http://ozreport.com/forum/viewtopic.php?t=4247
Hook in failure in New Zealand
Kevin Rooke - 2006/09/22 00:05:32 UTC
I see this thread winding down.
Nah. You're at about the halfway point. And the quality of this conversation will guarantee that there will be plenty more just like it.
Having had the first word I'd like to also make some concluding comments to what feel has become a very informative discussion.
Yeah. ONE fucking mention of a hook-in check without a definition of what it is and without a single word of response. Right.
The first word was something like ****, and happened seconds after coming to my feet after a tumble, to see my pretty glider, like model gliders of my youth, sailing into the distance, before disappearing on a mysterious and private journey.
Certain reported details are incorrect and quotes using my name have been have been fraudulently posted but I am indeed relatively lucky - as Jim Rooney points out - to have egg on my face rather than the alternative.
THE alternative? There's lots of them ranging from nothing more than oops to we don't even wanna talk about it.
My clip in omission was demoralising but not physically traumatic.
THAT omission wasn't the problem. It's what you omit from ALL of your launches that's the problem.
Contrary to "eye witness accounts", I sustained no personal injury and people nearby were low key and light-hearted about the whole thing, calling me up on the radio complimenting me on the best flying they'd ever seen of my glider, etc.
Did anyone say anything about hook-in checks? Just kidding.
Claims I created a threat of colliding with a gaggle of gliders was incorrect as only one or two gliders were in the area at the time.
And if there had been flocks of gliders nearby? People would've been too stupid to yield right of way to one with no one driving it?
I was particularly 'preoccupied' on takeoff.
Irrelevant.
Conditions offered X/C potential so I'd packed a lot of gear into my harness in case I landed out of contact and spent the night outdoors.
Irrelevant.
It was warm on takeoff but cold aloft and this was my first time on a new earth ramp, which I had concerns about and spent time clearing of long grass.
Irrelevant.
After separately carrying clothing, equipment, harness & glider close to takeoff I prepared to launch. Because all the other pilots were flying PGs and were preoccupied with their own plans, I determined very early on to do my own walk through hang check.
Irrelevant.
And there's no such thing as a walk through hang check.
However, I never pre visualised this step or thought of alternatives, and when this time arrived my focus skipped ahead instead, to the upcoming need to do a good balanced run on an unfamiliar and challenging takeoff (light, changeable, thermal conditions), in a harness that restricted my run due to the extra stuff packed in anticipation of XC flying - something I'd done little of in the last thirteen years.
You also skipped a hook-in check for every single flight you'd taken in the course of the past thirteen years and before and this time there's gonna be a somewhat expensive consequence.
On takeoff the wind was changeable and though I had a moment of hesitation, I over-rode this feeling to focus on conditions and my run.
Irrelevant.
When the wind straightened I ran hard, the glider was nicely balanced and lifted well, giving me confidence that all was good but before my third step...
Don't ya just LOVE people who have CONFIDENCE that all is good before their third step?
...the glider was clearly too high.
No shit.
At that time I recognised my oversight.
Can you think of anything you could've done to recognize your oversight five seconds prior?
I think I pushed the glider away, and went with the tumble, in which fortunately I encountered no rocks and felt pretty good about.
I'm thrilled that you're so easily pleased.
It probably was not possible to pull myself into the control frame as I was wearing gloves and leaned through the control frame to maximise running speed, allowing the glider to float upwards with only moderate downwards pressure on down tubes, so as to transfer weight to the harness as soon as possible.
Yeah? I can think of a way to transfer weight to the glider a lot sooner than that. Well, in light air, the suspension anyway.
The rest of the matter involved watching my glider fly around nicely by itself, the mentioned ribbing from another pilot over the radio, and an awful lot of time spent locating and extracting the glider from hundred foot high trees, which I did not find until the next day and then only because of its previous sighting by a PG pilot, made difficult because it was suspended vertically with only a wing tip showing above the tree canopy, in dense forest, on an expansive mountainside with difficult access.
It is difficult to tell whether any damage occurred when the glider 'landed' and how much occurred getting it down from twenty to thirty feet up in adjacent trees I had to climb in order to throw and attach a rope from. Due to the terrain it took three person / trips to recover everything.
Compare/Contrast to the cost of doing a a couple thousand or whatever lift and tugs for your solo flights over the course of the previous years of your career.
Reflections:
I am now mainly a tandem pilot these days and in this intended 'solo' flight I neglected to follow both my previous solo practise of prior attachment to glider of harness...
Hey Robert... Don't ya just LOVE the way Aussie Methodists condition themselves to believe that any time they're in a harness while standing under a glider they're connected to it? I know, if he had been a TRUE Aussie Methodist he would NEVER have gotten into his harness unless it was connected to his glider. So we really don't need to count this as a failure of that strategy.
...and the tandem process of involving a launch assistant in my checks.
WHAT checks?
