vigil incidents history

VIGIL INCIDENTS HISTORY

UNTIMELY IN-AIRCRAFT ACTIVATIONS

CUTTER FAILURES

Vigil untimely in aircraft activations and cutter failures

2

INDEX

Page

Summary 3

Vigil claim of $2.2 million against Vigil developers

AAD sa lawsuit against the developers of the Vigil

4

Fatal in-plane activation Cessna P206; NTSB DEN08FA078 5

Further known in-plane activations 6-7

Vigil activation risk chart

8

Cutter failures

9-11

Conclusion 12

APPENDIXES

NTSB report # DEN08FA078 13-18

NTSB photos crash Cessna P206 19-20

Statement Vigil about in-aircraft activations 21-23

Graph crash Cessna P206 24

Restriction Vigil on door openings (Vigil Manual) 25

Announcement Lawsuit Concerning the fatal crash of April 2008 26

Vigil claim of $2.2 million against Vigil developers

27-28

FURTHER STATEMENTS AND SERVICE BULLETINS

Statement misfires 2006 29

Statement activations in pressurized aircraft 30

Forum discussion on open door restrictions when Vigil is on board 31-32

Cutter Service Bulletins 33-42


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Summary:

- During the spring and summer of 2010, a total of 6 (six) in-aircraft Vigil misfires were

reported. At the moment of activation, the planes were flying almost level. Both models Vigil 1

and Vigil 2 were concerned. AAD NV issued an official statement claiming the units did what

they were supposed to do. Similar statements are used in most other Vigil untimely activations.

- On 19 April 2008, a Cessna P206 crashed near Mount Vernon. The crash killed two

skydivers and left another skydiver and the pilot seriously injured. The aircraft stalled at 10,500

feet. The pilot was able to recover between 3000 and 2000 feet. Seconds after recovery, a

reserve parachute deployed and got entangled around the tail. The reserve parachute was

activated by a Vigil automatic activation device, estimated approximately around 1500 feet.1

- In September 2006 AAD sa sued IPSO and Alliance, the contracted developer(s) of the Vigil

AAD, for having negligently designed and manufactured their safety devices and claimed 1.6

million Euro ( 2.2 million USD). These units are in the field. AAD sa is unable or unwilling to offer

any solution. AAD did not recall these affected units. They claim that the Vigil remains to work

as designed.

The NTSB report, the recent incidents, the questionable track record and the lawsuit raises

serious doubts about the reliability and exactitude of both models of the Vigil AAD.

1 Appendix I; NTSB Final Narrative DEN08FA078:

“The skydiver whose reserve parachute had deployed and became entangled around the airplane's tail was wearing a Vigil AAD.”


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1. AAD sa lawsuit against the developers of the electronics and software of the Vigil

In September 2006 The owner of the Vigil sued the contracted developer(s) IPSO/ Alliance* and

Declerck of the Vigil AAD for having negligently designed and manufactured the Vigil. AAD sa

claims 1.6 million Euro (2.2 million USD).2

The date of the lawsuit indicates that this is a direct response upon the mass misfire at the

World Freefall Convention at Rantoul in July 2006. (Text 3.1)

In an interview during the PIA Symposium 2007 mr. Smolders, CEO of AAD sa states that he is

not planning to issue a recall despite the multiple misfires in planes and beyond.3 However, at

the same period AAD sa sues the developers for the dangerous Vigils being around.

The similar misfires with Vigil 1 & 2 prove that at crucial points the software is identical and that

the same dangerous flaws in software design are back integrated in the Vigil 2. This is also

confirmed by the statement of the project manager of AAD sa, mr Bollaerts.

The motivation to sue was that there are dangerous Vigil units out there. An extremely worrying

factor is that the users of the Vigil AADs are not informed or officially aware of this and AAD sa

is unable or unwilling to modify.

In September 2006 one of our foreign subsidiaries, Alliance International BVBA, was named in

a lawsuit in the Belgian civil courts by a Belgian customer for having allegedly negligently

designed manufactured and assembled certain safety devices. These safety devices are not

being used in our products, but were sold to a Belgian customer prior to the CLD Acquisition. The

cause of the alleged defect is unknown and is being investigated by a court appointed expert. The

damages claimed of EUR 1.6 million by the Belgian customer are currently unsubstantiated.

