20140928018119I

IN ACCORDANCE WITH FAA ORDER 8020.11C:

NAME OF JUMPERS (TANDEM OPERATION):

^PRIVACY DATA OMITTED^ - INSTRUCTOR (STATIC LINE / TANDEM), "EXPERT SKYDIVER" RATING AS PER USPA D LICENSE. OVER 3000 JUMPS THE MAJORITY OF WHICH WERE TANDEM.

^PRIVACY DATA OMITTED^ - STUDENT

CLUB AFFILIATION:^PRIVACY DATA OMITTED^ HAD NO KNOWN CLUB AFFILIATION.

EQUIPMENT DESCRIPTION:

CONTAINER: UPT MICROSIGMA,

MAIN: SIGMA I 340 BY PERFORMANCE DESIGNS, DELAND FL,

RESERVE: VR 360 BY PERFORMANCE DESIGNS / UNITED PARACHUTE TECHNOLOGIES. .

AAD: AEROSPACE VIGIL.

PACKING RECORDS:

RESERVE PARACHUTE WAS LAST PACKED BY ^PRIVACY DATA OMITTED^, SENIOR PARACHUTE RIGGER # ^PRIVACY DATA OMITTED^ (SEAL SYMBOL : VBS) 7/30/2014. A NEW VIGIL SYSTEM CUTTER WAS INSTALLED DURING THIS SERVICE.

ON 9/28/2014 AT APPROXIMATELY 1845 THE REGIONAL OPERATIONS CENTER NOTIFIED THE ON CALL ASI THAT A PARACHUTE JUMPING INCIDENT HAD OCCURRED AT MARSTONS MILLS AIRPORT (2B1). THE ROC REPORTED THAT THERE WERE TWO FATALITIES. THE FATALITIES OCCURRED AT A LOCATION OFF AIRPORT, BUT IN CLOSE PROXIMITY. THEY ALSO REPORTED THAT THERE WAS NO AIRPORT INVOLVEMENT.

THE INSPECTOR ON CALL NOTIFIED THE SUPERVISOR TO DISCUSS DEPLOYMENT TO THE SCENE. DUE TO NIGHT CONDITIONS, THE DECISION WAS MADE TO RESPOND TO THE ACCIDENT SCENE ON 9/29/2014.

THE INSPECTOR ON CALL TELEPHONED THE MASSACHUSETTS AERONAUTICS DIVISION TROOPER ON DUTY AND ARRANGED TO SHARE PHOTOS AND EVIDENCE GATHERED AT THE SCENE AT A LATER DATE.

ON 9/30/2014, THE OWNER OF SKYDIVE BARNSTABLE FORWARDED A COPY OF A VIDEO TAKEN BY A GO PRO CAMERA ON ANOTHER JUMP INSTRUCTOR'S WRIST. THE VIDEO WAS ANALYZED. IT WAS DISCOVERED THAT AN AIRCRAFT SEATBELT HAD BECOME ENTANGLED IN A CONDUIT (SHROUD) THAT HOUSED A LINE USED TO ACTUATE THE MAIN PARACHUTE CANOPY. WHEN THE JUMPER EXITED THE AIRCRAFT, THE AIRCRAFT SEAT BELT EXERTED TENSION ON THE CONTROL CABLE CAUSING THE MAIN CANOPY TO BEGIN DEPLOYING PRIOR TO DROGUE CHUTE ACTUATION. THE OUT OF SEQUENCE DEPLOYMENT CAUSED A SITUATION KNOWN AS A "HORSESHOE MALFUNCTION". THE HORSESHORE MALFUNCTION MANIFESTS WHEN THE MAIN CANOPY IS DEPLOYED BUT THE DROGUE REMAINS IN THE PACK. THE INSTRUCTOR ATTEMPTED TO ADDRESS THE MALFUNCTION BUT WAS UNSUCESSFUL. AT SOME POINT DURING THE EVENT, THE INSTRUCTOR MADE THE DECISION TO DEPLOY THE RESERVE PARACHUTE PRIOR TO "CUTTING AWAY" THE MAIN RISERS. CONSEQUENTLY, THE RESERVE PARACHUTE ASSEMBLY BECAME ENTAGLED IN THE MALFUNCTIONING MAIN PARACHUTE. THE ENTANGLEMENT PREVENTED THE RESERVE PARACHUTE FROM DEPLOYING.

TWO INSPECTORS FROM THE BOSTON FSDO WERE PRESENT DURING AN EVIDENCE INVESTIGATION CONDUCTED ON 10/3/2014. ALSO IN ATTENDANCE WAS A MASTER RIGGER AS WELL AS NUMEROUS ADVISORS FROM THE MANUFACTURER OF THE DEVICE.

THE INSPECTION VERIFIED THE EVIDENCE CONTAINED WITHIN THE SECOND INSTRUCTOR'S CAMERA FOOTAGE. THE MAIN CANOPY WAS EXTREMELY ENTANGLED. THE DROGUE BRIDLE WAS ENTANGLED IN THE ELONGATED CONDUIT MAKING DROGUE DEPLOYMENT IMPOSSIBLE. FURTHERMORE, THE BAG CONTAINING THE RESERVE PARACHUTE ASSEMBLY WAS FOUND TO BE SEVERELY ENTANGLED IN THE MAIN PARACHUTE SUSPENSION LINES.