Kristin Czyz

[mknutson]

Kristin Renee

Date: May 13, 2016 Nationality: Canadian
Object Type: Span
Location: Perrine Bridge, Idaho, USA
COD: Impact (PC hang-up)
Clothes / Suit: Normal Clothes
Equipment: Black Jack (220^ ?), Morpheus container
Age: 34
Experience: 40 jumps (5 the day of incident)
Time of day: 6:17pm


Description:

SEE REPORT BELOW

* If anyone has additional information, and images we can use for this entry, please contact us.

http://www.cbc.ca/news/canada/calgar...dent-1.3596022
http://www.cbc.ca/news/canada/calgar...gary-1.3582894
http://www.cbc.ca/news/canada/calgar...ered-1.3583316


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BFL

[mknutson]

Incident Report Kristin Renee Czyz (BFL-283)

http://www.blincmagazine.com/forum/wiki/Kristin_Czyz

To whom it may concern,


I'm writing this incident report to detail the facts as well as a few theories about the nature of this incident.

My intention is to be able to learn from the mistakes and also shed light on possible scenarios regarding this incident in hope to help others.

The facts:

1. Kristen had spent several days at the base-jumping gathering in Las Vegas. It is unclear how much (if any) affect this engagement caused Kristin to suffer fatigue. It is certainly possible due to the fact that on May 12, she joined some friends that drove from Las Vegas to Twin Falls. This drive is roughly 7 to 8 hours.
2. Kristen had 35 jumps prior to May 13.
3. Kristin performed five jumps on May 13.
4. The fatality occurred on Kristin’s fifth jump of the day
a. There were approximately 15 jumpers and 4 to 6 spectators on the top of the bridge.
b. There were approximately 10 to 15 jumpers and spectators on the side of the bridge as well.
c. Kristin was the third or fourth jumper to jump out of everyone at the top.
d. Kristin took a very soft 1-second delay appeared to deploy her pilot chute yet there was no immediate canopy extraction.
e. Kristin appeared to be struggling with the issue of no canopy extraction, and when impacting the water most of the physical damage was to her left side depicting she was fighting to clear the issue, and rotating to her right side to attempt to clear the issue at hand.
5. A preliminary examination of the equipment was performed on scene/afterward
a. There was extensive and damage to the plastic helmet Kristin was wearing. There were several large cracks on the left side of the helmet, depicting the impact was mostly on her left side.
b. The pins on her rig were pulled slightly before impact with the water. This is confirmed by inspection of the pins and closing loops. There was no damage or bending or fraying that would have been presence if the pins were closed on impact.
c. The tailgate on her canopy was fully engaged at time of canopy of the inspection. Which was approximately one hour after the incident.
6. The incident occurred at exactly 6:17 PM.

Notes from witnesses:

1. It was noted by several jumpers that Kristin appeared to be in a hurry to make her jump. It was also noted that she did not state clearly she was jumping, she just climbed on the rail and left.
2. It was observed that her bridle was routed from her pin to the PC and the "tucked" under the right side flap between her pin and PC was long and inadvertently got stuck behind the large corner flap on the rig. (With a tight pack job, that would have prevented proper extraction and result in a bridle entrapment.)
3. It was observed that her PC was packed with the mesh and bridle deep in her PC because just before she jumped.
4. It was observed that her PC vent (sticking out of her BOC) was loose, sloppy and through the vent mesh on the hat, could see it empty as the mesh and bridle were stuffed in the BOC deep.
5. It was noted that Kristin appeared to be struggling to clear an issue to get her canopy to extract.
6. It was noted that at least part of the canopy was out of the container just prior to impact.
7. It was noted to appear that her pilot chute appeared to be out but in-tow, but only 2-3 feet off her back.

Notable findings from the gear inspection:

I was on the top of the bridge preparing to jump when this incident occurred. I immediately jumped after her incident to see if I could assist in any way.

By the time I got to the bottom then ran to the water's edge, Kristin was already on the boat heading to the dock.

The gear was inspected approximately one hour after the incident. Here are some notable photos that were taken during the inspection.

There was no major damage to the bridle, but it was noted there was some wear that could have been from a soft-hang-up.

Tailgate was still engaged:


Zipper on LEFT leg at Saddlebag: (not the flat zipper head attachment. Some zippers are rounded, this one is flat and square, and could cause a potential snag point


Zipper on RIGHT leg at Saddlebag. Note the zipper head is broken, and there is no sign tarnish, nor corrosion/oxidation.


REFERENCE ONLY (example of saddlebags on rig. This example was NOT the same rig Kristin was using):


REFERENCE ONLY (example of saddlebags on rig. This example was NOT the same rig Kristin was using):


REFERENCE ONLY (example of saddlebags on rig. This example was NOT the same rig Kristin was using):


Pilot chute was examined and was in excellent condition except for this one rip. There was no other damage at all.