No court hearing is expected before the third quarter of 2008. No injury has been reported as a

consequence of the alleged defect. Although the outcome of this matter is not predictable with

assurance, management believes that the amount of any potential damages resulting from this action

would not exceed accruals and available indemnification recoverable from LSG pursuant to the

CLD acquisition agreements.

Text 3.1

*The team was responsible for manufacturing and design at least from the period 2003 -2006

2 IPSO YEARLY REPORT page 24, 25 3 Link to PIA interview of February 2007 < http://www.youtube.com/watch?v=glW9qnFQvG c>

http://www.youtube.com/watch?v=glW9qnFQvG


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2. Fatal in-plane activation - Cessna P206; NTSB Final Narrative DEN08FA078

Two skydivers killed, pilot and one skydiver seriously injured.

“ Contributing factors in this accident were the entanglement of the parachute

in the elevator control system, reducing the pilot's ability to regain control.”

“The skydiver whose reserve parachute had deployed and became entangled

around the airplane's tail was wearing a Vigil AAD”

The reserve deployed due to the activation of the Vigil AAD.

AAD S.A., the manufacturer of the Vigil, states that:

- The unit, set in PRO mode, activated at an altitude of 1097 feet as the vertical velocity was

over 79 Mph. This should be 840 feet.

- There is a 260-foot safety margin incorporated to allow for pressure differentials and body

positions, making the unit to activate at 1097 feet.

- The unit activated because the unit registered a vertical speed of 79MPH.

Airtec, manufacturer of the Cypres AAD contradict this as onboard was a skydiver equipped

with an Expert Cypres AAD.

Airtec's report to the NTSB mentioned: "The parameters for an activation were not met at any

time.

That the parameters to justify activation have been met is further questionable as:

1. Several witnesses have stated that the plane leveled out and flew when the reserve

parachute appeared. This indicates that the Vigil still activated despite the lack of significant

vertical speed.

2. The vertical speed of the plane increased after the reserve parachute appeared. (It was only

than the aircraft started to nose dive.)

3. No other devise registered anything near vertical triggering speed (Cypres, L&B).4

4. Activation altitude was 260 feet above the set parameter of 840 feet.

This lethal accident took place in 2008. The known incidents of 2010 cast a doubt about the

uniqueness of the 2008 accident and formed the proof that it could happen again anytime soon.

Several lawsuits have been introduced.5

4 Appendix 3, Fig 1.11 5 Article: Plane Crash: Parachutist Sues for Injuries: Appendix 5 < http://www.lawyersandsettlements.com/articles/10659/plane-crash-parachutist-injured.html >

http://www.lawyersandsettlements.com/articles/10659/plane-crash-parachutist-injured.html


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3. Further known in-plane activations

In the spring and summer of 2010, a total of 6 Vigils fired inside the plane or during exit. Planes

known to be involved were the Cessna 205 and the Airvan.

In August 2010, while ascending to exit altitude a Vigil activated aboard an A-Star helicopter (in

French Ecureuil). In all cases the Vigil triggered in what AAD calls “the activation zone” while the

plane flew almost level or was climbing.

2010 Type Aircraft Location

April 14 Vigil 2 Airvan Narbonne, France

April 14 Vigil 2 Airvan Narbonne, France

May 2 Vigil - ? N. Carolina, USA witnesses claim right out the door

May 8 Vigil 2 Cessna 205 Colorado, USA

May 8 Vigil 1 Cessna 205 Colorado, USA

August 6 Vigil 2 A-star Belluno, Italy left door removed (open door)

2006 Type Aircraft Location

July Vigil 1 Cessna Canada Door closed

July Vigil 1 Cessna Canada Door closed

In response to the incidents in Colorado the Vigil manufacturer, AAD SA published a statement

on 10 June 20106. The statement contains two quotes that give reason to serious concern:

Vigil statement - 10 June 2010 (appendix 2)

Quote 1 “The opening of the door alone should not have activated the cutter”. Here they clearly

admit they don‟t know the cause of these activations (Fig. 2.1)

Fig 2.1

Quote 2 “If you take off with an open door (even partially) nothing will happen because the

pressure will be equal to the outside pressure” (Fig. 2.2)7

Fig. 2.2

This last statement is since the activation in Belluno, Italy also questionable.

