According to the coroner's report, this jumper suffered a heart attack in freefall and died before he reached the ground. Although his AAD activated at the correct altitude and his reserve landed him relatively softly in an open area, rescue personnel were unable to revive him. The report did not indicate whether the jumper had any known prior medical issues that would have increased the risk of a heart attack during skydiving or strenuous activities.

As the skydiving population and USPA members grow older, each jumper needs to consider his personal health and the risks involved with skydiving, including the medical risks of a heart attack or stroke. USPA expects to see an increase in this type of accident as the baby boomer generation gets older and the average age of membership increases.

Skydiving is a physical activity that requires reasonable physical strength and agility. Those at risk of heart attack or stroke should carefully consider the additional physical stress that can result from skydiving and consult their physician if they have any questions.

The jumper flying the right-hand pattern was a student with 14 jumps. The jumper using a left-hand pattern was a military jumper under a military parachute system. The canopy damage from the collision indicated the student was probably slightly higher than the military jumper because the student's body and canopy lines struck the front left corner of the military jumper's canopy and suspension lines. The military jumper's canopy had line burns on the leading edges of the top and bottom skins of the parachute, as well as along the top of the canopy. The burns were likely caused by contact with the suspension lines of the student's canopy passing across the nose and top skin of the canopy. The student's reserve container also had line burns, probably created from friction with the military jumper's main canopy lines when the student passed through them during the collision.

The student was not wearing a radio for this jump. Both jumpers may have been focused on the landing area, unaware of their close proximity to each other. The gray color of the military jumper's canopy and the low angle of the sun may have contributed to visibility problems. The planned landing pattern for either jumper was not reported, nor whether the drop zone requested right- or left-hand patterns for approaches to the landing area.

Jumpers need to ensure clear airspace before making turns and remain extra vigilant when lighting conditions make it difficult to see other canopies. The airspace directly above and surrounding the landing area is the most likely place for a canopy collision, as jumpers often reach pattern altitude at the same time as others on the same load. Establishing canopy flight guidelines and a flight plan for each jumper on the load can help ensure an orderly flow of canopy traffic.

As with many fatalities, this was caused by a chain of events that combined for a fatal result. Breaking any of the links in the chain may have changed the outcome. If the two jumpers had been farther apart during deployment, it may have allowed for the canopies to remain clear of each other after opening even though both jumpers experienced canopy problems that prevented on-heading openings. It's possible that the two jumpers tracked away from the formation in similar directions or that other traffic issues prevented them from tracking the direction they needed to go (typically 180 degrees from the center of the formation) to maintain a safe distance between them. Using a flat tracking position can help jumpers achieve more distance from the formation and gain separation from other jumpers in the group.

Skydiver's Information Manual Section 6-1 recommends a breakoff altitude of at least 2,000 feet above the highest planned deployment. This group broke 3,000 feet above the Basic Safety Requirements' minimum opening altitude for C- and D-licensed skydivers of 2,000 feet, which should have provided the necessary separation for 11 experienced skydivers. Both jumpers were using elliptical canopies; the first had a wing loading of 1.5:1 and the second a 1.6:1. Canopies with higher wing loadings can close large distances in a short time, requiring even more space between jumpers during deployment. Jumpers should break off even higher when they are using slower opening and faster flying canopies.

Investigators found the first jumper's main canopy with one brake unstowed, which may account for its off-heading opening and turn toward the other jumper. The second jumper experienced line twists, which would not have allowed for any directional control until they were cleared. Careful packing of the main canopy can help reduce the chance of line twists or a spinning main canopy upon deployment.

Canopy wraps and entanglements are very disorienting and often cause jumpers to lose altitude rapidly due to the rotation of the canopies. Additionally, since each collision and entanglement results in a unique outcome, it's difficult to prepare or practice for the necessary response. Still, jumpers must respond quickly and correctly to provide enough altitude for a successful cutaway and reserve activation. Jumpers in a rapid spin who are surrounded by canopy lines and fabric can easily become disoriented, making it difficult to clear the entanglement and find clear space for a reserve deployment. Therefore, both jumpers in a wrap must communicate, remain altitude aware and react quickly.

