Incident Report - Aerodyne Brand "Slinks"

[tdog 0]

This report details how both human factoring and poor product design led to a reserve ride.

I came home late at night after getting 2 hours sleep the night before. A friend and someone I never met previously are staying at my place so they can go to the DZ in the morning.

The guy I never met had an A licence but was 3 years uncurrent, planning on getting current the next day.

While packing he said, "I think I have a step thru". I quickly looked and found three MAJOR rigging errors on how the main was assembled, including twisted lines that would require taking the canopy off the risers, brake lines wrapped around suspension lines that would cause a mal, and brake lines attached to the toggles in the most unique way.

The gear was all brand new or new to him. I asked him who assembled the main: "My Rigger Back Home."

I asked, "the same rigger that installed your reserve?". "Yes".

I explained to him that the errors were exceptionally poor and I would not jump the rig. I even volunteered, "I will repack your reserve for free, and if I find a mistake, you will pay me and get your money back from the guy back home. But I can't do it tonight. I am way too tired."

The next morning at the DZ the jumper had two uneventful jumps on the rig "repaired rig".

On his third jump he had a reserve ride. One of the Aerodyne Soft Links released and he trailed the complete lineset on opening.

Facts:

PROBLEM: The softlinks were installed improperly. Instead of proper routing, the loop went thru the "ring" on the Aerodyne brand loop, then over the ring. Going thru the ring first is WRONG. This allowed the soft link to release when not under tension.

PROBLEM: I even glanced at one soft link for maybe 3 seconds - and without "pulling them apart a bit", they "looked clean". This glance was not as a formal rigger doing an inspection, just an attempt to see how many things were wrong with the rig. However I looked closely enough I am embarrassed I did not catch it. When the line goes thru the ring, after it is seated, it is just millimeters off of where it should be, and covered with line. Without twisting the ring and looking from multiple angles, it is very deceiving.

PROBLEM: The skydiver friend who fixed the continuity had to undo ONE link to clear lines. He copied the installation on the restore, so all four remained installed improperly.

Final Comment: The jumper admitted hours after the reserve ride that he did not trust me since I was a new acquaintance, so while I told him I did not trust the rig, I was not creditable. He apologized, and I told him no apology needed.


This is my formal incident report regarding the Aerodyne slinks. I know members of PIA and Aerodyne read these forums, so if they need more information, they can contact me.

However after this incident I believe:

1. The "ring" on Aerodyne brand slinks ALLOWS improper installation, and that improper installation is not very obvious on inspection. I encourage Aerodyne to choose a solid object, like the tab on PD brand soft links, so this routing error cannot happen.

2. Riggers should be made aware that on Aerodyne soft links, improper routing looks deceivingly like proper routing, and the only way to truly inspect is to loosen the system and take a very close look. Do not be fooled by a quick glance, even if the rig has many jumps on it.

[diablopilot 2]

Improperly blaming the product for someone's inability (not yours) to RTM, is not the answer. The soft links (and that's what they are, not "Slinks") work just fine.

----------------------------------------------
You're not as good as you think you are. Seriously.

[pilotdave 0]

The best way to mitigate a hazard is to eliminate it, even if it's human-induced. Relying on people to RTM is the worst way.

I don't completely disagree with you. This is skydiving, not golf. But if you can eliminate the possibility of a mistake, you're better off.

Dave

[bodypilot1 0]

Quote

This glance was not as a formal rigger doing an inspection, just an attempt to see how many things were wrong with the rig.

If you have a riggers rating, and you are inspecting ANY canopy, it IS a formal inspection. Otherwise do not touch the canopy......

www.WestCoastWingsuits.com
www.PrecisionSkydiving.com

[skybytch 273]

Quote

But if you can eliminate the possibility of a mistake, you're better off.

It would be nice if every piece of skydiving gear could be idiot proof. Chest straps that at a quick glance look fine can easily have been misrouted, instruments that fail, AAD's that require you to do specific things for them to operate correctly (turning on at the dz not at home, offsetting ground altitudes, etc); people have died because they didn't read an AAD manual! I can improperly install any connector link and I bet you can too.