Vigil manual modification - 14 June 2010

6 Vigil restrictions on door openings: < http://www.dropzone.com/cgi-bin/forum/gforum.cgi?post=3876615;search_string=vigil;guest=73836783#3876615 >> 7 Appendix 2

http://www.dropzone.com/cgi-bin/forum/gforum.cgi?post=3876615;search_string=vigil;guest=73836783#3876615


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In direct contradiction to the previous statement, Vigil writes in its manual, published 4 days

after the previous statement:

“Do not open the door of the plane during the flight in the activation zone to avoid a possible

pressure variation which could result in an unexpected activation” (Fig. 2.3).8

Remark: This is direct in the bail-out altitude window

Fig. 2.3

These statements are against standard operating procedures and are dangerous. The pilot in

command should at all times be able to order to open the door for a bail-out, disregarding the

AADs.

Activation zone

Vigil‟s recommendations have consequences for all skydiving situations, disciplines and

emergency situations. The activation zone reaches from 150 feet up to 2300 feet. (Tandem

activation altitude of 2040 feet plus 260 feet margin = 2300 feet.)

Affected disciplines & jumps

The door of the aircraft cannot be opened between 150 and 2300 feet in order not to trigger the

Vigil. (Fig. 2.4). If a tandem is on board; these recommendations prohibit the following:

The release of a wind drift indicator

Accuracy jumps (classic and sports)

Hop & pops

Demonstration jumps

Static line operations

Jumpmaster leaning out of the door to check the performance of a static line

student.

Classic progression

Bail-out

Bail-out and other emergencies

When a Vigil is aboard an emergency bail out is turning into an even more hazardous event.

Opening the door between 150 and 2300 feet may involve in a parachute entanglement with the

plane‟s controls and tail. This may cause serious injury or death even to people equipped with

other brand AADs or no AADs at all.

8 Appendix 4, AAD Vigil manual page 21, revised and published on 14 June 2010


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VIGIL ACTIVATION ZONE

VIGIL TANDEM

VIGIL PRO

0

500

1000

1500

2000

2500

1

Fe

et

VIGIL TANDEM

VIGIL PRO

Fig. 2.4

*Zone where the aircraft door has to be remained closed upon the risk of a Vigil activation

• ARMING

(150 Feet> 32 sec.)

RESTRICTIONS FOR The release of a wind drift indicator

Accuracy jumps (classic and sports)

Hop & pops

Demonstration jumps

Static line operations

Jumpmaster leaning out of the door to

check the performance of a static line

student.

Classic progression

Bail-out

ACTIVATION

RISK ZONE*


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CUTTER FAILURES

4. Exploding cutters

Vigil has a long-standing history of problematic cutters and issued 4

service bulletins about it. Vigil had twice to deal with an exploding cutter.

Of one out of two exploding cutter incidents, no bulletin was issued.

In both cases a skydiver pulled the reserve manually. The cutter

activated during the opening sequence and exploded. Otherwise the

cutters would have exploded inside the reserve container. The enclosed environment would

have burned the reserve canopy severely. In both incidents the cutter blade could not move

forward and was thus unable to cut the reserve loop.

Vigil presents this as an isolated case. Both cutters exploded to design flaws at different

locations:

By the first incident this was the top (Fig 4.1, 4.2)

By the second the bottom (Fig 4.3, 4.4, 4.5)

No Service Bulletin has been issued here (Fig. 4.1, 4.2),.

Fig. 4.1 Fig. 4.2

Burn mark


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Fig. 4.3 Fig. 4.4

Fig. 4.5

Two different incidents of structural failure at different places of the cutter show that the design

is flawed and dangerous.

