April 28
th, 2014 represents the second anniversary of the tragic tandem hang gliding death of Lenami Godinez-Avila. For those unfamiliar with this accident, Lenami was the passenger on a tandem hang glider where the pilot/instructor failed to properly connect Lenami’s harness to the glider and shortly after takeoff she fell to her death.
(News Link)
Immediately after the accident, acting on behalf of the Hang Gliding and Paragliding Association of Canada, I began an accident investigation. The investigation concluded in the summer of 2012. Recommendations were formulated over the fall and in late 2012, submitted to the HPAC via a senior instructors seminar in Vancouver B.C. Canada.
Eventually the legal system slowly formulated it’s response and on February 11
th 2014 our flying community saw the legal conclusion to the story of this tragic event. The legal system found the pilot guilty of “criminal negligence causing death” and has sentenced the pilot to 5 months in jail (and a series of other court assigned penalties).
The accidental omission of a basic, accepted procedure resulted in the death of Lenami Godinez-Avila, a person with far too much life left to live. The Godinez-Avila family and friends have all suffered a great loss. The pilot found responsible has undergone a permanent dramatic life altering event and will be his burden for life. There is no resolution that can possibly appear “just” or “proper”, sadly all the parties must live with what it has become.
The purpose of this “open letter” is to challenge our Tandem pilot community to give fair consideration to my thoughts and comments regarding safety in our sport. The inspiration for this letter came from comments in the press from the Lenami’s father. At the conclusion of the court case Miguel Godinez was asked for his thoughts on the sentencing, he replied “I think it was a very light sentence” and added he didn’t think any father in the world would stand for it.
The obvious grief expressed by family and friends was balanced by the wish that whatever the outcome, they hoped that actions would be taken to prevent this kind of tragedy from ever being repeated.
With respect to the family and friends of Lenami Godinez-Avila, I believe it is time to ask our tandem pilots community, what steps have you taken to improve safety in your sport?
Reacting to this question should be respectful. There is an attitude within our sport that such an obvious mistake would not likely ever be repeated. The sad truth, there have been several similar incidents, we are no doubt, without some sort of acknowledgment, doomed to repeat these mistakes. Pilots (both Hang glider and Paraglider) are susceptible to the infamous “Human Error”. . History has proven this statement.
(The following material is the content of my recommendations to HPAC/ACVL. At this point in time the Canadian national association is looking at ways to adapt or implement but will require further development of a mechanism to do so.)
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Recommendation for Implementation:
-Critical Prelaunch Checklist (CPC)
Like many other types of aviation, there is a reliance on learned skills and procedures. It is common practice to back up those procedures with a printed “checklists”. The “checklist” is referenced during the flight preparation and is used to check or confirm steps taken. Obviously, the cockpit of a powered aircraft is suited to the review of lengthy comprehensive checklists. The same cannot be said for the “cockpit” of tandem hang glider. To accommodate the benefits and use of a printed check list I suggest the implementation of an adapted checklist format.
The Critical Prelaunch Checklist (CPC) is intended to cover “groups” of checks already preformed during the pre-flight preparations (the intent being, to refocus the “pilot in command” back to each of the listed events). The CPC becomes a secondary or backup recognition of steps already preformed. Using the CPC creates a break in the traditional continuous procedural recall of the pilot. It provides an opportunity to slow down and recheck the “mental list”.
For tandem procedures, the CPC is also intended to change the traditional nature of a “passenger” to a participating member of the flight “crew”. No longer should a passenger be viewed as a “payload” or a “paying customer”. The use of a CPC for tandem flight is intended to be “interactive” with the passenger, to include the passenger as per the instructional aspect/purpose of the flight. The passenger is to participate in the process of reviewing the CPC.
The CPC becomes an external visual queue (outside the mental checklist) that combined with the passengers interactive review, will create additional layers of backup over and above the pilots memory recall. At the same time the CPC does not represent an exceptional burden to the process.
