http://ozreport.com/9.188
Mike Haas's accident at Hang Glide Chicago
The USHGA official hang glider Accident Review Chairman.
Joe Gregor - 2005/09/13
After Angelo's post in the Oz Report I decided to review my information concerning the reporting on Mike's accident.
So in the update we'll hear something about the release that your road trip buddy Steve Kinsley characterizes as stinking on ice and the Rooney Link that dumped him into the unrecoverable stall? Just kidding.
In his e-mails to me, Angelo's concern seemed centered on a lack of acknowledgement for his contribution, and the long timeframe required for the report to hit the magazine.
That's odd. In his post on the issue he states that the most frustrating and galling part was how the report simplified Mike's accident and made it easy to dismiss - which was exactly my take.
Angelo did indeed send me a detailed report via US Mail, which all have now seen, and which I used in drafting the Executive Summary for the column in HG Magazine. Other sources include statements from at least four other witnesses and numerous e-mail messages of discussions concerning the accident from a digest maintained by the local club.
- None of which, of course, cited the Quallaby Release and/or Rooney Link as possible issues.
- And I'm sure that local club was just as interested in getting to the bottom of things and fixing the underlying problems as was our local club after Ron Higgs, Frank Sauber, Bill Bennett, Mike Del Signore, Holly Korzilius, and John Dullahan were injured or half or fully killed in towing incidents.
At the time of Mike's accident I had been the HG Accident Review Chairman for only a few months. There was no one on the committee but myself.
So obviously there was no one who could or would have been able and willing to help you with any review and analysis.
In the previous three months, we had experienced seven fatalities or near-fatalities:
03/03 on an XC from LMFP,
Blown landing in injun country? What are we gonna learn?
4/22 on a launch from Sugarloaf Peak, CA,
Blown foot launch. What are we gonna learn?
5/17 a structural failure experienced during aerobatics in NC (Bo's accident),
Total fucking asshole blows up borrowed glider with race wires and throws chute not connected to harness. Next...
5/28 another structural failure at Dry Canyon, NM,
How 'bout we publish an article in the magazine telling people how to build stronger gliders?
6/19 a H-2 outlanding at Hull Mountain, CA,
Blown landing in injun country by a prematurely rated Novice? What are we gonna learn?
6/24 a severe weather related event at King Mountain, ID,
Caution: The Surgeon General has determined that flying hang gliders in severe weather may be hazardous to your health. Next...
...and 2 days later, on 6/26, Mike Haas' accident.
Manned Kiting
The Basic Handbook of Tow Launched Hang Gliding
Daniel F. Poynter
1974
"Never take your hands off the bar." - Tom Peghiny
"The greatest dangers are a rope break or a premature release." - Richard Johnson
There is no way that one man (even if he didn't have two jobs and a family) could simultaneously perform a creditable investigation...
Creditable by whom, Joe?
...of seven geographically separated accidents...
How is geographic separation relevant? Do we get better internet and telephone connections within a fifty mile radius?
...and maintain situational awareness with the constant flow of minor accident reports flowing in day-by-day.
What percentage of those reports involve issues other than flare timing and did you read the magazine article by Jayne DePanfilis eleven months ago?
The only solution was to create a process which relied on local volunteers to conduct the data collection and at least some of the analysis for each major accident.
- The ONLY solution?
-- I started towing in 1980 and, although I hadn't yet figured out The Great Standard Aerotow Weak Link Scam, I had developed the best aerotow release equipment on the planet. And I don't recall you asking ME for any help or input on that one.
-- How 'bout doing some triage? Prioritize and do a thorough piece on the guy who got snuffed doing everything by the Industry Standard book and save the Bo Hagewood aerobatics assholes for really slow news days.
- So after all this massive effort all these local assholes put into data collection and analysis we didn't get any info on the location of the "release" lever, the hook-in weight of the pilot, or the breaking strength of the weak link?
