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anarkhos


Jul 26, 2013, 10:29 AM
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Re: [lena_chita] Tito Traversa [In reply to]
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lena_chita wrote:
Andrew Bisharat said it well here:

http://eveningsends.com/...tito-traversa-death/

It started out well enough, but the factual errors just kept piling up.

In reply to:
I don’t know anyone who has ever inspected a rack of quickdraws.

I have. But then when climbing a route with 4 bolts per 100 ft, you tend to consider the pro.

In reply to:
Look at the differences between the draw that is incorrectly racked, and the one that is correct. They look almost identical.

No they don't

In reply to:
I would’ve taken those draws, put them on my harness and not thought twice about it. And you know what? You would have too.

Nope

In reply to:
Of course, setting up the draws in that wrong configuration is an incredibly stupid error to have made, obviously one born of inexperience. It’s something I can’t possibly imagine anyone ever doing. Obviously the person who made this mistake looked at a properly racked draw, and tried to recreate what she or he saw. It was a horrible mistake. But it was also a freak mistake—something none of us could’ve ever predicted.

Petzl predicted it, and warned against it.

Also, how the person did this is far from obvious. IMO it was racked by someone fundamentally lacking in curiosity.

In reply to:
But this was an accident that could’ve happened to any of us...

Sorry, but nope. This wouldn't have happened to me. I may succumb to some other error, but climbing on another person's gear always involves at the very least a cursory look. I'm especially wary of brand new gear due to some experiences...

The bottom line is that like any dangerous activity like driving or shooting, experience counts the most (followed by attentiveness and intelligence/curiosity.)


bearbreeder


Jul 26, 2013, 11:40 AM
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Re: [anarkhos] Tito Traversa [In reply to]
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anarkhos wrote:

Sorry, but nope. This wouldn't have happened to me. I may succumb to some other error, but climbing on another person's gear always involves at the very least a cursory look. I'm especially wary of brand new gear due to some experiences...

"this can never happen to me" thinking is dangerous

intraweb "experts" can rant on all they want ... but if 4 trained firefighters can miss something similar that leads to a fatality ... anyone here can as well, despite any "safer than thoult" attitude



Before the rappelling attempt, four people looked at or inspected Marovich’s rappelling gear: the spotter trainee who installed the “O” ring, Marovich, and in the helicopter a spotter, and another helitack crewperson who did a “buddy check”.

Marovich fell, unarrested, shortly after stepping out onto the helicopter skid. He was pronounced deceased about 30 minutes later.


http://wildfiretoday.com/...rappelling-fatality/

Crazy


lena_chita
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Jul 26, 2013, 12:30 PM
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Re: [anarkhos] Tito Traversa [In reply to]
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anarkhos wrote:
lena_chita wrote:
Andrew Bisharat said it well here:

http://eveningsends.com/...tito-traversa-death/

It started out well enough, but the factual errors just kept piling up.

In reply to:
I don’t know anyone who has ever inspected a rack of quickdraws.

I have. But then when climbing a route with 4 bolts per 100 ft, you tend to consider the pro.

In reply to:
Look at the differences between the draw that is incorrectly racked, and the one that is correct. They look almost identical.

No they don't

In reply to:
I would’ve taken those draws, put them on my harness and not thought twice about it. And you know what? You would have too.

Nope

In reply to:
Of course, setting up the draws in that wrong configuration is an incredibly stupid error to have made, obviously one born of inexperience. It’s something I can’t possibly imagine anyone ever doing. Obviously the person who made this mistake looked at a properly racked draw, and tried to recreate what she or he saw. It was a horrible mistake. But it was also a freak mistake—something none of us could’ve ever predicted.

Petzl predicted it, and warned against it.

Also, how the person did this is far from obvious. IMO it was racked by someone fundamentally lacking in curiosity.

In reply to:
But this was an accident that could’ve happened to any of us...

Sorry, but nope. This wouldn't have happened to me. I may succumb to some other error, but climbing on another person's gear always involves at the very least a cursory look. I'm especially wary of brand new gear due to some experiences...

The bottom line is that like any dangerous activity like driving or shooting, experience counts the most (followed by attentiveness and intelligence/curiosity.)

It would be nice if you actually included the names of people you are responding to, if you are copying from multiple posts. It appears that you are responding to me, but other than the first part, I haven't actually made any of the statements you are responding to.

I do, however, think that "it can never happen to me" mentality is overly confident. I am going to do my best to make sure that I do not make a mistake like this one, or any number of similar mistakes. sure. But even the most-careful people sometimes make mistakes.