Theories:

This report discusses a series of theories based on the facts as well as the gear inspection. I will also go through some witness notes.
Pilot Chute hang-up:
It an opinion that Kristin was a fairly in-experienced jumper and notably in a hurry to make as many jumps as possible. It is possible she might have been fatigued and during her jump executed a poor pilot chute extraction.

This gave the ability for her pilot chute to get caught on her right leg saddlebag yet all of her bridal was out of the BOC. She fought diligently to clear this issue and slightly before impact with the water, the pilot chute freed from the snag, and started the canopy extraction and she impacted with virtually nothing out to slow fall.

This is backed up by the notable damage mostly to her left side. Specifically, there was extensive damage to the left side of her helmet, and massive trauma to her left leg.

Notes about pilot chute in-tow theory:
It was noted by several accounts that it appeared that there was a pilot chute in-tow, but the pilot chute appeared to have some issue as only allowing partial inflation.

There was no major damage or issue with the pilot-chute inspection or problem with the bridal or bridal routing. There was some wear that could have been an indication of a soft hang-up. Thus it is a suggestion by me, that Kristin has a weak pull of her pilot chute. The entire contents were extracted, and all of the bridal was out of the BOC, yet the pilot chute was never inflated during the majority of the free-fall due to being snagged on the saddlebag zipper.

It is suggested that her large mesh catching on the zipper from an open saddle bag added further issue because she extracted at approximately 1-second of delay, then pulled hard enough to rip the large mesh and break the zipper hook to clear the PC. That was good, but the early toss and the drag from that hang up further decreased the snatch force that the PC inflation is supposed to have with proper execution, and insured that the bridle stayed pinned under the large corner flap, never reaching full bridle stretch or translating to the pin.

Theory the zipper was already broken, prior to this jump.
It has been stated after this incident, that the zipper in question was already broken prior Kristin jumping the rig.
Also, several witnesses heard the rip.

From pictures that I took during the gear inspection this does not seem to be the case. The pictures clearly depict raw aluminum with no corrosion or oxidation. This does not appear to me to be consistent with the wear and tear that gear would be subject to.

However, if this is the case then it does not explain the tear in the pilot-chute, nor does it explain why so much effort was taken to clear a malfunction leading Kristin to roll onto her left side in attempts to clear the issue. A pilot chute in-tow, as 4-5 second delay, could also help to induce this rotation.

But the zipper hang-up, is only one of many factors that are in-play with this incident.

Theory the pilot chute was hung up on shoes or clothes.
I was not able to inspect any of Kristin’s clothes or footwear. However it is very possible that the pilot-chute or bridal was hung up on her boots or some other article of clothing. This would still be a contributing factor to a delayed pilot chute opening and subsequent canopy extraction.

Theory the bridle was misrouted.
It is been suggested there was a bridal miss-route. I do not believe this to be the case because before impact there was at least partial canopy extraction. This is confirmed by the fact there was no damage to the pins, or is a lot of work the closing loops that would have occurred if the impact would've still had a closed container. Witnesses have also confirmed at least a partial canopy was extracted prior to impact.
Final Note:
On one final note I want to be clear that several of the potential causes that have been proposed here are an educated guess based on images and eyewitness accounts. There was neither video nor still photos taken of the jump itself thus there is limited information to be able to make a 100% conclusive determination.

I specifically left out names of other witnesses and am convinced this was not an issue of faulty gear.

At the end of the day this was still a jumper mistake and several factors went into a combination of issues that resulted in canopy extraction that was too late to be able to slow the free-fall prior to impact.

One specific note I believe is very important that still had some bearing on this incident was the mental and physical state of the jumper when this incident occurred. It is very important for every jumper to understand the ramifications that fatigue has on the human body. This can certainly lead to a slowing of mental and motor skills that can hamper our ability to make quick rational decisions during emergency situations, even when deciding to make a jump.

To summarize:
1. Check your Pilot-chute and bridle routing
2. Check for any and all snag points (shoes, zippers etc.)
3. Note that saddlebags were designed by the manufacturers for long hikes with tracking or wing suits. They still have snag points thus in a slider down jump scenario they can introduce a delay in which the jumper has little or no time to correct such an incident.
4. Take time to debrief each and every jump, even if the debrief is with yourself.
5. SLOW DOWN! Take your time! Don’t be in such a hurry!

Know your limits !!!
Thank you for your time and attention that I welcome feedback on this report.

Mick Knutson
BLiNC Magazine
http://www.blincmagazine.com/forum/w..._Fatality_List