I tried to outline a vision for this process in one of my early columns. The USHGA SOPs call on the Regional Directors to serve in this role, and they are the first people I look to...
- And the USHGA SOPs have ALWAYS provided such an EXCELLENT framework on which to operate. Perish the thought that anybody should think for a nanosecond about deviating from them in any way or to any degree.
- Really? Those motherfuckers are just ahead of tow park operators and crew on a list in descending order of people I'd be looking at to investigate one of these.
...but we are all volunteers (the accident review committee has limited resources and no budget)...
Which is another way of saying that USHGA doesn't give a flying fuck about the safety of its membership and really doesn't want any good data and analysis of crashes circulating. Much more interested in T-shirt sales.
...so I would appoint as Principle Investigator whomever seemed willing, motivated, and in the best position to accomplish the task.
The task, of course, being to blame the dead guy and whitewash the operation, industry, and USHGA to the maximum extent possible.
I would draft an Executive Summary for the column based on their input, be it a larger report (my ultimate desire) or just a collection of facts and analysis they were able to put together and/or send my way. I would share the Summary with the Principle Investigator for their comment and changes before submitting it to the magazine. Is it a prefect process? No, the resources don't exist for perfect but it was at least functional.
It's a MUCH easier job now.
http://ozreport.com/forum/viewtopic.php?t=25321
Stop the Stupids at the USHPA BOD meeting
Mark G. Forbes - 2011/09/30 23:21:56 UTC
Here's how it really works:
- Member submits an accident report. Could be the pilot who had the accident, or some other witness.
- Accident report is sent to Tim to maintain legal privilege. Tim reviews the report and determines whether there's significant legal risk associated with it. He may redact certain parts (personally identifiable information, etc.) if in his opinion exposure of that information poses a risk to us. If the report is very risky, he may decide that it can't be shared further, and will notify the ED about it. He may also notify our insurers if he sees a potential for a claim, as is normal practice for any incident where we are aware of such a potential.
- Redacted report goes to the accident review chairs, for incorporation into periodic articles in the magazine. Articles focus on root causes of accidents, not on personal narratives or details.
The whole procedure is outlined in SOP 03-16, which you can read by logging into the USHPA website and clicking on "Policy Manual".
In fact, because virtually all noteworthy incidents involve gross negligence at the top level we don't really even need an Accident Review Committee anymore.
In the case of Mike's accident several names were offered up to me as a potential Lead for the investigation. Angelo's was not one of them, presumably because he was not on-site at the time of the accident.
Yeah. You always get your best analyses from the people who were on site. The analysis that Steve Wendt did on Holly Korzilius...
...the results of some unfortunate poor decisions of the injured pilot.
...and completed 3 oscilations before it took her 90 degrees from the tow vehicle upon when the tug pilot hit the release and Holly continued turning away from the tow in a fairly violent exchange of force.
Holly for some reason chose to fly her Litesport, she has always towed it with proper releases and weak links...
...nor had she been trained to understand potential problems.
...one is that you have a proper weak link installed.
...and we can only assume that she didn't even consider the fact that she now didn't have a weak link link.
...she was cross controlling, and had no weak link.
The pilot also stayed on tow too long. She should have released after the first, or even the second oscilation when she realized that things were not correct. Failing to do so put the glider in a locked out situation that she could no longer control.
...was one of the best I've ever seen.
And I'd really like to see Paul and Lauren appointed as co-leads to get to the bottom of this latest one at Quest.
Everyone should be thankful to Gary for stepping up to the plate when no one else was willing.
Again, Joe... I don't recall you asking me for anything.
Had it not been for him, it seemed to me at the time, no creditable investigation of Mike's accident could have been accomplished.
Whoa, DUDE!!! And you got the EXACT SAME results WITH him. Who'da thunk.