This jumper was landing off the normal landing area into a field close to the drop zone; he had flown his canopy downwind of the intended landing area for unknown reasons. Investigators suspect that he then made a last-second turn in an attempt to avoid power lines near where he landed.

This jumper was jumping a elliptical canopy at a 1.4:1 wing-loading, which the manufacturer recommends for jumpers of intermediate experience level. The manufacturer does not list the number of jumps or experience required to be considered an intermediate jumper; however, jumpers at this wing loading should be very competent canopy pilots, which requires staying very current. At 500 jumps total and only 50 jumps in the past 12 months, this jumper's experience may have been a factor in the accidental low turn. Highly wing-loaded elliptical canopies will lose a large amount of altitude during a turn, and a jumper must always keep that in mind when flying this type of parachute. The landing pattern needs to be carefully considered, and all turns must be completed with enough altitude for the canopy to return to straight and level flight for the landing flare.

Skydiver's Information Manual Section 5-1 includes recommendations for off-field landings, which specifically warn against making low turns while avoiding obstacles. When faced with an off-field landing, a jumper should carefully scan the selected alternate landing area for any hazards while still high enough to fly to a different location if needed. Once the jumper has selected an alternate site, he should determine a descent strategy based upon the wind speed and direction, as well as the specific challenges of the area.

A braked approach and landing can provide for a slower, safer descent into an unfamiliar landing area. Jumpers should practice braked canopy flight and landings often to become familiar with flying a canopy at slower forward speeds and descent rates. All jumpers can benefit from canopy training beyond the basic instruction taught to student skydivers. Many professional canopy schools offer this type of training, and SIM Sections 6-10 and 6-11 include useful information and canopy drills designed to improve the skills and knowledge of each jumper who works through the training outline with an experienced canopy coach.

A witness under canopy above this jumper observed him turn approximately 180 degrees before he struck the ground. Investigators believe he initiated the turn at an extremely low altitude, although there were no witnesses in a position to accurately gauge the altitude.

Since there was no wind when this jumper's load took off, all seven skydivers on the plane agreed to land facing west unless the wind picked up from a different direction. A few minutes after they were under canopy, the wind increased slightly to a few miles per hour from the southeast. This jumper initially faced into the new wind direction during his landing approach but turned toward the northwest right before he struck the ground. He may have planned his final approach to land facing into the wind but changed his mind at the last minute in an attempt to face the direction initially agreed upon. There were no obstacles in the immediate area that should have influenced his decision about the landing direction.

The report described this jumper as a conservative canopy pilot who was not known to have attended any structured canopy training course or to have ever worked with a more experienced canopy pilot on canopy skills. The evidence seems to indicate this was a case of a turn initiated too low in an attempt to land in the agreed-upon direction; however, it is difficult to come to determine the reason for the jumper's final turn at such a low altitude.

Light, shifting winds can lead to jumpers on the same load landing in different directions as each jumper chases the wind sock or streamer when it changes direction. Wind speeds of just a few miles per hour will not greatly affect the landing flare, and it is almost always safer for jumpers on the same load to fly the same canopy pattern than for them to use a variety of approaches while attempting to follow a shifting wind sock. Smaller flags and wind streamers easily change direction with the slightest breeze, which can lead to confusion for jumpers under canopy trying to determine a wind orientation for their final approach and landing. A large tetrahedron can help establish a landing direction for all wind conditions, as it is unaffected by light winds and will stay pointing in one direction unless the wind speed increases beyond three or four miles per hour from another bearing.

Many structured canopy courses include discussions on a large variety of landing conditions, including traffic management in variable winds; course training exercises typically include at least one crosswind landing in a controlled environment as well. Skydiver's Information Manual Sections 6-10 and 6-11 include information and practice exercises that can help jumpers learn more about canopy flight through any course led by an experienced canopy coach.

Regardless of wind direction or speed, it is safer to land a parachute that is flying straight with the wing level than it is to initiate a low turn to attempt to land into the wind. Ultimately, all turns must be completed with enough altitude for the canopy to return to straight and level flight for the landing flare.

