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deviation spiral over Chris Derbak

NTSB Witness

 

NTSB Witness.gov

 Witness.gov is an email address to send messages to the National Transportation Safety Board on their investigations. I wrote to them on August 9, 2024 about the Special Investigation Report SIR-08/01 and about the accident on Mokuleia, Hawaii on June 21, 2019.

My experience at Skydive Chesapeake is quite like the operation in Hawaii, however the behavior of the United States Parachute Association should be of note to NTSB. In their response to the SIR Report of 2008 the USPA told them, in 2011, that Aircraft Operations Manuals and Pilot Training Syllabus had been written. I recently found out that the USPA has done nothing to see that those are used.

Less the illustrations, the following was sent to NTSB:


I.Avid Skydiver

I have been an avid skydiver, off and on, since 1975. I am a D License holder with the United States Parachute Association. In 2020 I helped the managers of Skydive Delmarva in Laurel, Delaware move too Gooden Airpark in Ridgely, Maryland. The owner, John Gooden went to high school with my son.

I decided to get my instructors rating with that new drop zone, Skydive Chesapeake. It was managed by Ben Harris and Chris Derbak.

II. Safety Issues at Skydive Chesapeake

A. Lost Control of Piper Navaho

Unsafe activities occurred there after it opened in 2020. On December 11, 2020, they leased a Piper PA31-310 Navajo (N6719L). The pilot was not trained on it and on the first jump he lost control of the airplane. He immediately regained control but it was disturbing.

First Group of Skydivers to Jump From Skydive Chesapeake's Navajo
First Group of Skydivers to Jump From Skydive Chesapeake's Navajo

B. Violation of Seat Belts regulations, FAR § 91.107

They operated that airplane in 2021 and flew it repeatedly without enough seat belts for each jumper. On February 25, 2021, a video depicts this. Derbak was one of the people who made that jump. He is sitting in the copilot’s chair!

Shortly after that I was on that plane when another skydiver, who has considerable experience as a jump pilot, warned him (the same one who last control in February) that if he was flying with one engine out, with an overloaded plane that he would have a distinct problem. The pilot was scared. As I said, he didn't have training and I didn’t have a seat belt.

Skydive Chesapeake Navajo pilot
Skydive Chesapeake Navajo pilot

That weekend, I wrote to both operators of the drop zone to inform them of the pilot and all the other questionable activities.

III. Kicked Out of Skydive Chesapeake

A. No USPA support

One week later I was suspended from the drop zone. At the meeting when I was suspended from the drop zone, I was told by Harris that Ron Bell, the USPA Safety Director, had been given my letter. My perspective on it couldn’t have come from Harris, so I wrote to Mr. Bell to explain it.

Bell was sick with Covid 19, so my letter was sent to the Eastern Region Director, Shauna Finley. Harris never did send my letter to Bell. Finley and Bell knew what happened with the FAR violations and the other items but never did anything about it. This was a few months after Harris signed a Group Membership pledge to honor FAR Regulations.

My suspension lasted a month. When Harris knew that the USPA was informed he permanently banned me from the drop zone.

IV. Special Investigation Report SIR-08/01

What’s happening at Skydive Chesapeake is exactly what happened on Mokuleia, Hawaii on June 21, 2019. That pilot was untrained. That aircraft was not airworthy for its mission.

In their report by the NTSB in 2008, there were 12 Recommendations. Many of them had to do with aircraft maintenance guidance packets and pilot training. In 2011, the USPA, in response to the Report, wrote a Flight Operations Handbook template and Jump Pilot Training Syllabus template for drop zones to use to make their operations safer. However, the USPA never did anything to make those templates effective.

I know this because, in February of 2024 I wrote to the current USPA Eastern Region Director, Dave Grabowski, of what drop zones in his region have aircraft operations manuals and new and current pilot training, according to the USPA 2011 templates. After thirteen years it isn’t known by the USPA if any drop zones are using them. Grabowski’s answer to my question was that those documents are “private information”. He and the USPA have no knowledge who has those items and who is using them.

According to what happened to the Oahu Parachute Center in 2019 and what I know of Skydive Chesapeake, neither of those drop zones are using them. Both have had deaths.

V. DZdeviance.org

I decided to write a blog. It’s at DZDeviance.org. The name derives from what happened on the January 1986 accident of the Space Shuttle Challenger. NASA deviated from safety and the USPA and their drop zones are doing it as well.

However, its worse for the USPA. They never actually had safety methods to be deviated from. Templates were written by the USPA in 2011, but they aren’t used today. In their final report in 2008 the NTSB was satisfied, but those templates aren’t used. If they were, and if they were part of Safety Management System plan, the USPA and every jumper would know about it.