Angelo's report was received by USHGA on 27 September - three months after the accident - and sometime later forwarded to me. I included it with all of the other information coming to me on Mike's accident, but I continued to look to Gary to lead this particular investigation, as I looked to others to lead the remaining six accidents. When Angelo e-mailed me six to seven months later wanting to know why nothing had been done, I believe I told him that Gary was on it and that he should send his information Gary's way so it could be included in Gary's report. I agree, it would be desirable for the committee chair to acknowledge every letter, report, and e-mail as they come in. There is simply not enough time in the day.
That wasn't EVERY letter, report, or e-mail. That was a real biggie on fatality in a very large and important branch of our sport that's extremely dangerous because it's based on a foundation of total crap and nobody knows what the fuck is going on.
I also acknowledge the long time it took for Mike's accident to make it into the magazine. I do not know what can or should be done to accelerate the process in this regard.
Scrap the useless fucking magazine and go entirely online? Just kidding.
When we were on the CHGA Board together I recommended scrapping the damned paper newsletter because with the advent of the internet it had become a massive time, money, energy, resources devouring waste but you fought for and won continuation because there were still two or three people living in caves who weren't connected. But there weren't too many more years of that lunacy continuing before it collapsed under its own weight.
Even running the extremely long columns I was writing, at two accidents per column, and one column every other month, and a two month set-up time for the magazine, it would take over nine months to achieve print on the fatal/near-fatal accidents we had lying in wait.
And then there's the cave paintings you gotta do for the people without mailboxes.
In addition, I felt it would be unfair to unduly rush those who volunteered to give up their time and energy to do the difficult job of investigating these accidents.
And silencing anyone who might have some take a bit more probing than:
Joe Gregor - 2004/09
There is no evidence that the pilot made an attempt to release from tow prior to the weak link break, the gate was found closed on the Wallaby-style tow release.
In my mind the major point of the magazine column is to relate lessons learned.
- Really? In my mind the major point of the magazine column is to portray the sport as as being as safe as finger painting for anybody who isn't a total moron like the one per thousand per year types who try to save a bad situation instead of getting off tow before there's a problem and thus die doing something they love.
- Bullshit. There ARE NEVER any lessons to be learned on these that haven't been well understood - and brutally suppressed - for most of the history of this sport.
These lessons will not spoil due to a few months delay.
Yeah, it's not like somebody could get killed next weekend due to the same issue.
They may spoil if the investigation is rushed, however.
Before everybody can get together on the same story, swear to stick to it no matter what, and promise to NEVER but NEVER attribute so much as a slightly bowed downtube to an Industry Standard release or loop of 130 pound Greenspot.
Since the magazine column format is ill suited to play the role of instant messaging anyway, I felt that any attempts to rush an investigation would prove counter-productive. If you want immediate dissemination, the Oz Report is the appropriate vehicle, not the magazine.
Yeah Joe, fer sure.
http://ozreport.com/12.081
Weaklinks - the HGFA rules
Davis Straub - 2008/04/22 14:47:00 UTC
At the 2008 Forbes Flatlands Greenspot for the first time was used as the standard weaklink material (thanks in large part to the efforts of Bobby Bailey). We applaud these efforts to improve the safety of aerotowing by using a better weaklink material.
http://ozreport.com/forum/viewtopic.php?t=592
Linknife
Davis Straub - 2010/04/03 12:46:26 UTC
Tad is gone.
http://ozreport.com/forum/viewtopic.php?t=24534
It's a wrap
Davis Straub - 2011/07/30 19:51:54 UTC
I'm very happy with the way Quest Air (Bobby Bailey designed) does it now.
http://ozreport.com/forum/viewtopic.php?t=30971
Zach Marzec
Davis Straub - 2013/02/09 16:45:39 UTC
I can't see how the weaklink has anything to do with this accident.
http://ozreport.com/forum/viewtopic.php?t=22660
What can be learned from this "scooter" towing accident?
Davis Straub - 2011/02/07 19:21:29 UTC
Okay, enough. On to new threads.