This jumper's 270-degree front riser turn created a diving approach toward the entry gates into the swoop course. As the canopy began to level off near the entrance to the course, he steered the canopy and flattened the recovery arc by pulling both rear risers evenly. After reviewing video footage of the incident, investigators reported that it appeared as though the right rear riser slipped from the jumper's hand as he pulled down on both rear risers, which caused the canopy to abruptly dive to the left. The diving left turn caused the jumper to strike the ground at a very high rate of descent and forward speed. Investigators could not determine if he had kept his steering toggles in his hands as he controlled his canopy with the risers, but he made no attempt to flare the canopy with toggles or rear risers. The video showed that only one-fourth second lapsed between the time when his riser apparently slipped from his hand and when he struck the ground—barely enough time to even realize what had happened, much less react to the situation.

This jumper had participated in canopy competitions before this event and had trained with very experienced canopy competitors to learn more about high-performance canopy landings. The report did not indicate the number of jumps this skydiver had made with his current canopy—a 90-square foot cross-braced parachute—but with only four years of skydiving experience and 1,100 total jumps, he would have had to downsize rapidly. His wing-loading of 2.1:1 exceeded the maximum loading recommended by the manufacturer for expert skydivers.

This accident shows there is no margin for error when flying highly wing-loaded canopies at fast speeds near the ground. There may have been a slight chance to flare the canopy with toggles and initiate a carving turn instead of striking the ground, but the response would have had to be immediate once the riser slipped from his hand. Jumpers should keep their toggles in hand until they have landed, even while using risers to control the canopy. Ultimately, all turns must be completed with enough altitude for the canopy to return to straight and level flight for the landing flare.

Although all witnesses agreed this jumper experienced line twists at the beginning and end of his canopy flight, some said he removed the twists for part of the canopy descent, while others reported that the twists never cleared and that he remained in spinning line twists for the entire descent. Investigators found this jumper with both toggles in his hands and both of the canopy's brakes released. This likely indicates that the he cleared the line twists at some point during descent and then released his brakes to steer his canopy.

The report indicated this jumper had made aggressive toggle turns in the past. On most makes and models of canopies, it's possible to induce line twists by rapidly pulling down one toggle. In this situation, it would be difficult to regain control of the canopy with the steering lines caught in the line twists, as the canopy would almost certainly remain in a turn until the jumper could clear the twists. This type of self-induced malfunction has led to several fatal landings in the past after jumpers induced spinning line twists at a low altitude and didn't have the time or altitude to safely handle the problem.

If a jumper encounters a main canopy that cannot be landed safely, he must initiate emergency procedures at a safe altitude. Section 5-1 of the Skydiver's Information Manual recommends that students and A-licensed jumpers cut away and deploy their reserve at or above 2,500 feet above the ground and that B- through D-licensed holders take action at or above 1,800 feet.

At some point, it becomes too low for a jumper to cut away, and deploying the reserve without first cutting away may be the only remaining option to try and slow the descent. Although the Skydiver's Information Manual doesn't recommend a specific altitude for licensed jumpers to transition to a reserve deployment without first cutting away, Section 4 of the SIM recommends that students who are 1,000 feet or below with a partial malfunction deploy their reserve without first cutting away their main. Experienced jumpers should also take into consideration their equipment and each possible malfunction scenario before deciding a hard deck for whether or not to first initiate a cutaway. A jumper should decide this altitude well before he gets on the plane so he can initiate a quick response when an emergency arises.

Investigators did not report any problem with this jumper's equipment and concluded that the uncontrolled spin was most likely the result of spinning line twists induced by a rapid toggle turn at approximately 1,000 feet.

Category G of the Integrated Student Program includes ground training and canopy drills, which include maximum-performance canopy turns. These drills help jumpers become familiar with the limits of each canopy they jump. The exercises should be performed above 2,500 feet in case line twists are induced; however, the intent of the drills is for each jumper to learn how his canopy reacts and how his harness begins to rotate just before line twists begin so he can stop the turn before twists are induced.