Jim Couch wrote an article in the USPA’s magazine in 2020. It highlights a crash in 1995 that is an exact example of “Normalization of Deviance” as NASA identifies it. A pilot, ten skydivers and a person on the ground were killed in that September 10, 1995, accident.

VI. Other Noncompliance

A. Advisory Circular AC 105-2E

In 1998 an Evaluation of Improved Restraint Systems for Sport Parachutes by the FAA Civil Aeromedical Institute and the Parachute Industries Association was produced. It has been in the Advisory Circular since 2011. The USPA has never done anything to implement this on any drop zone.

The Sullivan, Missouri Crash Report on July 29, 2006 and the Crash Injury report illustrates how bad restraints kill people and make them quad and paraplegics. The analyses showed that the peak deceleration on that flight was between 6.6 G and 19.7 G’s. These ranges fall within survivable limits according to the report but not from a single point and suspended like a fish on a hook. That’s what most parachutists have during such a crash.

Sullivan MI report figures 4 and 5
Figures 4 and 5 from July 29 2006 Sullivan Missouri accident report

B. No SMS, Safety Management System

The USPA has a page on their web site that discusses Safety Management System. In my blog I proposed a safety plan to solve this. It’s in the article in DZDeviance.org, Proposal for Reform.

I went to the USPA Board Meeting where I proposed that plan. Michael Wadkins, Chair of the Safety Committee, asked me what USPA documents I would change if that were to happen. I did that in August of 2022 and received no response.

USPA has said that a SMS plan should be in drop zones, but they have done nothing to do that. It’s the same with Aircraft Operations Plan’s, restraint systems and pilot training.

VII. Safety and Training Advisors, S&TA’s

USPA has a S&TA at every drop zone and they are usually paid by the owner. At Skydive Chesapeake there are two S&TA’s, the first jump instructor and Harris. Both receive most of their income from the drop zone. There are extreme conflicts of interest there.

VIII. USPA Directors Come and Go

The person who responded to the NTSB’s Special Investigation Report SIR-08/01 in 2008 isn’t the current director. The directors who were there at that time put together an operations plan and something that could serve to verify pilot’s training. All they are now, is templates and no one at the USPA is interested in solving the problems in the 2008 report. If the NTSB or the FAA or Congress expects anything to happen for restraints, aircraft operations or pilot training, or a SMS program, it won’t have the USPA, as it currently exists to do anything about it

IX. Laura Olson’s Death

It’s only been four years and Skydive Chesapeake has already had a death. The person only had three jumps, and she was supervised on that jump, and trained, by one of those S&TA’s. I wasn’t there, but I’m sure that what happened to her is partially an aspect of the safety culture there, which doesn’t exist. I’m also sure that if the USPA had more to with the drop zones and an actual SMS plans, the NTSB would be satisfied.

 

 

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deviation spiral over Chris Derbak

Skydive Chesapeake Is Deviant. The USPA Is Much Worse.

 

Skydive Chesapeake Is Deviant. The USPA Is Much Worse.

I began this blog referring to a phrase called “Normalization of Deviance”. That was a phrase that was NASA's flaw in the Space Shuttle Challenger Accident. This graphic illustrates it:

Normalization of Deviation Spiral
Normalization of Deviation Spiral

When I was jumping there, Skydive Chesapeake has many examples of this deviant behavior. They’ve gone through many “normal”, with untrained pilots, bad spotting, seat belt violations and others. The article that I originally sighted was from USPA Training Advisor, Jim Crouch, and it talked about an incident in 1995 when 12 people were killed. Their Queen Air lost power and crashed and the NTSB found many examples of the kinds of things that are Normalization of Deviance. They’ve been found in many skydiving accidents involving aircraft.

The United States Parachute Association isn't deviant. Their behavior has never wavered from what is normal.

On February 1st, 2024 I emailed Dave Grabowski, the Eastern Region USPA Director, with this request. “I’m interested in all drop zones in the Eastern Region that have current Flight Operations Handbooks and USPA Aircraft Status Forms. Please provide those to me. Thank you.”

Dave’s response verified what I knew. He said, “I don't have the info you are looking for, and even if I did, it's not my or USPA's place to provide what are essentially private business documents to a third party.”

Sixteen years before my communication with Grabowski, the National Transportation Safety Board issued a report, Special Investigation Report SIR-08/01 . It listed skydiving deaths as a result of aircraft crashes. It said that, “Since 1980, 32 accidents involving parachute operations aircraft have killed 172 people, most of whom were parachutists.”

The USPA responded to the report and said that they would put together a document about aircraft safety operations. They also had a document of pilot safety training. The Special Investigation was an NTSB product but the FAA responded by saying, in 2011, that “Your manual will help parachutists perform more safely.”