Implementing the CPC:
When the pilot has completed the normal preparations for flight, the CPC will be produced for review. A printed laminated card is the suggested format. The card could be stored on the pilots harness or gear or fastened to the aircraft in such a way that it is made available for review, while both pilot and passenger are hooked in. The following is the suggested content (subject to review):
Critical Prelaunch Checklist (CPC):
-Glider Pre-flight completed, aircraft ready for flight?
-Passenger/Pilot Harnesses connected, ready for flight?
-Helmet Chin Strap, Harness Leg Loops, ready for flight?
-Passenger/Pilot ready for flight?
The pilot and passenger will review the CPC and will confirm “ready for flight”.
Recommendations for HPAC/ACVL Committee Consideration
-“Hook-in” Visual Control Tag
A Visual Control Tag is a brightly colored strap that is mounted in plain view, clearly visible to the pilot while entering a hang glider control bar indicating an “un-hooked” status. (Often, this tag may include the warning “Hook In !”. It is a visual alert to a process that needs to be performed. )
Using a Visual Control Tag, the Pilot and Passenger will connect to the glider and the tag would be moved from the “plain view” and threaded through locked carabiners to signal/confirm a safe secure connection has been made. (Note, examples of similar “visual control indicators” can be found in other forms of aviation. Light aircraft often use warning flags that are positioned on the aircraft in various locations (examples include control surfaces locks and airspeed probe covers).
An alternate Visual Control Tag could require the carabiners on both pilot and passenger harness to have a clearly visible location (clipped to the front of the harness?) and flagged in such a way that clearly indicates that the carabiners have not been connected.
-Ground Support Person
The HPAC should consider use of a ground support person for all tandems.
One support person should be independent of any flight activity (while the tandem is in progress). The support person would assist the pilot/passenger in the operation of the tandem process. Duties would include the monitoring of the tandem safety checks and provide emergency communication in the event of an accident.
The ground support person need not be a permanent or specially trained employee. It would be recommended that they be familiar with the sport and capable of performing the tasks assigned. Students or Pilots could fulfill the ground support duties and be designated at the time of the flight. A ground support person should remain available for duty during the duration of the tandem and confirm a safe landing prior to being released from their duties.
-Disclosure of Risk/Flight Education
Tandem operators are encouraged to provide a complete disclosure of risk to the client. A clear and frank conversation with the tandem passenger and or student should be part of the flight preparations.
A discussion by committee should be encouraged to define suitable content based on similar industry standards. The passenger should be made aware of all potential risks and is expected to make an informed decision based on this “disclosure of risk”.
The HPAC should also make clear the purpose of the tandem process is to provide instruction to the client. This instruction should include basic flight ground school. The client is not just a passenger but is a student involved in an educational process. This does not mean the instructor is to provide an extensive ground school but it is recommended that rudimentary aerodynamic principles, aircraft/equipment design and operation be discussed and included in the instruction.
Proof of both “disclosure of risk” and rudimentary “flight education” should be provided to the HPAC during any certification process.
-Accident Reporting Standards:
The HPAC should re-evaluate any “Accident Reporting Standards” and make clear policies and procedures related to those standards. During the investigation, the pilot in question was associated with several incidents that brought to question his qualifications to be performing tandem instruction. The incidents were not properly documented and no official record existed (evidence evaluated suggested two failed foot launches with passengers on board and minor injuries associated with those incidents).
The HPAC will need to determine how to process and set criteria for “Accident records”. Accidents should be assessed for severity and should be evaluated by “peer” review. Action by the HPAC/ACVL (where necessary) should be clearly defined and included within any instructional endorsement.
-Bulk Participation Discount Fees (“Groupon” marketing).
It should be noted, the pilot involved in this accident did participate in a promotional discount offering. It was not be determined if this participation had any bearing on the accident in question.
As a general observation, I have noted the uses of group discount fees to promote our sport. It raises questions about value to both the customers and the sport. The expression “Quality over Quantity” comes to mind when looking at the benefits of typical discount program. It is unclear if large numbers of participants, acquiring steeply discounted lessons, being performed by instructors at or below operating costs, translates to any form of beneficial retention.
The appearance that discount programs create massive exposure and benefits to both instructors and HPAC/ACVL membership needs to be properly assessed. Specifically, the HPAC/ACVL should determine if these programs create any safety issues and if these programs should be encouraged or discouraged?