In service bulletin PSB 5 of 10 October 2009, Vigil states that the bottom “separated” from the

body. This is a serious understatement as actually the cutter had exploded. The photos of that

incident (Fig. 4.2) with clear burn marks speak for itself.


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5. Failing cutters

In the past Vigil issued failing cutters that were unable to cut the loop. The problem was

discovered by Strong Enterprises during a droptest, when a dummy bounced. Further testing

revealed that the propellant charge of all cutters of that batch was inadequate and all would

have failed when needed.9

9 Service Bulletin concerning failing double cutters


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6. Conclusion

1. The Vigil can activate even on level flights when it is getting nowhere near the vertical

activation speed of 78 Mph. Despite a fatal accident that killed two persons, Vigil still claims

to be the most accurate AAD ever. Its patent claims 3 criteria to activate (speed, altitude and

time). The activation at the fatal crash in 2008 and the recent in aircraft activations proves

that the Vigil can activate with altitude only and even when climbing.

2. The Vigil remains to be prone for misfires in all aircraft (non-pressurized and pressurized

alike).

3. Vigil is unable or unwilling to solve the misfires. Their answer is limited to adding extra

limitations and recommendations via the manual.

4. Vigil gives series of contradicting recommendations. E. g. Door open at take off. Door closed

at take off. (Appendix 2 and 4).

5. Vigil claims erroneously that other AADs will activate on level flight under the same

circumstances (Appendix 2). Other AAD manufacturers formerly contest this statement. An

AAD should not activate on horizontal flight.

6. The in point 3 mentioned restrictions imposes new limitations on the jump pilot in command

and do also affect skydivers not equipped with an AAD.

7. The Vigil is not suitable for instruction, accuracy, swoop, or any form of low altitude exits.

People equipped with a Vigil should not be sitting close to an aircraft door. Jump-pilots

should be properly informed about the flying restrictions when having Vigil equipped

parachutes on board. Bail-out altitude is direct in the „activation‟ zone.

8. The Vigil does interfere with the correct functioning of TSO‟d equipment such as parachutes

and type certified aircraft.

9. The use of an AAD should not change standard operating procedures and safety measures

in aircraft.

10. The company issues contradicting, dangerous and illegal advices, as if they ignore anything

regarding the aerospace safety.

11. With a Vigil, just opening the door could result in a reserve parachute/aircraft entanglement.

12. Despite a lawsuit against Alliance, the developers of the Vigil. AAD SA continues to state

that the Vigil AAD works as designed and activates as intended.

The constant denial and downplaying of their problems with untimely activations is unethical and

extremely dangerous. Disregarding all known facts Vigil remains to claim to be the most

accurate. By the vast majority of their huge number of untimely activations, Vigil states the unit

performed as designed.

Vigil knowingly sells dangerous and inaccurate AADs. Their one liner “the unit performed as

designed” versus the law suit says enough.


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*highlights added by reporter

ASF Accident Details NTSB Number: DEN08FA078

Aircraft and Flight Information

Make/Model CESSNA / 206

Tail Number N2537X

Airport N/A

Light Conditions

Day

Basic WX Conditions

VMC

Phase of Flight Descent - Uncontrolled

Narrative Type: NTSB FINAL NARRATIVE (6120.4)

Surviving skydivers said that as the airplane was climbing to the jump altitude of 10,500 feet agl, the stall warning horn sounded intermittently several times. They paid no particular attention to it because they had heard it on previous flights. When the airplane reached the jump altitude, the pilot signaled for one of the parachutists to open the door. When she did, she told the pilot that the airplane had overshot the drop zone by approximately 1 mile. As the pilot started a right turn back towards the drop zone, the stall warning horn sounded again, then the airplane "rolled off on its right wing" and entered a spin. The skydivers became disoriented and nauseated. Four skydivers managed to bail out safely, but one of them broke her right leg when she struck the right horizontal stabilizer after exiting the airplane. The reserve parachute on the fifth skydiver deployed and became entangled around the tail of the airplane. She sustained fatal injuries. The sixth skydiver was unable to exit the airplane and was found inside, fatally injured. The pilot was seriously injured. Ground witnesses reported hearing the engine RPMs decrease, then saw the airplane spinning. Somewhere between 1,000 and 5,000 feet, the airplane leveled out for a few seconds and witnesses saw a parachute wrapped around the tail. The airplane then spun or dove to the ground. Downloaded data from the onboard GPS and Automated Activation Devices worn by three of the skydivers corroborated these accounts.