The responsibility for ensuring correct installation and function of all components prior to use ultimately belongs to the gear user. Not to the manufacturers.

[tdog 0]

Quote

If you have a riggers rating, and you are inspecting ANY canopy, it IS a formal inspection. Otherwise do not touch the canopy......

You are right. In this case it was stretched between my sofa and kitchen while others were doing the work. The fact I saw it was not because it was delivered to me in any official capacity... I just happened to see things from a distance while walking around my house and I said: "I would not jump this until it is completely repacked and inspected. I don't have time to do it now otherwise I would do it for free because I am not comfortable with what I am seeing."

I think I clearly expressed my opinions and limitations. In a court of law, the other party in the room would testify I expressed my opinions and limitations, and that I did not do a complete inspection, but did say not to jump the rig until an inspection was done because multiple other errors were found.

Morally and legally, I believe I did everything I could or should.

[skybytch 273]

Quote

In a court of law, the other party in the room would testify I expressed my opinions and limitations, and that I did not do a complete inspection, but did say not to jump the rig until an inspection was done because multiple other errors were found.

In a court of law, the plaintiff could use your posts in this thread to show that a recognized expert - as a rigger, that'd be you - found a problem with the links made by Aerodyne. Would you still say you've done the right thing morally and ethically if Aerodyne was the defendant?

[ficus 0]

Quote

Improperly blaming the product for someone's inability (not yours) to RTM, is not the answer. The soft links (and that's what they are, not "Slinks") work just fine.

The Vector 2 tandem system works just fine, too. Why did they bother with the locking disc on the Sigma? Just don't pull out of sequence, right?

I agree with you that this is not Aerodyne's "fault", but the fact remains that this particular misrouting is impossible on PD Slinks. I have not reproduced the error at home, nor seen pictures, but if it is as easy to confuse for correct as OP says it is, then it's an even stronger point.

The stitching on reserve lines is now a different color than the lines. Most BASE canopies today have black (and red) lines. Improving ease of inspection saves lives, period.

[tdog 0]

Quote

Quote

In a court of law, the other party in the room would testify I expressed my opinions and limitations, and that I did not do a complete inspection, but did say not to jump the rig until an inspection was done because multiple other errors were found.

In a court of law, the plaintiff could use your posts in this thread to show that a recognized expert - as a rigger, that'd be you - found a problem with the links made by Aerodyne. Would you still say you've done the right thing morally and ethically if Aerodyne was the defendant?

Yes. I would say I notified the community of users and the manufacture once I found an issue with a product. If I kept my observations secret, I would not be able to sleep at night.

My only goal is to protect my friends lives by being the best professional, student and educator I can be. I have no interest in protecting a manufacture. However, in this incident, it is true their product failed because of USER ERROR and not following the manual, not manufacturing defects, so I would testify to that and recommend to the jury to not find fault with the manufacture. Making products better is the evolution of product design, and while this product could be made better in another revision, the existing version is safe if the instructions are followed.

[Andrewwhyte 1]

My only issue is with you referring to "poor product design" in your OP. Just because an improvement is available does not mean the original design was poor.

[tdog 0]

Quote

My only issue is with you referring to "poor product design" in your OP. Just because an improvement is available does not mean the original design was poor.

Look up one post. I posted at the same time you did - that addresses this point.

[pchapman 279]

Quote

PROBLEM: The softlinks were installed improperly. Instead of proper routing, the loop went thru the "ring" on the Aerodyne brand loop, then over the ring. Going thru the ring first is WRONG. This allowed the soft link to release when not under tension.

The loop does seem to 'snug down' better when it is looped onto itself (as is proper) rather than onto the slippery metal ring.

I found the same problem as you, but with Aerodyne soft links on a RESERVE. I had thought the 'slacking off with no load' problem to be only theoretical -- but your example shows it can happen.