Partner rgold


Jul 26, 2013, 1:08 PM
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Re: [anarkhos] Tito Traversa [In reply to]
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Bearbreeder's post makes it abundantly clear how tenuous the claim of "this would never happen to me" really is. It isn't simply a question of checking gear, you also have to be able to spot things you have no idea you are looking for. The research cited in the report on the USFS firefighter fatality confirms that this is not something we can do easily or well.

I'd take issue with one other comment, namely the one that says Petzl predicted this, suggesting that the rigging flaw was something people should have known to look out for. I don't think it is true that Petzl knew about this before Tito's tragic accident, and here's why:

Tito died, after several days in the hospital, on July 5 according to most on-line reports. The Petzl report identifying the problem has, at the bottom, the notation PRODUCT EXPERIENCE - STRING_M90-PE-01A(100713). I believe the part in parentheses denotes (in the European style) July 10, 2013, which would be five days after Tito died. Moreover, the document says, at the beginning,

This “Product Experience” document is a supplement to the Instructions For Use, which provides feedback from field experience and tips for using your product.

Taken together, these two items suggest very strongly that Petzl was not aware of this problem and produced the "product experience" bulletin in response to Tito's accident. It would follow that this was not a known issue that anyone would have thought to check for.


Gmburns2000


Jul 26, 2013, 5:13 PM
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Re: [rgold] Tito Traversa [In reply to]
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rgold wrote:
I'd take issue with one other comment, namely the one that says Petzl predicted this, suggesting that the rigging flaw was something people should have known to look out for. I don't think it is true that Petzl knew about this before Tito's tragic accident, and here's why:

Tito died, after several days in the hospital, on July 5 according to most on-line reports. The Petzl report identifying the problem has, at the bottom, the notation PRODUCT EXPERIENCE - STRING_M90-PE-01A(100713). I believe the part in parentheses denotes (in the European style) July 10, 2013, which would be five days after Tito died. Moreover, the document says, at the beginning,

This “Product Experience” document is a supplement to the Instructions For Use, which provides feedback from field experience and tips for using your product.

Taken together, these two items suggest very strongly that Petzl was not aware of this problem and produced the "product experience" bulletin in response to Tito's accident. It would follow that this was not a known issue that anyone would have thought to check for.

Hasn't there been at least one accident similar to this in the past though? I could have sworn that someone used a draw to secure himself or herself to an anchor not knowing that the draw was only through the rubber band and the band broke.

Even if what I'm remembering is not a petzl thing (I believe it was a homemade rig to copy what petzl does), it seems to me they would have known that this could have happened based on other accidents.

I can't remember the specifics unfortunately. Sorry.


anarkhos


Jul 26, 2013, 5:17 PM
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Re: [lena_chita] Tito Traversa [In reply to]
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lena_chita wrote:
It would be nice if you actually included the names of people you are responding to, if you are copying from multiple posts. It appears that you are responding to me, but other than the first part, I haven't actually made any of the statements you are responding to.

Um, I'm only quoting the article which was linked to, not multiple people. Maybe you didn't read it?


anarkhos


Jul 26, 2013, 5:19 PM
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I happen to think this is a better article, although some have disagreed:

http://rockandice.com/lates-news/dumb-climbing

It may be a bit flippant, but the fact is accidents like these are going to increase in frequency for the mere fact of how people are being introduced to climbing: gudes and schools. It doesn't pay to advertise climbing as dangerous.


wivanoff


Jul 26, 2013, 5:28 PM
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Re: [Gmburns2000] Tito Traversa [In reply to]
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Gmburns2000 wrote:
Hasn't there been at least one accident similar to this in the past though?

This one?
http://www.rockclimbing.com/...post=2348841#2348841


bearbreeder


Jul 26, 2013, 5:30 PM
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Re: [Gmburns2000] Tito Traversa [In reply to]
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Gmburns2000 wrote:
Hasn't there been at least one accident similar to this in the past though? I could have sworn that someone used a draw to secure himself or herself to an anchor not knowing that the draw was only through the rubber band and the band broke.

Even if what I'm remembering is not a petzl thing (I believe it was a homemade rig to copy what petzl does), it seems to me they would have known that this could have happened based on other accidents.

I can't remember the specifics unfortunately. Sorry.


no that was a different type of failure ... with an open sling and a rubber band ...