Narrative Type: NTSB PRELIMINARY NARRATIVE (6120.19)

HISTORY OF FLIGHT On April 19, 2008, approximately 1615 central daylight time, a Cessna P206, N2537X, registered to and operated by Freefall Express Skydiving, Inc., and piloted by a commercial pilot, was destroyed when it struck trees and impacted terrain following an in-flight loss of


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control near Mount Vernon, Missouri. Visual meteorological conditions prevailed at the time of the accident. The skydiving flight was being conducted under the provisions of Title 14 CFR Part 91 without a flight plan. The pilot and one parachutist were seriously injured, two parachutists were fatally injured, and three parachutists were not injured. The local flight originated from the Mount Vernon Municipal Airport (2MO) approximately 1530. Written statements were received from all four surviving parachutists, and two of them were interviewed in person. The following is a summary of their accounts. As the airplane was climbing to the jump altitude of 10,500 feet agl (above ground level), the stall warning horn sounded intermittently several times. The parachutists said they paid no particular attention to it because they had heard it on previous flights. When the airplane reached the jump altitude, the pilot signaled for one of the parachutists to open the door. When she did, she told the pilot that the airplane had overshot the drop zone by approximately 1 mile. As the pilot started a right turn back towards the drop zone, the stall warning horn sounded again, then the airplane "rolled off on its right wing" and entered a spin. One parachutist wrote, "We were spinning so fast, it was difficult for me to tell what direction we were facing or in what direction we were spinning. I was holding on to the pilot's seat with my left hand, the door frame with my right hand, my head was touching the ceiling, my feet on the floor, and I was being forced to the back of the plane." A second parachutist wrote, "We were holding on to each other. I felt sick from the spinning." A third parachutist said the force of the spin pushed her against the cabin. The pilot told everyone to move aft, "to transfer our weight to the tail of the airplane." Three parachutists exited the airplane and parachuted to safety. A fourth parachutist broke her right leg when she struck the right horizontal stabilizer after exiting the airplane. Because she was disoriented, she said she activated her reserve parachute and landed safely. The reserve parachute on the fifth parachutist deployed and became entangled around the tail of the airplane. She sustained fatal injuries. The sixth parachutist was unable to exit the airplane and was found inside, fatally injured. The pilot was airlifted to Mercy St. John's Hospital in Springfield, Missouri. Seven ground witnesses submitted written statements. One witness said he heard the engine RPMs decrease, "[an] indication that the [air]plane [was] slowing down for the skydivers to jump." Then he saw the airplane "falling nose down and spinning." He said that approximately 5,000 feet, the airplane seemed to slow or stop spinning and he observed four skydivers in the sky. Approximately 3,000 feet, he noticed "a white parachute on the tail of the plane." Approximately 2,000 feet the airplane leveled out on a westerly heading and appeared to climb. Then it started "spinning and heading nose down again." Another ground witness observed the same sequence of events, but estimated the altitude of the airplane to be between 500 and 1,000 feet when she saw the fifth parachute. "It appeared to inflate and then collapse." She said the airplane made a 90 degree turn to the west and she could see the parachute was attached to the tail. "The plane then angled 45 degrees toward the ground and fell nose first." A third ground witness saw the airplane "spiraling downward, nose first, and out of control. The pilot was able to pull the plane out from the downward spiral" between 2,000 to 3,000 feet, and it appeared to climb, then "it began to spiral nose first again." That is when the witness noticed a "white reserve [para]chute caught on the tail of the plane." Another ground witness saw the airplane "in a head-down spin. The plane leveled out and flew normal for a few seconds, and then a white parachute seemed to come out beside the plane and catch on the tail. The plane then began another series of spins." She said the parachute "appeared to come put of the door and inflate beside the plane."