Upon deployment, this jumper experienced an entanglement with his main canopy lines; the lines of the right front riser group were caught on his right foot. Investigators were unable to determine exactly why the canopy’s lines entangled with the jumper but suspected that he deployed while in a tracking position or while still slightly head down. Investigators believe that the main canopy’s slow, orbiting turn was due to the entanglement and that he was most likely hanging in an unusual position in this situation, such as sideways, nearly upside down or completed inverted.

Entanglements are one of the most difficult malfunctions a skydiver can experience. There are no clear-cut procedures that will work in every case. Each situation will be different, and so will the correct action necessary for a successful outcome. Although this jumper’s out-of-sequence emergency procedures did not cause an entanglement between his two canopies, deploying a reserve into a main canopy that is still attached to the jumper at the risers and another location greatly increases the chance of a main/reserve entanglement. Skydiver’s Information Manual Section 5-1 recommends that jumpers make two attempts to clear a horseshoe malfunction (where part of a deployed parachute is entangled with a jumper or his equipment) before cutting away the main canopy and deploying the reserve. Altitude permitting, clearing the entanglement can help ensure the main canopy will either fly correctly or, if it has malfunctioned, can be fully released when the jumper pulls the cutaway handle.

After this jumper had deployed his reserve, witnesses observed him under both his main and reserve canopies, which were both fully inflated but turning slowly in an unreported direction. Investigators believe he then pulled his cutaway handle to release his main canopy at approximately 1,500 feet, which is when witnesses observed the main deflate and streamer behind him, with the canopy attached to his foot by the one line group.

With the reserve canopy fully inflated and flying, the priority at this point should have been to steer the reserve canopy to a clear area and prepare for a parachute landing fall and possibly a hard landing. Instead, for unknown reasons at 500 feet above the ground, this jumper used a hook knife to cut the right rear line group of his reserve canopy. (He then apparently dropped the knife, as investigators did not find it with him at the scene though he had been equipped with one before the jump.) The reserve then deflated, and the jumper landed hard under the two mostly deflated canopies. Investigators reported he may have become disoriented or confused, thinking he was cutting main suspension lines, when he was actually cutting the reserve lines.

Horseshoe malfunctions can be particularly dangerous. No two situations are alike, and they are nearly impossible to simulate on the ground for training purposes. For these reasons, avoidance is the best defense. Careful packing procedures, maintaining your equipment, and deploying the main canopy in a stable, face-to-earth body position can help eliminate the chance of encountering a horseshoe malfunction in the first place.

A hook knife can be a valuable tool to free a jumper from a canopy or its lines that can’t otherwise be cleared. However, it is vital that a jumper first ensure that he is not worsening the situation by cutting the wrong component.

Witnesses reported seeing this jumper under canopy in what was described as an "orbiting-type turn" rather than a fast spin. The report did not indicate whether the jumper appeared to be conscious or was somehow incapacitated after opening. The coach who followed the jumper under canopy expected to find him possibly injured from the landing, but did not think the canopy's descent rate was fast enough to cause fatal injuries. This jumper was using a main canopy with a wing loading of 1:1, which the manufacturer recommends for jumpers classified as intermediate. (The manufacturer does not further define its experience levels to indicate what qualifies a jumper as intermediate.) Regardless of a jumper's experience, a landing under any canopy with a 1:1 wing loading and while in a turn will result in a hard impact.

Investigators at the scene found the main canopy with one steering line broken but no other damage to the canopy or suspension lines. The report did not indicate whether the toggle with its steering line intact was found stowed or unstowed. The slider had not been collapsed, and both the main canopy cutaway handle and reserve ripcord were found in place on the harness. In a test on the ground after the accident, investigators placed the harness and risers under a 200-pound load and were able to pull both handles easily. The report stated that this was the first time the rig had been jumped since it had received a reserve repack, but it was unknown who packed the main canopy. The medical report stated that the jumper died from multiple blunt force injuries, including a fractured skull, multiple facial and rib fractures, a broken pelvis and two broken femurs.

