The Hang Gliding And Paragliding Association Of Canada Cites Pilot Error In Woman's Death

The The Hang Gliding and Paragliding Association of Canada has released the results of its investigation into the fatal injury of a woman on a tandem hang glider flight in earlier this year. According to a media release, on Saturday, April 28th 2012, a Tandem Hang Glider, piloted by an HPAC tandem-certified instructor, Mr. Jon Orders, was involved in an accident that resulted in the death of the tandem passenger Lenami Godinez-Avila. An investigation was launched by HPAC.

The findings of this investigation were based on witness statements and evidence held by the RCMP. At this point in time, the investigation does not include any information or statement from the pilot, Mr. Orders (an HPAC accident report has not been received). The inspection of equipment and the review of evidence have eliminated any possibility of equipment failure. The equipment was found to be in good to excellent condition and well suited for tandem hang gliding instruction. All suspension straps and connecting devices were found to be without defect and in good working order. Weather conditions do not appear to have been a contributing factor.

The investigation concluded that the passenger's harness was not connected to the glider on takeoff. The required "hang-check" (or any other suitable method of harness/glider connection test) was not performed prior to the pilot committing to take off. The failure to ensure the connection of the passenger to the glider and failure to perform a thorough pre-launch readiness assessment suggests compounding incidents of pilot error. The investigation determined that these critical steps were included in the HPAC Tandem Course re-certification taken by Mr. Orders in March 2012, only a few weeks prior to this incident. The investigation was unable to determine the reason for the omission of the critical pre-launch safety checks.
 
A review of the events leading up to takeoff suggests that there were multiple distractions that may have resulted in a breakdown of standard operating procedures. On the day of the accident, Mr. Orders had two passengers booked for a tandem flight. These two passengers knew each other (boyfriend/girlfriend). To accommodate the two passengers Mr. Orders employed a tandem instructor, Mr. Shaun Wallace, an Australian national with substantial tandem experience, and a second glider to accommodate the second passenger. According to launch witness statements, the two pilot instructors appeared to deal with the two tandems as a team. Both pilot instructors assisted in preparation for the multiple launches. While Mr. Orders readied for launch, Mr. Wallace was in the immediate area and would have been present and available to assist in a hang check procedure.

Mr. Wallace participated in several actions associated with the operation of Mr. Orders' tandem, including delivering the passenger to Mr. Orders, the activation of Mr. Orders' video camera, and remaining directly behind the glider during the launch process.

Mr. Orders, as Pilot In Command, was solely responsible for the safety of his passenger. The unusual aspect of a second pilot instructor being present for the event makes it is difficult to understand how the multiple phases of the pre-flight where missed by both pilots, and how the hang check was not performed. The investigation concludes that the dynamics of multiple passengers and instructors may be the key to understanding why the critical pre-launch procedures were not performed.

Until such time that a statement from Mr. Orders is made available, the investigation assumes that pilot distraction resulted in a failure to perform recommended standardized safety procedures, resulting in the death of the passenger, Lenami Godinez-Avila.
 
The investigation advises that recommendations will follow at a later date.

(Tandem hang glider pictured in file photo)

FMI: www.hpac.ca