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PERSONNEL (CREW) INFORMATION The pilot, age 32, held a commercial pilot certificate with airplane single/multiengine land and instrument ratings, dated September 2, 2007. He also held a first class airman's medical certificate, dated October 24, 2007, with the limitation, "Must wear corrective lenses." A photostatic copy of the pilot's logbook was submitted for examination. It contained entries from July 13, 2000, to April 6, 2008. According to this document, the pilot began his flight training at Elmdale Airpark (6F4), Abilene, Texas. He made his first solo flight on October 19, 2001, and received his private pilot license on August 10, 2002. During this time, the pilot had no less than 18 lessons involving 18.2 hours of various stalls and slow flight. On November 12, 2006, the pilot enrolled in Pan Am Flight Training Academy's instrument and commercial curriculums at Deer Valley Airport (DVT), Phoenix, Arizona. The chief flight instructor failed to respond to this investigator's request for an interview. According to the pilot's logbook, he failed the instrument rating practical test on February 26, 2007, then passed it on March 14, 2007. During this time, the pilot was given no less than 6 lessons involving 7.9 hours of various stalls and slow flight. He failed the commercial multiengine practical test on July 24, 2007, then passed it on July 31, 2007. During this time, the pilot was given no less than 12 lessons involving 17.4 hours of various stalls and slow flight. He failed the commercial single-engine practical test on August 31, 2007, then passed it on September 2, 2007. During this time, the pilot was given no less than 2 lessons involving 1.9 hours of various stalls and slow flight. At no time during his training in either Abilene or Phoenix was the pilot given spin instruction. According to the various FAA practical test guides, only flight instructor applicants are required to have spun an airplane (or had a spin demonstrated). On November 15, 2007, he was given a Freefall Express Skydiving checkout in the Cessna 182. Between that date and April 5, 2008, he logged 66 hours in the Cessna 182, all of which was flying skydivers. On April 6, 2008, he flew skydivers in the Cessna P206 and logged 8.5 hours. This was the last recorded entry in his logbook. As of that date, the pilot had logged the following flight time (in hours): Total Time, 320.5 Single engine, 278.5 Multiengine, 42.0 Pilot-in-command, 222.3 Instruction received, 236.3 Night, 55.0 Actual instruments, 4.0 Simulated instruments, 73.5 Flight simulator, 30.0 Cross-country, 73.6 AIRCRAFT INFORMATION N2537X, a model P206 (s.n. P206-0037), was manufactured by the Cessna Aircraft Company, and received its FAA airworthiness certificate on December 11, 1964. It was equipped with a Continental IO-520-F-9 engine (s.n. 553089), driving a McCauley 3-blade, all-metal, constant speed propeller (m.n. D3A34C402). According to the aircraft's maintenance records, the last annual inspection of the airframe and 100-hour inspections of the engine and propeller were accomplished on May 18, 2007, at a tachometer time of 3,227.9 hours. At the time of the