Davis gets stuff out faster, the magazine is a little more thorough - but everyone's on the same page with respect to the basics so you know the conclusions are all spot on.
As for the Conclusions and Recommendations, I probably deserve to take a small hit there.
Can I weigh in on this one?
The Probable Cause is the part that relates to what made the accident happen. But the Recommendations, those are there to help others find a way to avoid suffering the same fate.
Like the guy who was pulling Mike Haas did along with his tandem student at the same operation ten days days before you posted this? Keep up the great work, dude!
The Probable (and I mean probable) Cause in Mike's accident was, quite literally, a failure to maintain aircraft control. Nothing more definitive than that can be said.
Try this, motherfucker...
Was the glider equipped such that ANYBODY would be...
Doug Hildreth - 1991/06
USHGA Accident Review Committee Chairman
Pilot with some tow experience was towing on a new glider which was a little small for him. Good launch, but at about fifty feet the glider nosed up, stalled, and the pilot released by letting go of the basetube with right hand. Glider did a wingover to the left and crashed into a field next to the tow road. Amazingly, there were minimal injuries.
Comment: This scenario has been reported numerous times. Obviously, the primary problem is the lack of pilot skill and experience in avoiding low-level, post-launch, nose-high stalls. The emphasis by countless reporters that the pilot lets go of the glider with his right hand to activate the release seems to indicate that we need a better hands-on way to release.
I know, I know, "If they would just do it right. Our current system is really okay." I'm just telling you what's going on in the real world. They are not doing it right and it's up to us to fix the problem.
Dave Broyles - 1990/11
I talked to a lot of pilots at Hobbs, and the consensus was that in the course of Eric Aasletten's accident, had a weak link break occurred instead of the manual or auto release that apparently did occur, the outcome would have been the same. Under the circumstances the one thing that would have given Eric a fighting chance to survive was to have remained on the towline.
...capable of maintaining aircraft control? Well, I'm sure YOU would've aced it with YOUR Wallaby-style tow release and Rooney Link - but I'm talking about your AVERAGE Joe.
(Ever bother reading any of the columns of any of your predecessors or do you feel they couldn't be saying anything worth listening to and you need to start everything from scratch to really do the job right?)
But telling pilots that the lesson learned here is to maintain control of your glider, that is less than illuminating.
Would being able make and have control of decisions to get off and stay on tow have any relevance on this one? Just kidding.
So when I write a Recommendation, it is not intended to outline what should have been done in this accident; it is intended to highlight things that could be done to mitigate or prevent a similar future accident.
Damn! You really nailed this one down! Keep up the great work.
In the info I received on Mike's accident, there was no objective logbook review. Instead, in addition to Angelo's report, I received things like: "This pilot was very experienced at coastal ridge soaring, and less experienced (although he had recent experience at a FL aeropark)...
Possibly the one at which he acquired the Wallaby-style tow release on which the gate was found closed - indicating that the pilot made no attempt to release from tow prior to the weak link break?
Did you check out their website?
The Wallaby Ranch Aerotowing Primer for Experienced Pilots - 1998/02
A weak link connects the V-pull to the release, providing a safe limit on the tow force. If you fail to maintain the correct tow position (centered, with the wheels of the tug on the horizon), the weak link will break before you can get into too much trouble.
Did you congratulate Malcolm and Dave Glover for accurately predicting that the Rooney Link succeeded beyond all expectations in:
- providing a safe limit on the tow force?
- breaking when Mike failed to maintain the correct tow position (centered, with the wheels of the tug on the horizon) before he got into too much trouble?
...with aerotow." There was no consensus that Mike had ever towed the higher performance wing he was flying the day of the accident, and Angelo himself one e-mail stated that "It's very possible that this was his first tow on the Lightsport." One reporter indicated that Mike had recently taken a few years off to build a house "but still managed a few dune flights each year." His last reported aerotow was in October of 2003.
