A twist in a main parachute line, and an additional entanglement that prevented the deployment of a reserve parachute system at the correct altitude and time, caused a Navy SEAL to fall to his death in the Hudson River off New York City last year, according to investigation documents.
Special Warfare Operator (SEAL) 1st Class Remington J. Peters struck the Hudson near Liberty State Park, N.J., during New York Fleet Week on May 28, 2017 following back-to-back malfunctions that caused him to free fall invertedly and hampered successful deployment of his reserve chute, according to a command-directed investigation obtained by Military.com through the Freedom of Information Act.
A team of six jumpers, part of the Navy's elite Leap Frogs parachute team, were set to perform at 12:00 p.m. -- three as canopy performers and three as wingsuit maneuver performers. Peters was part of the three performing wingsuit maneuvers before deploying their parachutes, the documents show.
Peters, who had performed in more than 100 Leap Frog shows, had been with the demonstration team since February 2016. He was a skilled jumper, having completed more than 600 jumps with the team, including practice jumps, and about 300 civilian jumps, according to his qualification records. He had "completed this specific type of jump, 'wingsuit flocking-flying in proximity to other wingsuiters,' approximately 150 times," the records showed, and he was up to date on his medical and fitness tests.
During the fateful jump, the canopy jumpers went first, with Peters and two team members following minutes after, exiting from a CH-53 helicopter 8,500 feet above ground level. The team performed the wingsuit demonstration successfully before deploying their main parachutes at approximately 2,500 feet.
But Peters' main parachute deployed with "a line-twist malfunction above his break handles," the investigation stated.
"As per emergency action procedures, SO1 Peters attempted to clear the malfunction and unzipped his wing suit arms to further work the malfunction, all while monitoring his altimeter," the documents said.
Peters quickly determined that standard emergency procedures -- which called for the jumper to attempt to first rotate out of the line twist -- would force him to cut away his main chute if the malfunction could not be resolved. Peters had performed a similar cutaway on the 577th jump of his career with his own equipment.
But on this jump, Peters spent about 40 seconds working to untangle his line twist.
The decision to make a cutaway should occur at around 1,800 feet, with the cutaway itself occurring at 1,600 feet, according to procedures. But per Peters' "CYPRES [Cybernetic Parachute Release System] Automatic Activation Device and Ditter Altimeter data, SO1 Peters performed the main chute cutaway at 1,300 feet," the investigation said.
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The forceful cutaway, in tandem with the descent, propelled Peters backward, placing his direction of travel downward on his back.
While falling, Peters faced with another dilemma: "As the pilot chute for the reserve deployed, the bridle, which attaches the pilot chute to the reserve canopy deployment bag, became entangled with the smoke bracket on SO1 Peters' left foot," it said.
The smoke bracket is used by wingsuit jumpers to provide "visual reference for both the public and an aid for the Drop Zone Safety Officer to easily spot and track [individuals] in the demonstration," according to the report.
Investigators said the parachute team's procedures also dictate that Peters should have conducted an "extended pause" after the main chute cutaway prior to deploying the reserve parachute, because the pause provides time for a jumper to make a "very deliberate" decision.
"Due to SO1 Peters passing the decision altitude while being carried under the canopy backward, he may have rushed to deploy his reserve in order to not sacrifice altitude for stability," the findings said.
The complex nature of his entanglement, cutting away his main chute below the standard altitude and free falling at a rapid rate while inverted all likely hastened his choices, the findings stated.
Navy parachute operations require the CYPRES 2 backup system to be set at a minimum of 1,050 feet, but by default, the system was set at an activation of 750 feet above ground level, according to the altimeter evidence.
Peters' CYPRES Expert 2 system deployed at 810 feet, despite being set at 750 feet, because the system had detected a rate of descent "higher than approximately 78 miles per hour," the report said.
"It had activated because SO1 Peters' reserve chute malfunction did not decrease his freefall speed," it said. But because the pilot chute snagged, "Immediately prior to impact, SO1 Peters' reserve parachute was still contained within its deployment bag."
Investigators determined through eyewitness testimony from fellow team members that the original twist in the main parachute line likely was caused by a "step-through malfunction," meaning the parachute container accidentally flipped through the lines as it was packed. While a canopy still may be controllable under those conditions, the malfunction "increases the severity of a potential line twist," the report stated.
This human error "cost SO1 Peters time and altitude as he worked to clear the malfunction," contributing to his death.
Naval Parachute Team chutes are inspected and repacked every 180 days as a precaution. The report did not disclose who packed Peters' reserve chute, other that it was certified and "in-date." Each member of the Leap Frogs packs his own supplies the day of a demonstration, it said.
But the main cause of the fatality was the failure for the reserve system to properly deploy.
"The deployment of the reserve [system] prior to attaining a stable body position placed the smoke bracket in a position to become entangled and directly caused SO1 Peters' death," it stated.
The Navy is working through ways to prevent such a case from happening again, according to the report. For example, officials are alerting units that smoke brackets could snag on uniforms, making it harder to conduct emergency parachute procedures.
While human error -- i.e. packing of Peters' equipment -- played a role, investigators said Peters' death "occurred in the line of duty and was not due to misconduct."
Peters was pulled from the water by the U.S. Coast Guard and pronounced dead at 1:10 p.m.at Jersey City Medical Center from blunt force trauma, according to the coroner's report.
"My deepest sympathy extends to all who loved SO1 Peters," wrote Vice Adm. Tim Szymanski, one of the approving authorities of the report. "His service to our nation will not be forgotten," said Szymanski, who, at the time of the accident, was a rear admiral and commander of Naval Special Warfare Command.
Peters enlisted in the Navy in 2008 and had deployed to both Iraq and Afghanistan. A native of Grand Junction, Colorado, Peters was 27 when he died.