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accident, the airframe and engine had accumulated 4,302.7 and 4,394.2 hours, respectively. The engine and propeller had accumulated 1,621.7 and 440.95 hours since major overhaul. According to the FAA principal airworthiness inspector who had been recently assigned to Freefall Express Skydiving, neither the engine nor the propeller were certificated for the Cessna P206. Other anomalies that were uncovered by the inspector were: A.D. 76-07-12, Bendix ignition switches, due every 100 hours, last complied with July 6, 2006, 405 hours ago A.D. 78-05-06, fuel system inspection, due every annual inspection, last complied with on July 6, 2006, 21 months ago A.D. 85-10-02, induction air box inspection, due every 100 hours, last complied with on July 6, 2006, 405 hours ago A.D. 87-20-03, seat rails, due every annual inspection, last complied with July 6, 2006, 21 months ago Other recurring inspections that had expired were the transponder, pitot-static system, encoder, and altimeter tests, and the emergency locator transmitter check (see FAA Form 1360-33, attached). METEOROLOGICAL INFORMATION The following Aviation Routine Weather Report (METAR) was recorded at Springfield-Branson Regional Airport (SGF), Springfield, Missouri, at 1552: Wind, 290 degrees at 10 knots; visibility, 10 statute miles (or greater); sky condition, few clouds at 3,500 feet; temperature, 17 degrees C.; dew point, 7 degrees C.; altimeter, 29.94 inches of mercury; remarks, sea level pressure 1038 mb. FLIGHT RECORDERS The airplane was equipped with a Garmin GPSMAP 195, which was sent to NTSB's Vehicle Recorder Division for download and analysis. According to the GPS Factual Report, 33 user defined waypoints, 8 user defined routes, and 2 tracks were recorded on April 19, 2008. The first tracklog began at 1028:06 (a previous flight) and ended at 1218:02. The second tracklog began at 1256:04 and ended at 1606.45. Approximately 1543:23, Track 02 recorded "groundspeeds above 58 mph with motion on a northerly course" over Mt. Vernon Municipal Airport. "Recorded track data indicate that the aircraft maneuvered in the immediate vicinity of the airport for approximately 18 minutes before turning to a northwesterly course. At 1601:15 recorded groundspeed began to drop below 58 mph and fluctuate between 34 mph and 78 mph. At about 1605:01, tracklog data indicates that the aircraft initiated a right hand turn to the southeast with groundspeeds well below 59 mph. At 1605:28, tracklog data indicates that the aircraft made a sharp right hand turn to the north, followed by another sharp right hand turn to the south one (1) second later. Recorded groundspeed during the next 3-4 seconds varied from 246 mph to 187 mph. Tracklog data indicates that the aircraft traveled on a southeasterly heading for the next 5-seconds at groundspeeds between 18 and 162 mph. At 1606:20, tracklog data indicates that the aircraft course changed 90 degrees in one (1) second, to a southwesterly heading. Five (5) seconds later the airplane changed 90 degrees in three (3) seconds to a


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northwesterly heading, and two (2) seconds later changed back to a southwesterly heading. The remainder of the tracklog data indicate that the aircraft entered a right turn before recording ceased 16-seconds later. The final recorded GPS location was recorded at 1606:45 and placed the airplane at N37 degrees, 04.966'; W093 degrees, 53.886'. Calculated average groundspeed and course during the last 3 seconds of recorded data were 81 mph and 226 degrees true, respectively." Most of the skydivers were wearing Automatic Activation Devices (AADs). The AAD senses freefall speed and, if exceeded, will automatically deploy the reserve parachute at a preselected altitude if the skydiver hasn't already done so or is unable to do so. AADs also record data that can be downloaded. The skydiver whose reserve parachute had deployed and became entangled around the airplane's tail was wearing a Vigil AAD. The Vigil AAD has three modes: PRO, STUDENT, and TANDEM. It was set in the PRO mode. In this mode, the reserve parachute will deploy at 840 feet (256 meters) if the freefall speed is equal to or greater than 78 mph (35 m/sec). According to the company, there is a 260-foot safety margin incorporated to allow for pressure differentials and body positions. The unit should have activated approximately 1,100 feet. Preliminary (filtered) data was graphed by Vigil USA, Deland, Florida, and the raw data was analyzed and graphed by Advanced Aerospace Designs, Vigil, Belgium. According to these graphs, maximum altitude attained was 10,223, feet. Time spent in freefall was 91 seconds, reaching a maximum speed of 101 mph. The AAD deployed the reserve parachute at 1,097 feet. The recording ended at an altitude of 155 feet. The other deceased skydiver was wearing an Cypres-USA AAD, manufactured by Airtec Safety Systems, Bad Wunnenberg, Germany, and distributed by SSK Industries, Inc., Lebanon, Ohio. The Cypres AAD will deploy the reserve parachute at 750 feet (229 meters) if the freefall speed is equal to or greater than 79 mph (35 m/sec). Two flights were recorded on an unknown date (the unit does not have a calendar function). The highest altitude recorded on the second flight, which lasted 23 minutes, was approximately 3,220 meters (10,500 feet) agl. According to Airtec's report, "The parameters for an activation were not met at any time. The unit shut itself off automatically after 14 hours total running time. The unit did not detect a vertical speed higher than 35 m/s (79 mph) below 750 feet on the second flight of the day and therefore did not activate." Since witnesses said the airplane recovered from the spin momentarily approximately 1,000 feet, this cancelled its sensing of the freefall velocity. The surviving skydiver who was seriously injured was wearing an audible altimeter "Pro Track," manufactured by L&B of Germany. It is worn on the skydiver's hemet. It is an audible altimeter and freefall computer. It gives altitude warnings and tracks the skydiver's freefall speed, freefall time, and other parameters, and creates a digital logbook. "Pro Track" data indicates the maximum altitude attained was 10,470.85 feet. Times and distances indicate the skydiver was in the descending aircraft. She exited the airplane and deployed her reserve parachute at 1,576 feet. The airplane was also equipped with an J.P. Instruments EDM 700 Engine Analyzer/Monitor. The unit was removed from the airplane's instrument panel and sent to NTSB's Vehicle Recorder Division for readout. According to graphs attached to this report, the readout included exhaust gas temperature, cylinder head temperatures, fuel flow, fuel used, oil temperature, and battery voltage parameters. The parameters were within normal operating limits throughout the flight.


