HKPA report number 19

Site: Lantau Lantau West

(***Click here for site guide***)

Date of Event: Saturday 16th of April 2011

This Accident report was filed on Friday 15th of March 2013 and the last change to the report was made on Friday 15th of March 2013 by Mark Mohan

Injury Index = 5
( 0 =No Injuries or Minor - brief visit to Doctor)
( 1 =Significant - hospitalized or work time loss less than 48 hours)
( 2 =Temporary Disabling Injuries)
( 3 =Permanent Partial Disabling Injuries)
( 4 =Permanent Total Disability)
( 5 =Fatal injuries)

Details:

A pilot holding a Student Licence with 1 years of experience whist flying at Lantau at approximately 12-1400hrs on Saturday 16th of April 2011.

The conditions at the time were reported to be Variable with a SW wind blowing approximately 26-30kph. The temperature was 25-29deg C with Some Cloud and Hazy Visibility.

There were reported to be 2-5 pilots at the site.

Factors in this Accident:
Stall
Hard Landing
Injury
Collapse
Airmanship
Impact with Obstacle
Strong Winds
HKCAD
POLICE
GFS
AMBULANCE
Death

Event Description:

Accident Description

As far as the Board of Inquiry can ascertain, the following sequence of events unfolded.
The deceased proceeded to Lantau Island on 16th April 2011 with Mr. YUEN Wai Kit and another student pilot. Having assessed the conditions on arrival in the area and identified that the wind was south-west, it was decided to opt for the take-off best suited to a south-west wind. On arrival at the take-off the pilots decided the conditions were marginal but nonetheless the other student pilot opted to fly. This he successfully accomplished managing to fly the ridge for about 15 minutes before he went into land on the Cheung Sha beach.
The deceased then opted to launch. His first attempt at take-off was apparently unsuccessful due to his inadequate control of the paraglider as it came up. As a result he fell over, rolled on the ground and twisted his risers. The deceased was then cautioned by the experienced pilot not to take off if he felt the conditions were unfavourable. The deceased disconnected the risers and re-connected them although the evidence suggests he may have twisted the risers whilst re-connecting them. This is not a fatal mistake as it should be possible to fly with twisted risers assuming the brakes lines are free to move.

The deceased opted to reverse launch. This is the recommended technique for strong wind conditions as the pilot is able to observe the wing as it comes up to ensure that it’s flying correctly.

The witnesses report that the deceased turned the incorrect way as the wing came up into a flying position and this would have further twisted the risers. He was immediately seen to rise about six to seven metres above the launch point.
Two witnesses, Mr. YUEN Wit Kit and Mr. LAI, report seeing the risers twisted and the paraglider oscillating back and forward in pitch. In addition, Mr. YUEN Wit Kit states the pilot was spinning below the paraglider as the risers sought to untwist themselves.

Further, Mr. LAI states the brakes were being applied fully as evidenced by the trailing edge of the paraglider being pulled down as if conducting a landing approach. This would have slowed the paraglider close to the stall speed and explains the oscillations as the paraglider neared the stall speed, then recovered. In a matter of seconds the paraglider drifted to the right with the deceased swinging into a large rock to the right of the take off point. The pilot bounced, rose in the air again, and then swung into the rock a second time hitting with his back. The deceased eventually came to rest suspended in his harness with his paraglider draped over a nearby tree some 40 meters from his take-off position.

At this time several other pilots had arrived at the launch site, all coming to the aid of the deceased. They disabled the wing, disconnected the risers from the harness and assisted the deceased in attaining a more comfortable position.
The deceased was conscious and told those around him that he felt intense pain in the back. As the deceased was able to move his legs and arms, it appeared that his back had not received a severe injury.
It was noticed that the right foot of the pilot was distorted. After carefully removing the deceased’s shoe, an open fracture was observed. The deceased was unaware of this injury and mentioned that he could walk down the hill by himself after resting. As this was obviously impossible, emergency services were therefore contacted.

After approximately 10 to 20 min, the deceased’s breathing rate suddenly increased. This condition last for about 2 minutes before stopping altogether.
Suspecting that the deceased had gone into shock, those present at the scene began CPR.
After approximately 30 minutes the GFS helicopter arrived with paramedics and transported the deceased to Eastern Hospital where he was pronounced dead shortly thereafter.