For solo flying I must resume my former practise...
Fer sure, Kevin. Keep up that conditioning. It'll do wonders for your confidence and self-esteem.
...and/or devise an improved verification system.
1. "OR"?!?! There is no "OR" in Aussie Methodism. You must be TOTALLY DEVOTED to it and ignore all entreaties of heretics and blasphemers.
2. Hook-in check maybe? Just kidding.
My current thought is to adapt my tandem verification system (an extra hang loop that is threaded through all karabiners and hang loops and secured).
Unless you're distracted.
This hang loop would have its own karabiner and be tied via a bungee cord to the keel at the A Frame apex. After pre flight checks, this loop would be pulled down and attached around the base bar, making it difficult to move the glider or attempt takeoff due to its obvious visibility and obstruction.
Which you disconnect when you need to move the glider and reconnect afterwards - unless you're distracted.
Then, as part of my pre takeoff check I would secure this loop through the karabiner, a separate harness loop, the hang loops and back onto itself, thus providing a back up in case of karabiner or hang loop failure, as well as verification of clip in.
Yeah, hang loop and karabiner failure. We could save so many lives if only more people would do something like this.
Whilst this mistake is disappointing to me and perhaps others too...
I'm NEVER disappointed by one of these, Kevin. The Davis Show would be SO BORING without them.
...there are several useful conclusions over and above reinforcement of the fundamental principal...
Oh good. FINALLY an unhooked launch incident from which we can learn something useful.
...that no matter how clever I/we sometimes believe myself/ourselves to occasionally be, I/we can (and shall) continue to overlook the obvious from time to time.
1. I think that what we can learn is that...
- The more clever someone is the more confident he is that he's gotten his shit together by the time he's in launch position.
- A total idiot has no confidence whatsoever that he's gotten his shit together by the time he's in launch position and is thus a lot more likely to make damn sure he has.
- There's an appallingly high percentage of clever people participating in this sport and gearing it for themselves without accommodation for the concerns of the minority of total idiots.
2. This is NOT - IN ANY MANNER SHAPE OR FORM - *OBVIOUS*. The fucking carabiner, engaged or not, is BEHIND YOU. That's why we've killed so many people this way.
Same with firearms. It's very seldom OBVIOUS whether they're loaded or not. The ONLY safe solution is to always assume that they ARE and treat them as such.
Same deal with the fucking glider. You MUST assume at all times that you're not connected and ONLY commit to launch right after you've tensioned the suspension to briefly make it OBVIOUS that you ARE connected.
The David O'Hare report into human factors associated with the tandem fatality where the passenger was not attached, highlights the need to better understand human factors associated with poor decision-making and errors of omission.
What a load of crap - by a clever person intended for clever people.
With tandem clip in failures to date in NZ we have gone from a pilot omission (around 1995), to a passenger omission (2003)...
Steve Parson / Eleni Zeri.
...back to your pilot omission (2006).
Rooney. And that total asshole never has been or will be a pilot.
One wonders whether there is a subconscious over-compensation for known and recent accidents that might predispose a pilot to committing the other type of oversight.
Do the fuckin' hook-in check. Do the fuckin' hook-in check every third flight if that's the best you can manage. It'll be a lot more useful to you and everybody else than spouting off all this useless bullshit.
It doesn't matter HOW or WHY this oversight occurs. We can bet the farm that it WILL occur and the only solid strategy for dealing with it is to ASSUME that it is about to EVERY TIME.
The most constructive part for me has been to successfully apply the early recognition and response to clip in failure;
Yeah Kevin, let's discuss the first couple of seconds AFTER you've committed to an unhooked launch.
- things we do in developing clip in verification systems for the greater good!
Except for hook-in checks!
Walking around trying to find the glider there were moments of regret about not attempting to hold on but contemplating that prospect becomes increasingly horrific with time.
The odds are pretty good that you'd have ended up as in a lifeless heap on the slope and the glider would've ended up pretty much as it did as things were.
The pilot has little time to make a rational decision about their response, and the pre-programming of a suitable response and early recognition of the warning signs may save a great deal of physical harm.
REAL pilots never EVER move a foot without having verified the connection a couple of seconds prior. Time is never a critical issue for them.
You, on the other hand ALWAYS commit to launch based upon some assembly and/or preflight ritual you (think you) remember having done five or ten minutes ago. You get away with it a few thousand times in a row and then you pay a big price and we all get to listen to all this lunatic crap about the best thing to do when one is trotting along and finds the basetube up at his chest.
I'm sure holding on even for two seconds makes the decision to hold or drop difficult, often wrong and sometimes fatal. Knowing that I was capable of committing that omission, and also knowing that I'd been in circumstances accentuating probability of this scenario, made it easier to recognise and respond to the error without hesitation.
Good job, Kevin. Totally righteous stuff.