MANY intrawebbers believed this was the same type of failure because no one could conceive of someone clipping ONLY the rubber keeper on a quickdraw

you can see this on the first page of this thread and others ones around the intraweb

UKclimbing perpetrated that error by posting up a video of the open sling failure in their article on Tito's accident ... not even they could conceive that someone could only clip the rubber band of a quickdraw despite quotes in the press showing that was exactly what happened

as the firefighter accident above shows ... even the best trained people have real issues preventing things that they dont know what to look for

any RCer thinking otherwise is just deluding themselves ...

Crazy


(This post was edited by bearbreeder on Jul 26, 2013, 5:32 PM)


Gmburns2000


Jul 26, 2013, 6:17 PM
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Re: [wivanoff] Tito Traversa [In reply to]
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wivanoff wrote:
Gmburns2000 wrote:
Hasn't there been at least one accident similar to this in the past though?

This one?
http://www.rockclimbing.com/...post=2348841#2348841

yeah, that's the one. she used the Petzl String on the dyneema sling and clipped to the rubber and not the sling. it's essentially the same thing: in each accident the biner was clipped directly to the biner. It's just that different draw setups were used.

I know it's not the same thing exactly, but it seems to me that these are similar enough accidents that someone at Petzl probably should have thought of it. Of course I can't say that for sure, and of course they are very unlikely to ever say that it's true. I really don't think it's so far fetched that someone who is paid to think about these things would have thought about it.

Either way, there have been two accidents now where someone used the String directly into the biner. Do we need a third to argue semantics?


Gmburns2000


Jul 26, 2013, 6:19 PM
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Re: [bearbreeder] Tito Traversa [In reply to]
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bearbreeder wrote:
Gmburns2000 wrote:
Hasn't there been at least one accident similar to this in the past though? I could have sworn that someone used a draw to secure himself or herself to an anchor not knowing that the draw was only through the rubber band and the band broke.

Even if what I'm remembering is not a petzl thing (I believe it was a homemade rig to copy what petzl does), it seems to me they would have known that this could have happened based on other accidents.

I can't remember the specifics unfortunately. Sorry.


no that was a different type of failure ... with an open sling and a rubber band ...

MANY intrawebbers believed this was the same type of failure because no one could conceive of someone clipping ONLY the rubber keeper on a quickdraw

you can see this on the first page of this thread and others ones around the intraweb

UKclimbing perpetrated that error by posting up a video of the open sling failure in their article on Tito's accident ... not even they could conceive that someone could only clip the rubber band of a quickdraw despite quotes in the press showing that was exactly what happened

as the firefighter accident above shows ... even the best trained people have real issues preventing things that they dont know what to look for

any RCer thinking otherwise is just deluding themselves ...

Crazy

I'm not arguing that accidents happen or that bad things happen to people who should know better. Of course they do. I'm a strong believer that it can happen to me. I just think that a product engineer really should be thinking about such things well in advance.


Partner rgold


Jul 26, 2013, 6:33 PM
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Gmburns2000 wrote:
Hasn't there been at least one accident similar to this in the past though? I could have sworn that someone used a draw to secure himself or herself to an anchor not knowing that the draw was only through the rubber band and the band broke.

I don't think there's been another such incident. There was indeed an incident in which a woman died when her tethers failed, but that was attributed to the use of rubber retainers with open slings. The possibility of accidentally clipping one of the open strands and thereby creating a sling that depended only on the rubber retainer has been known for a few years I think, and I believe that possibility was illustrated in a previous Petzl warning and is included in the current warning. But the open sling situation is completely different, even if the failure in both cases is the same. The major difference is that the open sling retainer failure can't happen with (properly assembled) closed-sling draws, so there would be no reason to even think about or such a failure or inspect for it in the context of a sport draw.

In any case, my response was to the claim that Petzl had "predicted" this accident, suggesting that a reasonably informed climber should have known about this danger, and I still do not think that is true.

As for the suggestions of product engineer negligence, I think they are way off the mark. There are millions of ways to misuse climbing gear, and every bit of climbing technology comes with its own unique set of fatal goofs, some of which, sadly, have yet to be discovered. The incorrect assembly of those draws, not one but eight of them, is, frankly, an inconceivable chain of errors. I don't think anyone can wrap their brains around how it could have happened, and I think the suggestion that engineers should have been thinking of ways to prevent it is ridiculous.


(This post was edited by rgold on Jul 26, 2013, 6:44 PM)


Gmburns2000


Jul 26, 2013, 6:52 PM
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rgold wrote:
Gmburns2000 wrote:
Hasn't there been at least one accident similar to this in the past though? I could have sworn that someone used a draw to secure himself or herself to an anchor not knowing that the draw was only through the rubber band and the band broke.