Altogether in my mind, this became an experienced foot-launch pilot who had relatively little aerotow experience, and none of it current. I admit that this may have been a poor characterization, but that is what I came away with from the information presented to me of a pilot whom I unfortunately never knew.
OK, let's make him an experienced foot-launch pilot who had relatively little aerotow experience, and none of it current. So, given that, how well was he equipped for the flight that day?
With 20/20 hindsight, in the case of Mike's accident, I should have written "flying a new class of wing" or "after a long break in activity, indicated reduced proficiency" or something similar...
Why should you have written that? What's the evidence that those were relevant issues?
He'd have been perfectly OK flying at low altitude into that thermal...
http://ozreport.com/9.179
Fatality Report
Angelo Mantas - 2005/08/30
Soon after launching, the glider and tug flew through a strong thermal. This is confirmed by witnesses watching the tug, and the tug pilot's reporting a strong spike in climb rate.
...if he had been super experienced, qualified, current...
Bill Bryden - 2000/02
Dennis Pagen informed me several years ago about an aerotow lockout that he experienced. One moment he was correcting a bit of alignment with the tug and the next moment he was nearly upside down. He was stunned at the rapidity. I have heard similar stories from two other aerotow pilots.
Dennis Pagen - 2005/01
I hung on and resisted the tendency to roll to the side with as strong a roll input as I could, given that the bar was at my knees. I didn't want to release, because I was so close to the ground and I knew that the glider would be in a compromised attitude. In addition, there were hangars and trees on the left, which is the way the glider was tending.
By the time we gained about sixty feet I could no longer hold the glider centered - I was probably at a twenty degree bank - so I quickly released before the lockout to the side progressed.
The glider instantly whipped to the side in a wingover maneuver.
...and had written the fuckin' book on aerotowing?
...rather than using the all-encompassing "new launch method" phrase. Water under the bridge. I have done the best I know how given the limited resources at my disposal.
Such a pity that you got so fucked over with the critical thinking and common sense allocations.
My Reserve commander once said that you know you are in the zone when your employer, your family, and the Reserves are all equally pissed-off at you. By that criterion I have achieved 'balance'.
Is that what he says to people under his command in front line combat? Did Mike Haas, Arlan Birkett, Jeremiah Thompson, and Zack Marzec get any less killed by crappy training, procedures, and equipment on the ends of towlines than they would have by ground fire as consequences of third assed intelligence reports?
Some things you decide you're gonna either do right or not at all. And hang gliding would've been a lot better off with NOTHING from you than with the crap you wrote which leaves the reader with the impression that the only thing wrong with his Wallaby-style tow release was his failure to elect to use it and that we're all supposed to be flying with Rooney Links which always break before we can get into too much trouble and dump us into fatal stalls whenever we're trying to deal with moderate levels of trouble.
I strongly encourage anyone interested in the position of HG Accident Review Committee Chair to contact USHGA and let them know. I see no need to carry out a task that could be better performed by another willing volunteer.
- Define the task, Joe... Fix the massive and perpetual issues of incompetence and shoddiness which kill people like clockwork or assign as much blame as possible to the losers of the roulette game that everybody's playing?
- Better performed from whose perspective? The bottom level people just interested in participating in the sport or the top level people primarily interested in selling it and themselves?
Your application will have my full support.
As will my article on unhooked launches.
That's alright, Joe. It's really hard to imagine anyone doing a better job for the commercial interests than you are.
Lemme tell ya sumpin', asshole...
You and everybody and his fuckin' dog know perfectly goddam well that bullshit EXACTLY like this happens ALL the time - just almost all the time high enough to be able to get away with it 'cause only rarely are the thermals at the altitudes at which people are playing for keeps powerful enough to set one of these off.
And to totally ignore all the incidents which are IDENTICAL except for pulling out well prior to impact because they pulled out well before impact is a grotesque dereliction of duty. So do the fuckin' job right or don't do it at all.