In the case I found, assembly had been done by a quite experienced rigger but he hadn't seen the Aerodyne links before, didn't have the manual around, and forgot to double check the manual later on as he planned.

It's a subtle error, one that takes a close look to notice.

I only saw the error as the soft links had NOT been tacked down. Had they been tacked down they would have been quite difficult to inspect, and it might have sent the signal that they were supposed to be out of sight and thus not really inspectable. I personally like the ability to better inspect the links. (The Aerodyne Icon manual says to tack the links, but the Smart manual does not.)

I think I posted pics of the case I found, in some thread in '06.

Tacking the links might prevent finding an error, although it would also greatly reduce the chance of the loop slackening and coming off the ring. (A tack through the ring would technically prevent the loop from moving past and coming off the ring, but if the loop came past the widest part of the ring, on a shock loading one would be relying on the tacking only to hold it all together.)

EDIT to my edit: Tdog -- So I get the impression the jumps were made before anyone got to check the reserve. When he did use the reserve, all was OK with it? (Either no Aerodyne links; or the links were done right?)

[tdog 0]

Quote

Improperly blaming the product for someone's inability (not yours) to RTM, is not the answer. The soft links (and that's what they are, not "Slinks") work just fine.

That is your opinion.

My opinion is that every component in a system should be analyzed for every possible mode of failure. If an user error failure mode can be eliminated by a simple change - then that change should be made. And - when that failure mode is observed in the field, it should be brought to the attention of the community so more careful attention could be paid to it on future installations, inspections, and design changes.

[tdog 0]

Quote

I found the same problem as you, but with Aerodyne soft links on a RESERVE. I had thought the 'slacking off with no load' problem to be only theoretical -- but your example shows it can happen.

That was my fear. I am glad someone else noticed it and brought it to our attention. I even thought - the fact the reserve sits for months with slack on the lines in the pack tray, the soft link could wiggle loose.

I too thought, "well on a tacked reserve it is likely this would not happen." But, I did not think about - until your post, how much harder it would be to inspect on a repack when tacked...

[relyon 0]

Do you apply the same logic to every piece of "gear" you use in any capacity in all aspects of your life? Your car for example. Do you do a complete inspection of every component - the tires, brakes, steering, and suspension notable among them - before you drive? If not, don't you think you should? Not doing so is ignoring the "correct installation and function of all components prior to use" that "ultimately belongs to the gear user."

Physics ultimately wins all arguments. Good design in the first place can avoid complications in actual use.

Bob

[pilotdave 0]

Quote

The responsibility for ensuring correct installation and function of all components prior to use ultimately belongs to the gear user. Not to the manufacturers.

Of course. I don't ask PD to inspect my slinks after installing them. That's my job (along with my riggers). But it's PD's job to make the best, most idiot-proof product possible.

I know, back in your day you had to walk to altitude, both ways, in the snow. And you didn't have chest straps, you just held on tight. And you liked it! But hey, instead of just defending the manufacturers of imperfect gear, why not encourage them to do even better? I don't blame aerodyne because someone hooked up their links incorrectly. But that doesn't mean aerodyne shouldn't try to eliminate one way a stupid person could mess up. It's called progress!
Dave

[billvon 3,116]

>and it might have sent the signal that they were supposed to be out
>of sight and thus not really inspectable.

Well, I don't think ease of inspection determines whether or not something should be inspected, although I can see your point in that tacking the links down might convince some less thorough riggers that it was OK to not inspect the links/tops of the risers. Perhaps this will serve as a note that you really do have to inspect that stuff, even if it's hard to get to. (Riser tops especially - it's easy to damage them yanking hard links out.)

[billvon 3,116]

>I can improperly install any connector link and I bet you can too.

Well, right. Just like you could improperly use Capewells during a nasty mal, and you could improperly use a three-ring cutaway system. There's still a good reason we use three rings nowdays.

>The responsibility for ensuring correct installation and function of
>all components prior to use ultimately belongs to the gear user. Not to
>the manufacturers.