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(I would like to point out that the content of these recommendations inspired a re-assessment of my own personal pre-flight check list used in my towing operation. The benefit of this review resulted in a “save” … the story can be found on my blog post, dated July 5
th 2013:
http://towforce.blogspot.ca/2013/07/from-something-bad-comes-something-good.html )
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After my report, and after the comments from Lenami’s friends and family I decided to add a few more thoughts for consideration…..
Risk:
Hang Gliding and Paragliding is dangerous. After 40 + years of hang gliding experience and more recently 6+ years of Paragliding experience I firmly believe in this statement. I don’t like to sugar coat this opinion, you make a mistake in our sport and it can be fatal.
So why on earth would I (or any other pilot) wish to be exposed to this danger ?... This “danger” also known as “risk”. Most pilots can easily answer this question by pointing out the personal reward. I don’t feel there is much more of an explanation required here as almost every pilot that I have ever met can spend hours upon hours expanding on what exactly this “reward” can be.
Here is something to consider, In our sports of Hang Gliding and Paragliding we have the ability, as individuals to understand, accept and manage our personal risk. Over time, we learn to establish our own personal tolerances or acceptance of what risk is worth what reward.
The difference between a solo pilot and a tandem pilot becomes massive if you are willing to accept that you (as the pilot) must not only assess your own personal risk, you must assess and convey that risk to your passenger. In addition, your passenger must be briefed in such a way that this “risk” is fully understood. It is my opinion; the industry needs to do a much better job educating their clients as to the real risks associated with our sport. A pilot that fails to properly investigate the clients perspective of risk is doing the client a disservice. Proper and full discloser of risk is needed in our sport.
Pilot Skill:
Are you the very best pilot that you can be? Do you seek out your peers for critique and evaluation?
Many years back I performed tandem hang gliding flights. I very quickly determined that flying tandem was not for me. I believe that being a tandem pilot requires exceptional specialized skills. Taking an unprepared “newbee” into the sky is one of the most unpredictable experiences a pilot can perform. I would hope all tandem pilots would be honest with their own personal assessment and prepared to make judgment calls based on the limitations of tandem flight.
I also believe that not only the pilot needs to be honest about a skill assessment; the passenger also requires a basic level of skill to participate. I’m not saying the passenger needs flying skills, more like, the passengers need to be trained as to understand the basics of the task at hand. They need to be fit enough to accomplish the task. They need to be able to comprehend and understand instruction.
Tandem pilots need to be able to communicate with their passengers and have this communication understood. This may all seem very basic but I have witnessed tandem flights where, because of language barriers, the pilot and passenger could not communicate. I have witness flights were the passenger was simply not fit enough to be a passenger. In some cases the fear was so great the safety of the flight was compromised.
I’m not saying that only perfect healthy trained individuals can become tandem passengers. There are opportunities in our sport for a very wide range of passengers, some with extreme limitations. A good tandem pilot will know their limitations and manage the risks associated with specific challenges. Good judgment, strong skills are key to managing this risk.
Equipment:
There should be no compromise. You are obligated to provide the best aircraft, the best safety equipment possible. Hang glider pilots must not use old out of date wings and parachute systems that are not suited to the increased demands of tandem flight. Hang gliders must never be flown in excess of the manufactures limitations. Para glider pilots must ensure safe wings, proper safe reserve systems and must provide harnesses that provide their passengers suitable protection. There should be no compromising safety.
One further comment regarding equipment. The recent advent of “action cameras” has added an additional layer of complexity to the system of aircraft, pilot and passenger. These systems must not be used in a manor that detracts from safety protocols used to manage the flight. Pilots using an “action camera” must carefully assess operating procedures and not allow these cameras to interfere with safe practices.
Closing Comments:
It is my hope that Tandem pilots across Canada and around the world will give my open letter fare consideration.
To the family and friends of Lenami Godinez-Avila, my deepest sympathy.
Thank You,
Martin Henry
HPAC/ACVL 2012 Accident Investigator.