Committee Response: (if any )

Site Report

The site being flown is identified by the Civil Aviation Department as a paragliding zone and designated as Lantau South West. The take off point selected on 16th April 2011 is infrequently used as it works best in a south-west wind and involves a fairly demanding climb to the launch point. Board of Inquiry members Steve Wordsworth and Mark Mohan visited the take-off point with witness Mr. YUEN Wai-kit and Police officers of the Tung Chung detachment, on the afternoon of 27th April 2011.
The launch point is a grassy area facing South West about the size of two tennis courts. On examination the site was assessed as a suitable launch point given its size and lack of obstructions in front. To the east of the launch and perpendicular is a lower spur line and to the West the terrain raises to Lantau Peak. The launch point is approximately 460 meters above sea level. The ground consisted of ankle length grass with a gentle slope providing an ideal take off point. Board of Inquiry members performing the site visit considered this location would work best in a direct south-west wind with potential threats coming from rotors created by the adjacent terrain if the wind is not directly on to the launch point.

Equipment Inspection

On 27th April 2011 Board of Inquiry members Steve Wordsworth and Mark Mohan, inspected the deceased’s paragliding equipment at Tung Chung Police Station. Also present was Mr. YUEN Wai-kit and investigating officers from Lantau Police District. The equipment consisted of one paragliding wing, one reversible harness, one helmet and a reserve parachute.

Paraglider

The wing is a UP Pico serial number XA45-02-1-102-0029, which according to its identification stamp was manufactured on December 2010. The UP Pico Wing is rated as suitable for beginners. All paragliders are graded according to their handling characteristics with the Pico certified as LTF 1 / EN A, which is given to paragliders that are secure in flight, and relatively easy to launch making them the ideal choice for beginners. Paragliding wings come in sizes according the pilot weights and this wing was a size “S”. The weight range for this paraglider is between 70 and 95 kg. Given the lightweight nature of the deceased’s flying equipment (Paraglider weight 4.45 kg, harness weight 2.8 kg, reserve parachute weight 1.25 kg, clothing/ helmet/ water etc 4 kg) this would place his all up flying weight at approximately 87 kg and is within the accepted weight range of this paraglider.
The key components of the wing were examined, these being the risers, the mailons, the brake lines and anchor points, the individual lines and the attachment points between the lines and the wing. In addition, the wing surfaces were also examined for any damage or tears. All these examinations proved negative. The wing appeared to be in a good condition, obviously relatively new and had no visible damage. Mr. YUEN advised that he had kited the wing, during which the wing performed to expectations and displayed no odd behaviour.

Analysis and Causal Factors

Given the evidence presented, the board of inquiry has identified the following causal factors:
  • The deceased was brought to an unfamiliar flying site in marginal conditions.
  • Marginal flying conditions existed for a student pilot.
  • The deceased displayed a strong desire to fly in the face of marginal conditions after being cautioned.
  • Poor launch technique as evidenced by the failed first launch attempt.
  • Failure to re-evaluate conditions and personal capability after the first failed launch attempt.
  • Failure to clear the riser lines and ensure a correct reverse launch connection to the harness. (Strong wind conditions may have contributed in preventing a full wing spread out and proper line clearing).
  • Incorrectly connected and crossed riser lines would have been aggravated once the turn forward was made at launch.
  • The twisted risers on launch would have been immediately recognized once the turn forward was complete.
As a student pilot, the deceased would have attempted to abort the takeoff by applying full brake. This would:
Increase the angle of incidence of the wing and therefore the angle attack to the relative wind. The increased angle of attack equates to increased lift.
In strong winds –pull the pilot off the ground.
Lock the brakes in the applied position due to the riser twist.
With full brake applied the glider could not obtain sufficient airspeed to penetrate the launch headwind.
Oscillations in pitch (as witnessed) can be attributed to full brake application as the glider approach stall speed.

The spinning of the pilot as the risers sought to untwist and the pitch oscillations could cause disorientation and impair situational awareness. This would hamper the pilot’s ability to assess his situation and correctly control his wing.
The deceased was overwhelmed by the rapidly developing situation he faced and was not in control.
It is considered that the spinning of the pilot below his glider and the lack of forward airspeed gave little opportunity for the airbag harness to properly inflate effectively negating a critical safety feature.
A seat mounted reserve parachute system may have afforded some additional protection.
Verbal testimony by Yuen Wai Kit , identified that the deceased was wearing low cut ankle high hiking boots. Proper paragliding boots with firm ankle support may have reduced the injury to the right foot.