Although the canopy apparently opened hard, it is not clear what caused it to do so. Over the years, hard openings have led to many injuries and several fatalities. Canopies made from zero-porosity canopy fabric, along with suspension lines that do not stretch (or "give") during deployment can lead to severe forces being placed on a jumper's body during an instant opening. Freefall speed, body position, temperature and altitude all factor into the speed of the deployment. However, carefully following the canopy manufacturer's instructions for assembly and maintenance, as well as careful packing procedures and deploying the canopy at a normal freefall speed in a stable body position are most likely a jumper's best protection against experiencing a hard opening.

The report indicated that this jumper apparently suffered a debilitating stroke soon after deploying his main canopy. He had released his brakes and stowed his slider, both normal activities following a main canopy deployment. At some point above approximately 2,000 feet, he apparently lost consciousness, as he was no longer steering his parachute. He was jumping an elliptical canopy at a wing loading of 1.7:1, which produced a significant forward speed and descent rate. Although the cause of the gradual turn is unknown, it may have been due to the jumper's body position leaning more toward his left in the harness after he became unconscious. Striking the ground in a slight turn and almost in full flight at such a high wing loading resulted in fatal head and neck injuries, along with broken ribs and facial injuries.

The coroner listed the cause of death as blunt force trauma following a stroke. Even though the jumper had suffered a stroke first, the examiner deemed the trauma from the hard landing as the actual cause of death. However, the coroner determined that the stroke was severe enough that even if the jumper had suffered it while on the ground, he most likely would not have survived.

As jumpers get older, they must consider the additional physical stress that skydiving places on their body and keep an eye on any medical conditions they may have (such as high blood pressure or a family history of heart or vascular problems). This jumper underwent surgery in 2002 to have stents installed, apparently to open clogged arteries. Following the surgery, he was cleared by a doctor to resume skydiving. However, regular physical checkups are no guarantee against experiencing a stroke or heart attack while skydiving. Jumpers, especially those with pre-existing conditions, should closely monitor their health and err on the side of caution any time they don't physically feel up to jumping.

The exact details of this fatality may never be discovered. However, several factors may hint toward a potential cause. This jumper had completed approximately 20 wingsuit jumps out of his 119 total jumps. Skydiver's Information Manual Section 6-9 recommends that jumpers making wingsuit jumps have at least 500 freefall skydives—or at least 200 freefall skydives within the previous 18-months—and that they receive one-on-one instruction from an experienced wingsuit jumper. Wingsuits can add additional risks to skydiving; knowledge, practice and skill are necessary to minimize these risks. Much of this can only be acquired by gaining experience and proficiency with the basics of skydiving first.

Although oxygen was available on the load, this jumper chose not to use it. Witnesses stated that he did not exhibit any signs of hypoxia. This jumper's altitude awareness might have been affected by the visuals of jumping at a different drop zone or by the longer freefall time that is common on wingsuit jumps. He was wearing a wrist-mounted visual altimeter but not an audible altimeter, which is recommended as a valuable backup device by providing reminders at several pre-assigned altitudes. However, some audible altimeters do not work during wingsuit jumps due to the slow descent rate associated with wingsuit flights. This jumper's altimeter indicated 1,000 feet above ground level when found on the scene, but the area was actually located just 100 feet higher than the DZ's landing area. The altimeter error could have resulted from its impact with the ground at a high rate of speed, or the jumper may have set it incorrectly before the skydive.

This jumper's rig was not equipped with an automatic activation device. A functioning AAD may have deployed his reserve at a safe altitude, although it is possible for a wingsuit pilot to slow his descent rate in freefall below the speed required for most AADs to activate. Skydiver's Information Manual Section 6-9 recommends that beginning wingsuit jumpers initiate deployment no lower than 5,000 feet. Additionally, SIM Section 2-1 requires that students and A-license holders deploy their main parachute no lower than 3,000 feet AGL, B-license holders by 2,500 feet, and C- and D-license holders by 2,000 feet. As with many no-pull accidents, it is difficult to find a specific cause.

Investigators found this jumper's gear with the reserve deployed, the reserve's slider all the way down to the risers and both brakes still stowed. The cutaway handle had been pulled, but the reserve ripcord handle was still attached to the harness. The main canopy had released from the harness and was found nearby, still in its deployment bag due to a bag lock malfunction. The main canopy, cutaway handle, reserve pilot chute and freebag were all found within a 20-yard radius of the jumper, which would indicate that the cutaway and reserve deployment took place at very low altitudes, likely lower than 1,000 feet above the ground. The jumper likely struck the ground before his reserve had a chance to fully inflate and slow him down to a survivable descent rate.