I don't think there's been another such incident. There was indeed an incident in which a woman died when her tethers failed, but that was attributed to the use of rubber retainers with open slings. The possibility of accidentally clipping one of the open strands and thereby creating a sling that depended only on the rubber retainer has been known for a few years I think, and I believe that possibility was illustrated in a previous Petzl warning and is included in the current warning. But the open sling situation is completely different, even if the failure in both cases is the same. The major difference is that the open sling retainer failure can't happen with (properly assembled) closed-sling draws, so there would be no reason to even think about or such a failure or inspect for it in the context of a sport draw.

In any case, my response was to the claim that Petzl had "predicted" this accident, suggesting that a reasonably informed climber should have known about this danger, and I still do not think that is true.

As for the suggestions of product engineer negligence, I think they are way off the mark. There are millions of ways to misuse climbing gear, and every bit of climbing technology comes with its own unique set of fatal goofs, some of which, sadly, have yet to be discovered. The incorrect assembly of those draws, not one but eight of them, is, frankly, an inconceivable chain of errors. I don't think anyone can wrap their brains around how it could have happened, and I think the suggestion that engineers should have been thinking of ways to prevent it is ridiculous.

Just to clarify, I agree that petzl didn't predict it. I think "predict" is too strong of a word. I also agree that climbing gear is not idiot proof, nor should products be engineered with this in mind.

However, as you said, it happened eight times. Don't know, but if someone who obviously had no clue could have assembled eight draws like this then a product engineer could have thought of it once.

My bet is that they knew the risk and didn't think it would actually happen, and that knowing the rubber wouldn't hold a fall wasn't enough of a concern to outweigh the advantages of putting it on the draw.


bearbreeder


Jul 26, 2013, 9:52 PM
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well if you want the opinion of someone in the industry ... 8a.nu had an interview with mammut about the incident

http://www.8a.nu/...x%3FArticleId%3D8689
the relevant quote at the bottom IMO

In the light of what just happened, do you think it would be better to skip the rubber strings all together, or is there any other ways to make the use of the strings more safe?

Definitely not, this would create new, probably higher risks – use a short dog bone for thicker, or with thin slings an inside rubber type (my opinion: this can still be assembled incorrectly) to avoid this problem. Never use any a fixation on open slings. And probably generally: don’t use gear from other persons. However, my perception about when failure is possible or not, changed quite a bit after this case.


the draws were owned and just purchased for a young girl according to reports ... she may well have assembled them, who knows ... its pretty hard to predict every possible failure mode that youngsters or anyone else can cause

again the cause of failure is different from the open sling situation ... in that case the sling turned onto itself

in this case the quickdraws were assembled deliberately and incorrectly ... i dont think theres every been a reported accident or warning from manufacturers on this specific type of assembly error since the start or quickdraws? ... thats likely tens if not hundred of thousands of draws and decades of climbing, not to mention millions of whippers

Gmburns2000 wrote:

My bet is that they knew the risk and didn't think it would actually happen, and that knowing the rubber wouldn't hold a fall wasn't enough of a concern to outweigh the advantages of putting it on the draw.


i wouldnt accuse petzl of poor risk management without evidence ... they are generally very good with putting out safety literature and pulling products they dont feel are "safe"

every piece of gear can be misused ... and wil be eventually i bet ... many of those warnings you see on product information literature have been learned the HARD WAY ... with people dying or getting hurt

Crazy


(This post was edited by bearbreeder on Jul 26, 2013, 10:08 PM)


curt


Jul 27, 2013, 8:48 AM
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rgold wrote:
...As for the suggestions of product engineer negligence, I think they are way off the mark. There are millions of ways to misuse climbing gear, and every bit of climbing technology comes with its own unique set of fatal goofs, some of which, sadly, have yet to be discovered. The incorrect assembly of those draws, not one but eight of them, is, frankly, an inconceivable chain of errors. I don't think anyone can wrap their brains around how it could have happened, and I think the suggestion that engineers should have been thinking of ways to prevent it is ridiculous.

"Negligence" is probably going too far, but this is clearly poor product engineering. It reminds me of the warning marks that some rope manufacturers started putting near the ends of their ropes, which were (foreseeably?) mistaken for middle-marks, with a number of tragic outcomes resulting.