The USPA's response in 2011 didn’t have the effect that the NTSB sought on Skydive Chesapeake or to the Oahu Parachute Center. On June 21, 2019 a King Air crashed there killing 11 people. That is reported on in Oahu Parachute Center accident investigation. Three of them were not skydivers, just tourists seeking tandem jumps.

Bryan and Ashley Weikel  on their 1st anniversary (KKTV News11 (Colorada Springs, CO)

What happened on June 21, 2019 at Dillingham Airfield (HDH), Mokuleia, Hawaii was exactly like what the NTSB reported on in 2008. Jim Crouch warned about and its occuring at Skydive Chesapeake and other drop zones today.

The FAA said that the USPA's Operation's Manual and it Pilot Training Guidance would enhance skydiving safety but that assumes that those documents would be used. It is not. The USPA has no knowledge of any drop zone using them. According to Gabowski those are, "private business documents".

In their report, the NTSB said the Oahu Parachute Center operator had 18,000 tandem jumps but, “no previous experience running a parachute operation.” He also didn’t have the integrity to operate a safe drop zone. I mentioned this at Safety Day in 2024. Ben Harris, Skydive Chesapeake's operator, does not have the integrity to operate a Safety Culture. That got me physically removed from the event.

Many people who were at the event that day know what Harris did me. It's in my original post , "Deviance at Skydive Chesapeake". His character counters safety.

The NTSB Report from Hawaii stated that the OPC did not have a training curriculum or company training manuals for OPC pilots. A former OPC pilot, who was not a flight instructor but provided training to multiple OPC pilots (not including the accident pilot), stated that the company did not provide him with direction for training except to teach new pilots to start the engines, taxi, take off, fly the jump run, and land the airplane, after which the pilots would be “good to go.” The former pilot also stated that “there was no money to take the airplane off the line” for training and that training consisted of “a couple of jump runs.” The former pilot further stated that most of the company’s training involved viewing King Air Academy videos on YouTube instead of hands-on training.

Another former OPC pilot stated that the company’s King Air training “was a joke.” This former pilot also stated that his training on the airplane was “minimal” and that his instructor advised, at the completion of training, “not to get uncoordinated.”

The airplane was not airworthy. The pilot was not trained. No aircraft operational assignment existed.

I was banned from jumping at Skydive Chesapeake after citing safety violations. They included not having enough seat belts in the Piper Navajo, N6719L. (This is a violation of CFR § 91.107) Welding going on in the packing area, no ground Support Personnel at boarding and poor pilot training, among others.

The 2008 NTSB Report was repeatedly cited in the Report of what happened at Oahu. Many of the things that happened between 1980 and 2008 were repeated at the field in Hawaii. The operational plans and the pilot training mission that the USPA specified after 2008 did nothing at Hawaii and nothing at Skydive Chesapeake.

When they published their report, the NTSB thought the USPA would do something, and they did. They published a template, the “Skydiving Aircraft OPERATIONS MANUAL”. In 2011 the FAA said it will positively effect how,  “parachutists perform more safely”. According to Grabowski, there is no info on who in the Eastern Region has an operational plan or who is training their pilots. They don’t want fellow skydivers to have these documents because, “it's not my or USPA's place to provide what are essentially private business documents to a third party.”

Why is that true? The current USPA “Group Membership Manual” asks if there is Skydiving Aircraft OPERATIONS MANUAL for the drop zone, but according to Grabowski, he doesn’t know which drop zone’s have it. It also asks if there is an initial and recurrent training for jump pilots at the drop zone? According to Grabowski that’s private information and not available. He doesn’t know it. If there was an Operations Manual, and it was followed, what happened in Hawaii wouldn’t have happened. Bryan and Ashley would be alive.

Many of the things that happened in Mokuleia, Hawaii are present at Gooden Field in Ridgely, MD, (Skydive Chesapeake). I attended Skydive Chesapeake’s Safety Day on March 23, 2024 and was told by the Drop Zone owner that he does have a Operation’s Manual, because of insurance requirements. It’s not available to any of his customer’s. Why is that? If he had a safety plan his customer’s should know about it. Maybe he has first time and recurrent pilot training. That would be another aspect of his operation that his customers should know.

In my original posts from 2021, Deviance at Skydive Chesapeake and Much is Awry in Ridgely it can be seen how far that drop zone is from where it should be.

In that original post I referred to a welding operation in the packing area. That was quite bizarre. There wasn’t a lease so the owner could do whatever he wanted.

Not having enough seat belts in Navajo, N6719L happened repeatedly. Loadmasters and jumpmasters don’t exist then and they probably still don’t exist now and it’s because the Safety and Training Advisor (S&TA) is the drop zone owner!