Whilst I accept criticism for my oversight, I can indeed consider myself fortunate for a successful post incident response, for which I'm indebted to the contribution of knowledge of those who went before me, and the good analysis, critique and development of knowledge about human factors and post incident procedures by my peers, CAA and most importantly, Associate Professor, David O'Hare Dept of Psychology, Otago University, NZ.
Idiot.
It has been satisfying to read the postings and several interesting points strike a chord with me.
Pay extra attention to Rooney. I always find his comments solid. They're based on hundreds of hours and tows worth of experience and backed up by a keen intellect and knowledge of the issues when it comes to most things in general and hang gliding and aerotowing in particular. Wanted to go on record in case anyone reading wanted to know the one person to whose comments they should give the most weight.
Checks are not guarantees: I like this one and the constructive doubt this instils. Certainly we are able to convince ourselves of having done checks when we haven't, particularly if flying more than once in a day, or distracted for any reason, particularly in relation to omission errors. We easily switch off and fail to properly go through the checks even if talking them out loud, so clarity of mind, consistent sequence and external feedback are important factors in the quality of our checks.
Make the fucking check the beginning of your fucking launch sequence - EVERY TIME.
Hazard Elimination: Ultimately as David O'Hare states, being unable to proceed until the threat is removed is ideal (eg a car that cannot be started if already 'in gear'), hence the idea of a hang loop fastened to the base bar with a bungee chord between it and keel might may prevent takeoff and remind the pilot that checks are incomplete. On the negative, it makes moving the glider around takeoff difficult, and once attached, makes detachment on landing / takeoff more complicated and potentially dangerous in strong winds.
Yes.
'Flying When not in Peak Awareness is Dangerous': I'm paraphrasing the comments of others here and relate it back to previous comments about human behaviour and human factors. "If you are tired, fatigued, or just in the wrong state of mind, you are really vulnerable". It's often our lack of recognition (or denial) of vulnerability that leads us to omit a critical step. We cannot easily step outside ourselves and see ourselves as others do, or into our areas of ignorance. This is where we benefit from experience, constructive feedback, shared perceptions and knowledge.
We're NEVER flying or launching in states of peak awareness. It's a REALLY BAD IDEA to be engaging in activities which require peak awareness to have reasonably good expectations of survival. That's one of the big reasons I went into hang gliding instead of Grizzly cub kicking.
Fatigue &/or distraction &/or narrowing of focus are common factors in omission errors. Although it has been suggested that we shouldn't fly if fatigued, unwell, confused or emotionally disturbed we are likely to never be 100% free of such influences...
PRECISELY. I'm always shooting for twenty-five percent myself.
...and perhaps when at our worst, least likely to see our increased vulnerability.
Irrelevant. People who do hook-in checks don't launch unhooked, people who don't - DO.
Pilot Attitudes: People who are less methodical and conscientious about checks are more likely to commit errors.
And always make sure to stuff your battens in the precise same order. I just can't emphasize that enough.
Whilst thorough, safety conscious pilots still make mistakes; they are less likely to do so than those without checking systems or an awareness of their human fallibility.
Give me someone with a good doses of common sense, threat assessment capabilities, and muscle memory conditioning who knows he's an idiot any day over some anal retentive asshole who spends 45 minutes prior to every flight checking safety rings, backup loop condition, bar clearance, and chinstrap buckles.
Thinking about options if indeed something goes wrong...
If, indeed, "something" GOES wrong?
...might help to control the 'hurry up' impulse and put feelings of impetuousness into perspective.
I don't waste time thinking about options if, indeed, "something" GOES wrong - especially when they all totally suck. I assume I'm gonna die and that substantially decreases the probability of "something" GOING wrong.
- Thinking about previous accidents in similar situations has often worked for me.
If thinking about previous "ACCIDENTS" in similar situations OFTEN works for you then think about them just prior to EVERY launch. If you find something that WORKS and there are no downsides to it then MAXIMIZE its implementation ferchrisake.
Post Incident Response: It really helped in my situation to have thought through what to do in this situation. Certain factors were still outside my control but there are generic responses that apply in most cases e.g. letting go. It is probably better still to contemplate the best response in a variety of scenarios before each takeoff, integrating them into the flight plan. Inevitably things don't always go as expected or come in a 'one size fits all' box. Mental preparation for the unexpected vastly improves likelihood of appropriate response.
I'm sorry, could you repeat that? My mind started wandering at "Post Incident".
I shall look at publishing the O'Hare report in full to this or an alternative site and anyone wishing to do so on another or obtain it in full is welcome to contact me, provided the author is acknowledged and his work used constructively to promote awareness of human factors in aviation.
Great idea! And perhaps you could post a copy of the seminal work on aerotow weak links by Drs. Lisa Colletti and Tracy S. Tillman. It would be really wonderful if we could reference all of the best works on hang gliding topics at one place.
Happy & sustainable flying,
Kevin Rooke.
Idiot.