After deploying his main canopy, the jumper apparently experienced a bag lock malfunction; however, it's impossible to determine at what altitude he deployed his main. Investigators concluded that the jumper's automatic activation device had deployed his reserve parachute since the reserve closing loop had been cut by the unit's cutter and the reserve ripcord was still in its pocket on the main lift web of the harness. The rig was equipped with a reserve static line, but it was not connected to either riser, and it's unclear whether it was disconnected before or during the jump. Evidence at the scene indicated that the reserve canopy had inflated but did not have enough time to fully slow the jumper before he struck the ground.

Investigators could not determine at what altitude this jumper initiated main canopy deployment. Skydiver's Information Manual Section 2-1 requires that students and A-license holders deploy no lower than 3,000 feet above the ground to allow enough altitude for them to properly handle a main canopy malfunction, with minimum altitudes of 2,500 feet for B-license holders and 2,000 feet for C- and D-license holders. Section 5-1 recommends students and A-license holders decide upon and take action to initiate emergency procedures by 2,500 feet, while B- through D-license holders should do so by 1,800 feet.

Although this jumper pulled his cutaway handle at some point, it's unclear at what altitude. It's also unknown whether his AAD had already deployed his reserve while the main risers and main deployment bag were still attached or if he pulled his cutaway handle to release his main canopy before the AAD activated the reserve. The investigator did not report finding any friction burns on either canopy or line set, indicating that the main and reserve canopies most likely did not rub together during deployment and that the jumper apparently pulled his cutaway handle and released his main canopy before the AAD deployed his reserve.

If the RSL had been hooked up to the main risers, the reserve deployment may have been initiated sooner, saving precious altitude and possibly providing more time for the reserve to slow the jumper before landing. Although the AAD had cut the reserve loop, investigators did not return the unit to the manufacturer to determine what altitude the device actually activated the reserve. According to a representative from the AAD's U.S.-based service center, at least two reasons could explain the low reserve deployment in this jumper's situation: The AAD may have activated the reserve at the unit's preset altitude of 750 feet, but the reserve canopy could have experienced a hesitation during some stage of the deployment and inflation. Just a short delay in any part of the reserve deployment would be enough to make a difference between a safe descent rate and striking the ground at a high rate of speed while the reserve was still inflating. The representative suggested that another possibility was that the inflated main pilot chute and deployment bag may have provided enough drag to slow the jumper below the 78 mph descent rate required to activate the unit. If this was the case and the jumper had pulled his cutaway handle somewhere around 750 feet or slightly higher, it would have taken him a few seconds to reach the necessary speed to activate the AAD, thus initiating the reserve deployment lower than the normal activation height. Still, without the data from the unit or any witness accounts, it's impossible to determine exactly why the reserve did not have enough altitude to slow the jumper to a safe descent rate.

The jumper initially survived the landing, as indicated by the fact that he had removed his rig and was found 30 feet away from his gear. However, either no one noticed that he had not returned from the jump or people thought he had intentionally landed near his trailer where he stayed on the drop zone since it was the last jump of the day. If a skydiver doesn't plan to return to the regular landing area or packing hangar after a jump, he should tell at least one other jumper on the load his plan and make a phone call to manifest after he lands to let them know he landed uneventfully. Some drop zones use a system that requires each jumper to check in with manifest after each load, which can help the DZ determine if a jumper is missing so a search can begin immediately if necessary.

Lastly, the toxicology test conducted on the jumper following the accident indicated a positive test result for the presence of marijuana in a concentration strong enough that the lab technician said the jumper was more than likely under the influence of the drug at the time of his accident. Jumping while under the influence of drugs or alcohol has resulted in injuries and fatalities in the past and is prohibited by the FAA and USPA for good reason. Drugs and alcohol can slow reaction times and cause many other adverse reactions that can lead to skydiving injuries and fatalities.