The USPA accepts this despite saying that operating without enough seat belts is breaking the law. Evidence of this is at Ten Jumpers in an airplane configured for eight. Ron Bell, USPAs Director of Safety and Training went to Skydive Chesapeake a week after I was suspended from the drop zone in March of 2020. He was told about the lack of seat belts and he should have established that it happened. There was nothing done about it.

Operations Manuals are “private information” according to the USPA. Nobody knows if any drop zone Operations are acceptable. The kind of training done for pilots at the Oahu Parachute Center was nothing, and this was many years after the USPA wrote Operations Manuals for their drop zones.

This isn't the only thing where USPA has done nothing. The Federal Aviation Administration’s Civil Aeromedical Institute, the Parachute Industries Association, and the USPA has known, since 1998, that restraint systems for parachutists are inadequate. Read the Sullivan, Missouri Crash Report and for those with strong stomachs, the Sullivan, Missouri Injury Report will shock you. Since 2011 Advisory Circular 105-2D clearly stated how to make it safer. I don’t think that any drop zone in the world has done it.

Furthermore, the USPA has established that Safety Management System (SMS) should be at drop zones. Nothing is happening about this either.

I made a proposal to the USPA in their board meeting in 2022. It recommended a safety proposal for drop zones with a Safety Committee just like in the SMS system. That’s in my post Proposal for Reform. The plan that I proposed would not put anyone on that board that receives an income from the drop zone. The safety personnel at the Oahu Parachute Center, if there was one, was the drop zone owner, just like Skydive Chesapeake.

My proposal calls for two types of Group Memberships. One type does have members on the committee who receive income from the drop zone. Skydive Chicago would be potentially a “Legacy Group Member”. They would provide most or all of the functions and services called for in USPA’s Skydiving Aircraft Operations Manual and the drop zone’s Flight Operations Handbook with paid staff members. The other type would be “Safety Committee Group Member”. They have qualified volunteers who form drop zone Safety Committee to provide some of the functions and services called for. In those drop zones the Committee’s do not receive income.

Skydive Chesapeake and the Oahu Parachute Center would be Safety Committee Members. Of course, no drop zone would have to be either. They could choose just not to have an SMS system. I wouldn’t want to jump at a drop with no safety system.

That’s another thing I’ve heard from Graboski and other USPA directors. USPA “C” and “D” license holders don’t want to get involved in dealing with safety on their drop zones. Maybe that is true but what about the others? Bryan and Ashley Weikel would have wanted to know. Every drop zone should tell their customers their safety system. They should admit to that and have the credentials to prove it. If they don’t, they should admit to that to. That is where the USPA should get involved. The  USPA’s Skydiving Aircraft Operations Manual and the drop zone’s Flight Operations Handbook should be open to the public.

On July 10, 2022 Laura Olson was killed in a skydive at Skydive Chesapeake. She had three jumps. An Incident Report says the accident was recorded in August of 2023. That too is little weird being thirteen months after the event. The incident says that the weather was good with a five mile-an-hour wind and that Olson landed in trees and fell out of them. The fall from the trees caused a fatal injury.

I was kicked out of the drop zone just before Safety Day on 2020 because I brought safety issues up. At that time a lot of the jumpers were landing off the drop zone for bad spots. I made a map with all roads identified so that my wife and I could retrieve jumpers that landed outside the drop zone. It happened nearly every day.

In that map, it can be seen that there are no trees, except in the east and southeast. Olson’s jump was in a 5 mph wind so the spot was close to the landing area. If the wind wasn’t out of the east or southeast there were no trees over the spot. The spot might have been bad, and if so, that is why she landed in trees.

Because of the bad spots and because the pilots aren’t trained that should be looked at. They were jumping a Caravan at 13,500 feet. Did other jumpers know the spot was wrong? If it was wrong, that should be called to attention. Both S&TA’s at Skydive Chesapeake make all their money from the drop zone and it isn’t too much. The drop zone owner is one of the S&TAs at the drop zone. The other S&TA was Mrs. Olson instructor on that skydive.

I think the USPA and drop zones run like Skydive Chesapeake and the Oahu Parachute Center are doomed. The NTSB and Congress have their reports. Poor newlyweds are killed. If the drop zones don’t take the steps, like valid SMS System, and if skydivers don’t make it happen, our sport won’t survive, unless you want to go to The Mid-East.

The fault there is with the USPA. Drop zone owners have very conflicted interests. The Oahu Parachute Center was sealed from the start. The practices that owner undertook were awful. A viable SMS system is called for where somebody outside profit is needed. The current USPA system does not have it.

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