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Final Accident Investigation Final Accident Investigation Factual Report Smith Prairie Smokejumper Fatality Smith Prairie, Idaho September 27, 2013 Table of Contents Serious Accident Investigation Team Members ................................................................................................................................ ii Delegation of Authority .................................................................................................................................................................... iv Acknowledgement ......................................................................................................................................................................................... vi Purpose .............................................................................................................................................................................................................. vii Prologue .......................................................................................................................................................................................................... viii Executive Summary ........................................................................................................................................................................................ 1 Maps ...................................................................................................................................................................................................................... 3 Investigative Process ........................................................................................................................................................................... 5 Acronyms and Glossary ...................................................................................................................................................................... 8 Photos and Sketches ....................................................................................................................................................................................12 Background ......................................................................................................................................................................................................16 Timeline .............................................................................................................................................................................................................23 Narrative ...........................................................................................................................................................................................................25 Timelines: Video and FDR/Vigil AAD Data .....................................................................................................................29 Equipment Report.........................................................................................................................................................................................31 Findings .............................................................................................................................................................................................................46 Appendix I—Human Factors Analysis .................................................................................................................................50 Appendix II—Altimeter Inspection Report ....................................................................................................................58 Appendix III—Parachute Flight Data Recorder Report .......................................................................................64 Appendix IV—Data Analysis Final Report .......................................................................................................................65 Appendix V—Vigil AAD Report ..................................................................................................................................................66 Smith Prairie Serious Accident Investigation Factual Report Page i Delegation of Authority Smith Prairie Serious Accident Investigation Factual Report Page iv Smith Prairie Serious Accident Investigation Factual Report Page v Acknowledgement The Smith Prairie Serious Accident Investigation (SAI) Team (SAIT) would like to thank the employees and leadership at the Great Basin Smokejumper Base. Their willingness to share information about the Smith Prairie incident and the tragic loss of their co-worker and friend, while difficult and emotional, will provide learning opportunities and an increased understanding of the event for use by the wildland fire and safety community to help prevent future similar accidents. The SAIT would also like to thank BLM Boise District and Dispatch; BLM National Interagency Fire Center Branch of Fire Operations; U.S. Forest Service (USFS) Audio/Visual Specialist Eric Hipke; USFS Wildland Firefighter Medical Qualifications Program Manager and Medical Officer Jennifer Symonds (D.O.); Missoula Technology Development Center Photographic Technologist Ian Grob; Sandy Reid of Rigging Innovations, Inc., who was an integral part of the team during the initial phases of the investigation; Elmore County Sheriff's and Coroner’s Offices; Ada County Sheriff's and Coroner’s Offices; Steve Greene from the Bureau of Alcohol, Tobacco, Firearms and Explosives; National Advanced Fire and Resource Institute; and Life Flight/St Luke's for their support and cooperation. This SAI was conducted in the true spirit of interagency cooperation. The USFS subject matter experts (SMEs) were an integral part of the investigation from start to finish. Other USFS smokejumper SMEs and technical specialists provided support, knowledge and expertise at different stages throughout the investigation. Smith Prairie Serious Accident Investigation Factual Report Page vi Purpose The purpose of a serious accident investigation (SAI) is accident prevention and learning—not to identify and assign blame. The objectives of the Smith Prairie SAI were to (1) present the facts about the September 27, 2013 accident that resulted in a loss of life; and (2) share the SAI team’s analysis in a way that enhances the reliability and resilience of the BLM and the smokejumper organizations across the agencies. The Smith Prairie Management Evaluation and Factual Reports are intended to provide the fire and safety community, at all levels, learning tools to prevent future accidents. Smith Prairie Serious Accident Investigation Factual Report Page vii Prologue The Smith Prairie Serious Accident Investigation is dedicated to the memory of 40-year-old Mark Urban who lost his life on September 27, 2013, while performing an extended drogue ride parachute jump for research and development purposes. Mark, along with 33 other wildland firefighters this season, paid the ultimate sacrifice during the course of wildland fire operations. May the facts detailed in this report provide other smokejumpers, wildland firefighters, managers, and others involved in wildland fire management with the information needed to reduce and manage future risks so that similar accidents are avoided and lives are saved. Smith Prairie Serious Accident Investigation Factual Report Page viii Executive Summary On September 27, 2013, Mark Urban and other jumpers from the Great Basin Smokejumpers were performing extended drogue ride parachute jumps for research and development (R&D) purposes on a remote airstrip outside of Prairie, Idaho, approximately 50 miles ESE of Boise. Mark was fatally injured when his main parachute did not deploy until 138'AGL. The R&D jumps that took place on September 27 were part of a test plan to refine operational parameters of the Vigil Automatic Activation Device (AAD) for future smokejumper use. The intent was that the testing would result in the approved use of more than one AAD for Bureau of On September 27, during an extended drogue ride for Land Management (BLM) Smokejumpers. research and development purposes, Mark Urban lost his life on this remote airstrip near Smith Prairie, Idaho, Currently, the CYPRES AAD is the only approved when his parachute began to deploy at an altitude too AAD for the BLM smokejumper reserve low to allow the main parachute to fully inflate. parachute container. Mark was the second jumper on the second plane load at Smith Prairie Airstrip that day. Mark left the door of the plane with his gear configured properly and his altimeter set to the correct altitude. Upon exit, the drogue parachute inflated fully and Mark exited in a good, tight body position and can be observed rotating to the right. At the point he leaves the camera’s view, flight data recorder analysis indicates that he slowed his rotation and then became reasonably stable relative to the other jumpers until shortly after pull altitude. At pull altitude Mark’s main parachute did not deploy. At 29 seconds he was spinning. Mark’s drogue released at 138' AGL and his main canopy achieved line stretch prior to his impact with the ground but too late to arrest his rate of descent. Mark impacted the ground and sustained fatal injuries. Following Mark’s accident, jump operations immediately terminated and emergency response was initiated. Mark’s fellow jumpers took great care to preserve and document the accident site for future investigative work by the Serious
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