Curt


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I honestly don't think it is poor product engineering, and I don't think the end-marks are a good analogy. The end marks are used and have to be recognized for what they are in the field, possibly under stressful circumstances by climbers who may be very fatigued. But no one assembles sport draws mid-pitch. You do that at your leisure, in a comfortable environment, when you have every opportunity to pay attention to what you are doing and double-check everything you've done, with the full realization that an assembly error could lead to your or a partner's death.

I just don't see why product design needs to take into account the fact that someone will, under these circumstances, assemble draws incorrectly. Yes, we know it can happen, the USFS firefighter fatality makes that clear. And of course, a child should never be alllowed to do this, surely that is the primary lesson of the tragedy. Would you jump out of a plane with a parachute packed by a twelve-year-old? One can think of other classes of people who should not be given such responsibility. But I don't think it is the job of product designers to anticipate and protect against such extreme instances of inattention and incomprehension. Climbers ought to have some responsibility for proper set-up and handling of their equipment, and I think that installing a rubber O-ring in a way that makes it a load-bearing component of a draw is firmly within the boundaries of personal responsibility.

By the way, if we stipulate that the rubber keepers are useful for sport draws and that at some point climbers will assemble their own draws, then how do you redesign this product? The fatal assembly was one that was clearly visible to anyone capable of looking at it without preconceptions. How could you make that any safer?

I think the lesson of the tragedy ought to point in a different direction, one that keeps the responsibility where it belongs and doesn't even suggest that such problems should be solved by product engineering. Things like sport draws and knotted slings should be bounce-tested before use, because simple inspection may not provide an adequate check.


marc801


Jul 27, 2013, 2:33 PM
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curt wrote:
"Negligence" is probably going too far, but this is clearly poor product engineering.
This is clearly a case of user incompetence and most definitely not "poor product engineering". That's like saying a Ferrari is poorly engineered because it doesn't float when you drive it off a road into a lake.


curt


Jul 27, 2013, 9:08 PM
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marc801 wrote:
curt wrote:
"Negligence" is probably going too far, but this is clearly poor product engineering.
This is clearly a case of user incompetence and most definitely not "poor product engineering". That's like saying a Ferrari is poorly engineered because it doesn't float when you drive it off a road into a lake.

No, it's not like that at all--unless you actually expect the Ferrari to float when you drive it into a lake.

Curt


curt


Jul 28, 2013, 3:00 PM
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rgold wrote:
I honestly don't think it is poor product engineering, and I don't think the end-marks are a good analogy. The end marks are used and have to be recognized for what they are in the field, possibly under stressful circumstances by climbers who may be very fatigued. But no one assembles sport draws mid-pitch. You do that at your leisure, in a comfortable environment, when you have every opportunity to pay attention to what you are doing and double-check everything you've done, with the full realization that an assembly error could lead to your or a partner's death.

I just don't see why product design needs to take into account the fact that someone will, under these circumstances, assemble draws incorrectly. Yes, we know it can happen, the USFS firefighter fatality makes that clear. And of course, a child should never be alllowed to do this, surely that is the primary lesson of the tragedy. Would you jump out of a plane with a parachute packed by a twelve-year-old? One can think of other classes of people who should not be given such responsibility. But I don't think it is the job of product designers to anticipate and protect against such extreme instances of inattention and incomprehension. Climbers ought to have some responsibility for proper set-up and handling of their equipment, and I think that installing a rubber O-ring in a way that makes it a load-bearing component of a draw is firmly within the boundaries of personal responsibility.

By the way, if we stipulate that the rubber keepers are useful for sport draws and that at some point climbers will assemble their own draws, then how do you redesign this product? The fatal assembly was one that was clearly visible to anyone capable of looking at it without preconceptions. How could you make that any safer?

I think the lesson of the tragedy ought to point in a different direction, one that keeps the responsibility where it belongs and doesn't even suggest that such problems should be solved by product engineering. Things like sport draws and knotted slings should be bounce-tested before use, because simple inspection may not provide an adequate check.

Well, I guess we're just going to disagree on this one. I realize that operator error was the proximate cause of this particular accident and I fully realize that engineering around all imaginable forms of product misuse and stupidity is impossible. But, when I was out climbing today I looked at several different quick draw designs--and there are some out there (with rubber keepers) that are designed such that this type of accident would be impossible.

Since this accident did happen, it's my personal opinion that Petzl and others should redesign their quick draw products so that a known failure mode is eliminated--much in the way most harness buckles these days can not fail to be doubled-back.

Curt


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Jul 28, 2013, 7:27 PM
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Re: [curt] Tito Traversa [In reply to]
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Fair enough Curt.

Hope all is well!


