any way to know he was missing.  He later ran into a disagreeable shipmate, who was his 'nemesis' in the narrative, and who chided him laughingly for not having checked himself back in, and having forced said nemesis to do it for him.  As the author turned purple and tried to explain the folly and serious breach of rules this was, that the reason that he hadn't checked himself back in on the board was that he was definitely NOT back on board, that he could have died from this, the nemesis either couldn't comprehend or wouldn't accept responsibility, and kept blaming the author for not having checked back in, and having forced him to do so in his stead.

It's clear from this account that too many overlapping redundant systems can cause more harm than good, as they create confusion and allow some people to slack off on some systems, trusting that the others will get the job done.  So I'll be interested to learn more about the redundant systems that failed in this instance.

A seemingly preventable accident and a horrible situation, and I offer my condolences to the deceased's loved ones.

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