Literally true, but I'd expect that manufacturers that manufacture gear that often fails (even if it fails due to user error) will go out of business, or at least realize that they're not making enough money on a component to continue its production. That might provide the impetus for them to do a better job on their gear.

[377 22]

Quote

Quote

If you have a riggers rating, and you are inspecting ANY canopy, it IS a formal inspection. Otherwise do not touch the canopy......

You are right. In this case it was stretched between my sofa and kitchen while others were doing the work. The fact I saw it was not because it was delivered to me in any official capacity... I just happened to see things from a distance while walking around my house and I said: "I would not jump this until it is completely repacked and inspected. I don't have time to do it now otherwise I would do it for free because I am not comfortable with what I am seeing."

I think I clearly expressed my opinions and limitations. In a court of law, the other party in the room would testify I expressed my opinions and limitations, and that I did not do a complete inspection, but did say not to jump the rig until an inspection was done because multiple other errors were found.

Morally and legally, I believe I did everything I could or should.

T Dog, you did the right thing and showed considerable courage and ethics in posting about something you missed. To hell with lawyers (and I am a lawyer). If you can improve safety just do it. If you see something wrong, call it out. You may not find every error but any error pointed out is a good thing. Just let the person know, as you did, that there may be other things wrong.

2018 marks half a century as a skydiver. Trained by the late Perry Stevens D-51 in 1968.

[rushmc 23]

Quote

This report details how both human factoring and poor product design led to a reserve ride.

I came home late at night after getting 2 hours sleep the night before. A friend and someone I never met previously are staying at my place so they can go to the DZ in the morning.

The guy I never met had an A licence but was 3 years uncurrent, planning on getting current the next day.

While packing he said, "I think I have a step thru". I quickly looked and found three MAJOR rigging errors on how the main was assembled, including twisted lines that would require taking the canopy off the risers, brake lines wrapped around suspension lines that would cause a mal, and brake lines attached to the toggles in the most unique way.

The gear was all brand new or new to him. I asked him who assembled the main: "My Rigger Back Home."

I asked, "the same rigger that installed your reserve?". "Yes".

I explained to him that the errors were exceptionally poor and I would not jump the rig. I even volunteered, "I will repack your reserve for free, and if I find a mistake, you will pay me and get your money back from the guy back home. But I can't do it tonight. I am way too tired."

The next morning at the DZ the jumper had two uneventful jumps on the rig "repaired rig".

On his third jump he had a reserve ride. One of the Aerodyne Soft Links released and he trailed the complete lineset on opening.

Facts:

PROBLEM: The softlinks were installed improperly. Instead of proper routing, the loop went thru the "ring" on the Aerodyne brand loop, then over the ring. Going thru the ring first is WRONG. This allowed the soft link to release when not under tension.

PROBLEM: I even glanced at one soft link for maybe 3 seconds - and without "pulling them apart a bit", they "looked clean". This glance was not as a formal rigger doing an inspection, just an attempt to see how many things were wrong with the rig. However I looked closely enough I am embarrassed I did not catch it. When the line goes thru the ring, after it is seated, it is just millimeters off of where it should be, and covered with line. Without twisting the ring and looking from multiple angles, it is very deceiving.

PROBLEM: The skydiver friend who fixed the continuity had to undo ONE link to clear lines. He copied the installation on the restore, so all four remained installed improperly.

Final Comment: The jumper admitted hours after the reserve ride that he did not trust me since I was a new acquaintance, so while I told him I did not trust the rig, I was not creditable. He apologized, and I told him no apology needed.


This is my formal incident report regarding the Aerodyne slinks. I know members of PIA and Aerodyne read these forums, so if they need more information, they can contact me.

However after this incident I believe:

1. The "ring" on Aerodyne brand slinks ALLOWS improper installation, and that improper installation is not very obvious on inspection. I encourage Aerodyne to choose a solid object, like the tab on PD brand soft links, so this routing error cannot happen.