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WRECKAGE AND IMPACT INFORMATION The accident site was at a location of 037 degrees, 04.955' North latitude, and 093 degrees, 53.920' West longitude, and at an elevation of 1,232 feet msl. The airplane impacted trees and terrain on a magnetic heading of 285 degrees, and came to rest in a nose down, slightly inverted attitude of approximately 105 degrees. There were chops marks on several tree limbs. Flight control cable continuity was established. The parachute lines were not binding the elevator or rudder. MEDICAL AND PATHOLOGICAL INFORMATION The pilot submitted a written statement to the effect that he had not regained cognitive skills and could not recall the accident. The statement was recorded by his wife. Neither Lawrence County or the State of Missouri requested autopsies on the two deceased skydivers. TESTS AND RESEARCH On June 19, 2008, under the supervision of the National Transportation Safety Board, the engine was successfully test run at the facilities of Teledyne Continental Motors, Mobile, Alabama. Full power was achieved and no anomalies were noted. ADDITIONAL INFORMATION N2537X was equipped with a Sportsman STOL (short takeoff and landing) kit, manufactured by Stene Aviation, Polson, Montana. The kit extends the wing leading edge cuff, adding wing area and thus reducing the stall speed and dampening stall characteristics without an attendant increase in drag. According to a company spokesman, stall speed reduction of 8 per cent (forward c.g.) to 10 per cent (aft c.g.) can be expected. According to the Cessna Aircraft Company, the clean configuration stall speed of the Cessna 206 in a wings-level attitude is 69 mph calibrated airspeed (CAS). In a 60-degree bank, the stall speed is 98 mph CAS. With the installation of the Sportsman STOL kit, the stall speeds should have been reduced to 63.48 mph (forward c.g.) and 62.1 mph (aft c.g.) CAS, respectively. In a 60-degree bank, the stall speeds should have been reduced to 90.16 mph (forward c.g.) and 88.2 mph (aft c.g.) CAS, respectively. In addition to the Federal Aviation Administration, parties to the investigation included the Cessna Aircraft Company and Teledyne Continental Motors.

Narrative Type: NTSB PROBABLE CAUSE NARRATIVE

The pilot's failure to maintain adequate airspeed, resulting in an inadvertent stall/spin. Contributing factors in this accident were the entanglement of the parachute in the elevator control system, reducing the pilot's ability to regain control.


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APPENDIX 3

Fig.1.1


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APPENDIX 4


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APPENDIX 5


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*highlights added by reporter


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APPENDIX 2

“2


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APPENDIX 3


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vigil incidents history

Documents

cutter failureshighlights

vehicle recorder

teledyne continental

static line

freefall express

maximum altitude

engine rpms

sustained