Discussions de vol libre au Québec

Un communiqué de presse que je "forwarde" pour ceux qui s'interessent au

parapente acrobatique...

En attendant, bons vols

Claude

>Date: Wed, 13 Aug 1997 23:10:47 -0500

>From: Gilles Tuchschmid <gilles.tuchschmid@wanadoo.fr>

>Reply-To: gilles.tuchschmid@wanadoo.fr

>MIME-Version: 1.0

>To: mctamone@mactamone.com

>Subject: Pre-Mondiaux de parapente acrobatique

for the first time, to a student whilst under instruction. We have received

a thorough accident report from the Instructor which has been fully

corroborated.

Accidents are investigated to provide guidance toward the prevention of a

recurrence.

The content and record of this report is confined to cause-related

circumstances and is for statistical record keeping and accident prevention

purposes only.

HPAC accident investigations follow under the guidelines of the

Transportation Safety Board of Canada. It is not the responsibility of the

HPAC nor any of its members to apportion blame. That is the duty of police

and coroners. Our goal is the prevention of a recurrence.

For your future reference, the file Number for this occurrence is # 1807.

Therefore, for (internet) security reasons, you can refer to section XXX in

File # 1807 for comments or questions without opening up any other doors.

All reports are considered confidential.

The fatality occurred Aug. 6th 1997 at approximately 12:30 PM at the

Etobicoke Centennial Park training field. The victim was a 24 year old

young lady named Julie Pogson.

With all due respect to the victim's family and to the witnesses to the

event, this occurrence was as unexpected and as accidental as I can

imagine, given the information provided to date. I believe there is a clear

dividing line between what would be best described as classroom (ground

school) instruction and flight instruction. In my estimation, again based

on current information, this fatality clearly occurred during what I would

consider a classroom stage of instruction.

The instruction was taking place on a soccer field in an area north of the

training hill. The students were being shown an opened Paraglider and were

being given the opportunity to inflate it to see the proper layout of the

glider and lines as well as to get a feel for the aircraft. At no point

leading up to the event, nor after it, were there any thermals. The victim

was experiencing difficulty inflating the canopy, and the instructor was

pushing her in the back to ensure an adequate counterweight to inflate the

canopy, when a freak thermal came through and lifted the student about 6'

off the ground. A second gust came through, which lifted her up to about

15' AGL and then carried her about 30' to the side and out of site of the

witnesses where she impacted the ground.

The accident report lists one of the students (and witness) as a paramedic.

The police report states all three students were paramedics: but the young

lady succumbed to head injuries.

She was not wearing a helmet at the time. I have had several discussions

with several Instructors who agree with my opinion that, as in this case,

the wearing of helmets is always recommended but that at this stage of

instruction is optional (and in my opinion possibly counter-productive.

This is because the critical factor at this stage is to get the student to

have a full and unobstructed view of the canopy and its lines and controls

as the wing inflates.)

If one were to ask: "What would a similar instructor with similar

experience have done in a similar situation?" I believe one would answer

that "they would have had a similar prerequisite for the use of helmets:

that is, it would not be mandatory."

Therefore we extend our condolences to the family of the victim and to our

friends and witnesses to the accident. This must be a very difficult time

for all of them, and I would ask all of you to extend your support to them

at this time.

However, no matter how unexpected and accidental this occurrence was, it is

in the nature of commercial operations to be more exposed to litigation

than would a recreational accident. Therefore, accident investigations, by

nature, can or may extend to a far different level in these circumstances

than you or I may have previously experienced.

It is expected practice for accident investigations to have a reverse

hierarchy or "flow chart" in a commercial or industrial occurrence than in

a recreational. By this, it is expected us to start our investigation from

the top down, not the bottom up.

Therefore we have initiated a wholesale analysis of the HPAC Accident Form,

its questions, the HPAC Safety Policies and Procedures Manual and whether

or not the leadership we provide is adequate to the task.

Further to this I have asked the Instructor to prepare for a

self-examination called a Postmortem in which he will reanalyse the

accident, utilizing the viewpoints of the witnesses. This will include an

analysis of the operational policies and procedures of the school involved.

I am pleased to announce that this process will be overseen and critiqued by:

Instruction Standards Committee Chairman

Mark Tulloch Email airdream@krdata.com

615 Brookleigh Rd. Victoria BC V8Z 3K1

Hm / Wk. / Fax: 250-658-0119

and

Wayne Bertrand Email: aerial@direct.ca

I am grateful to the instructor for allowing me to include Wayne Bertrand

in this investigation process. Wayne is the PGer half of the BCHPA Safety

Committee (me being the other half.) He is also employed each year in Risk

Management for Big White Ski Hill near Kelowna BC.

I have been intensively involved in Safety throughout my career: it is how

I earn my living. However, since leaving Fletcher Challenge in 1988, my

experience with industrial accident investigation has been _rather_

restricted. Wayne, on the other hand is actively involved in this area,

including Risk Management.

He has also been in court on cases relating to sport / business liability

exposure and will be able to give advise and council that would be

inappropriate for me, in my position, to do. I hope you find him as helpful

and as useful as I do.

This event also highlights the requirement under CARs for us to develop an

Operations Manual for use by schools throughout Canada. (Schools would

append documents where there were significant variances to the norm.) I

hope that Wayne, myself and you will join Mark in pooling the talents and

experience of our HPAC instructors in order to develop such a manual as it

is unreasonable to expect each school to do so each on their own.

It is expected of us to review such policies and procedures manuals as are

found on Operations Manuals and Procedures subsequent to such an occurance.

The time has come for us to prepare one.

In finality I would like to clearly express two statements.

It is inappropriate for anyone to make any comments in public or in private

on matters relating to this occurrence. I would ask you all to listen to

what may said, but at some point it will be obvious to you when a point has

come for you interrupt and to state that any further comment would be not

be acceptable. Anyone can file a written, signed report relating to any

accident in our history, and I would ask you to ask them to submit the same

to me. However, let me state clearly I will have little tolerance for

speculative comments on this or any other accident.

Secondly, again, we extend our condolences and support to the family and

friends of the victim and witnesses.

Thank you

HPAC Accident Review & Safety Committee Chairman

Fred T L Wilson Email: fwilson@IslandNet.com

102 - 1236 Pandora Victoria B.C. Canada V8R 3R4

Ph: 1-250-360-0696 Work: 250-386-6773 Fax: 250-386-3941