2. Riggers should be made aware that on Aerodyne soft links, improper routing looks deceivingly like proper routing, and the only way to truly inspect is to loosen the system and take a very close look. Do not be fooled by a quick glance, even if the rig has many jumps on it.

I too learned of this first hand while teaching at a rigging course.

In the class I was assembling (with another rigger) a rig with a SMART reserve. It did not come with the link instructions. I asked the IE to download the instructions but the other rigger and I kept going to keep the class moving.

Long story short, we installed them as you explained here (in front of the class). We pulled on the lines and it came apart. The IE brought instructions in seconds later

It gave us a good entrance into how important the manufacturers instructions are.

At first we were a bit embarassed but, what a learning experience.

"America will never be destroyed from the outside,
if we falter and lose our freedoms,
it will be because we destroyed ourselves."
Abraham Lincoln

[377 22]

T Dog wrote:
"Final Comment: The jumper admitted hours after the reserve ride that he did not trust me since I was a new acquaintance, so while I told him I did not trust the rig, I was not creditable. He apologized, and I told him no apology needed."

Congrats to the uncurrent A licensed jumper for handling the emergency successfully, BUT... what was he thinking jumping a rig where the same rigger who packed his reserve made some BIG errors in rigging his main???

That conditional free reserve repack offer was commendable and way above the call of duty T Dog. Your level of concern should have raised major caution flags with the jumper.

I visited a DZ in the 60's intending to use their rental gear. A rigger who was also visiting told me that he wouldnt jump the gear because it showed poor maintenance (weak pilot chute springs, missing or loose tacks on stiffener plate, a loose strand on a ripcord cable, etc). I didnt have my own rig and ended up spending the day as a whuffo. When riggers talk I listen, no matter who they are.

2018 marks half a century as a skydiver. Trained by the late Perry Stevens D-51 in 1968.

[skybytch 273]

Quote

I know, back in your day you had to walk to altitude, both ways, in the snow. And you didn't have chest straps, you just held on tight. And you liked it!

I find it extremely interesting that those who insist that personal responsibility is vitally important in this sport are routinely characterized in these forums as old fogeys who are out of touch with reality.

Does nobody else think that it might be better to contact the manufacturer with a gear related concern, if not instead of, at least prior to posting about it on the internet?

Sorry, there I go being an old fogey again...

[diablopilot 2]

Quote

Quote

Improperly blaming the product for someone's inability (not yours) to RTM, is not the answer. The soft links (and that's what they are, not "Slinks") work just fine.

That is your opinion.

My opinion is that every component in a system should be analyzed for every possible mode of failure. If an user error failure mode can be eliminated by a simple change - then that change should be made. And - when that failure mode is observed in the field, it should be brought to the attention of the community so more careful attention could be paid to it on future installations, inspections, and design changes.

For comparisons sake only (I think they are a good product) PD Slinks have a pretty common mode of failure when assembled by novices who don't RTM.

French links are often not installed correctly by those who don't RTM.

----------------------------------------------
You're not as good as you think you are. Seriously.

[pilotdave 0]

Do you think maybe somebody learned something about installing aerodyne soft links because he posted his concern? Isn't that a good enough reason to post it publicly instead of just telling the manufacturer?

I am all for personal responsibility. But at the same time, we should understand that sometimes human error can be designed out. When people make the same mistake over and over again, maybe a manufacturer could make that mistake impossible.

I'm not saying aerodyne needs to go redesign their soft links... i was just defending what tdog had said in his first post. Just because a person has to fail to follow the directions to end up with a problem doesn't mean that there isn't a problem.

Dave

[JustChuteMeNow 0]

Quote

For comparisons sake only (I think they are a good product) PD Slinks have a pretty common mode of failure when assembled by novices who don't RTM.

French links are often not installed correctly by those who don't RTM.

Amen Brother. I think it needs repeating. RTFM

Think of how stupid the average person is and realize that statistically half of them are stupider than that.