Committee Action: (if any )

Recommendations to the HKPA Executive Committee Given the analysis of this incident the Board of Inquiry would like to make the following recommendations:
“The deceased was brought to an unfamiliar flying site in marginal conditions.”
The HKPA membership must become proactive in guiding visitors and students while they fly our site’s in Hong Kong.
To this end, it is our recommendation to develop a more positive and readily identifiable method of identifying visitors and student pilots flying in Hong Kong.

The Board of Inquiry recognizes the fact that the HKPA has no authority over anyone wishing to fly in Hong Kong regardless of their capability, training or equipment being used.

“Marginal flying conditions existed for a student pilot.”
It is our recommendation that the executive committee consult certified flying instructors in Hong Kong with regards to placing a limit or cap on the maximum wind speed allowed for students to fly. This cap can be removed or raised as the individual attains more flying hours and experience.

It is our recommendation that the executive committee consult the Hong Kong Observatory with regard to making their weather instrumentation at the Tung Chung gap available for public display on Observatory website.

This would provide the paragliding community in Hong Kong a more accurate indication of wind conditions on South Lantau Island than those currently in use. At 13:30 on the day in question, winds were quite variable from one a weather station to the next.
For example:
  • Cheung Chau Winds WSW - SSW @ 10 km/hr
  • Ngong Ping Winds SW – WSW @ 28 – 35 km/hr
  • CLK Winds WSW @ 28 km/hr
  • Waglan Island Winds SW @ 23-25 km/hr

“The deceased displayed a strong desire to fly in the face of marginal conditions after being cautioned.”
“Poor launch technique as evidenced by the failed first launch attempt.”
“Failure to re-evaluate conditions and personal capability after the first failed launch attempt.”

It is our recommendation that the executive committee consult certified flying instructors in Hong Kong with regards to the type of human factors training provided that addresses peer pressure and self evaluation.

“Failure to clear the riser lines and ensure a correct reverse launch connection to the harness. (Strong wind conditions may have contributed in preventing a full wing spread out and proper line clearing).”
“Incorrectly connected and crossed riser lines would have been aggravated once the turn forward was made at launch.”
“The twisted risers on launch would have been immediately recognized once the turn forward was complete.”
“As a student pilot, the deceased would have attempt to abort the takeoff by applying full brake.“

It is our recommendation that the executive committee consult certified flying instructors in Hong Kong with regards to identifying a strategy and training solution to counteract this twisted riser condition.

“It is considered that the spinning of the pilot below his glider and the lack of forward airspeed gave little opportunity for the airbag harness to properly inflate effectively negating a critical safety feature.”
It is our recommendation that the executive committee advise the membership of the safety implications presented by reversible harnesses and that such harnesses are not recommended for student pilots or pilots with low air time.

“Verbal testimony by Yuen Wai Kit , identified that the deceased was wearing low cut ankle high hiking boots. Proper paragliding boots with firm ankle support may have reduced the injury to the right foot.”
It is our recommendation that the executive committee advise the membership of the advantages of wearing proper paragliding footwear.

The board of inquiry would like to express its appreciation to those members present at the accident site for their help and assistance. In particular, our deep gratitude goes to Lai Wai and Ah Yau, for their unfailing efforts to revive Daniel Chau during this tragic event.

It is our recommendation to the executive committee to sponsor a First Aid clinic for the HKPA membership and to make this training available to any member who wishes to attend.

The Board of Inquiry would like to recommend to the Executive Committee a modification to the HKPA website to include an anonymous incident reporting function. The aim is to promote safety awareness by sharing incident information and to gain from the experiences of others. Miscellaneous Miscellaneous It is noted that the paragliding instructor, Man Kam Fai, is utilizing outdated HKPA documentation in filling out his student report forms. The student report forms and the HKPA training organization has been dissolved for many years. It is our belief that Man Kam Fai should be utilizing the documentation under which he is authorized. To this date, it has been difficult to independently confirm Man Kam Fai’s licence approval and recency with the licensing authority in Brazil. This report will be updated once further information becomes available.

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