JasonsDrivingForce


Jul 29, 2013, 9:57 AM
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Re: [curt] Tito Traversa [In reply to]
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curt wrote:
Well, I guess we're just going to disagree on this one. I realize that operator error was the proximate cause of this particular accident and I fully realize that engineering around all imaginable forms of product misuse and stupidity is impossible. But, when I was out climbing today I looked at several different quick draw designs--and there are some out there (with rubber keepers) that are designed such that this type of accident would be impossible.

Since this accident did happen, it's my personal opinion that Petzl and others should redesign their quick draw products so that a known failure mode is eliminated--much in the way most harness buckles these days can not fail to be doubled-back.

Curt


How would patents figure into this? Is it possible that Petzl can't do it the fail-safe way because of patents? I really hope that is not the case.


marc801


Jul 29, 2013, 10:54 AM
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Re: [JasonsDrivingForce] Tito Traversa [In reply to]
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JasonsDrivingForce wrote:
curt wrote:
Well, I guess we're just going to disagree on this one. I realize that operator error was the proximate cause of this particular accident and I fully realize that engineering around all imaginable forms of product misuse and stupidity is impossible. But, when I was out climbing today I looked at several different quick draw designs--and there are some out there (with rubber keepers) that are designed such that this type of accident would be impossible.

Since this accident did happen, it's my personal opinion that Petzl and others should redesign their quick draw products so that a known failure mode is eliminated--much in the way most harness buckles these days can not fail to be doubled-back.

Curt


How would patents figure into this? Is it possible that Petzl can't do it the fail-safe way because of patents? I really hope that is not the case.
If there's this much gas pain over properly building a quickdraw and wanting a fail-safe method for something that's easier to accomplish than tying-in, maybe climbing is not a sport for you.


JimTitt


Jul 29, 2013, 11:13 AM
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Re: [JasonsDrivingForce] Tito Traversa [In reply to]
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JasonsDrivingForce wrote:
curt wrote:
Well, I guess we're just going to disagree on this one. I realize that operator error was the proximate cause of this particular accident and I fully realize that engineering around all imaginable forms of product misuse and stupidity is impossible. But, when I was out climbing today I looked at several different quick draw designs--and there are some out there (with rubber keepers) that are designed such that this type of accident would be impossible.

Since this accident did happen, it's my personal opinion that Petzl and others should redesign their quick draw products so that a known failure mode is eliminated--much in the way most harness buckles these days can not fail to be doubled-back.

Curt


How would patents figure into this? Is it possible that Petzl can't do it the fail-safe way because of patents? I really hope that is not the case.

You are confused about patents, Petzl can force another company to allow use of their patents, they have to pay but if one person had a good idea and another a crap one that is quite reasonable. Since Petzl is one of the most active patent restricting companies in the climbing industry this would be natural justice anyway.
That said I think the Petzl system is perfectly adequate and see no reason they should change to cater for blatant incompetence, there are many considerably harder tasks one must master to be a competent climber.


Syd


Jul 30, 2013, 11:03 PM
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Re: [JimTitt] Tito Traversa [In reply to]
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curt wrote:
Well, I guess we're just going to disagree on this one. I realize that operator error was the proximate cause of this particular accident and I fully realize that engineering around all imaginable forms of product misuse and stupidity is impossible. But, when I was out climbing today I looked at several different quick draw designs--and there are some out there (with rubber keepers) that are designed such that this type of accident would be impossible.

In engineering it's called "poka-yoke" ... mistake proofing.


bearbreeder


Aug 25, 2013, 5:53 PM
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http://www.dpmclimbing.com/...after-titos-accident

According to the Italian news source La Repubblica Torina, manslaughter charges have been filed after investigation into the accidental death of Tito Traversa. On July 5, the 12-year-old Italian climber died after falling approximately 40 meters from the anchors of a climbing route in Orpierre, France. Initial investigations by French authorities revealed that his quick draws were improperly assembled with the carabiners attached to the webbing by only a small rubber keeper intended to hold the carabiner in position, not bear weight.

La Republicca Torina reported on August 21 that the public prosecutor of Turin, Raffaele Guariniello, opened a case against "unknown" after a complaint filed by Tito's father. Today, the same news source reports that Guariniello has communicated with the French police that investigated the case who have confirmed that eight out of ten of Tito's quick draws were improperly assembled. After reviewing the case and interviewing witnesses, the public prosecutor has filed manslaughter charges against five people.

The owner of the company that produced the rubber keeper is charged for not including proper instructions for assembly in the packaging. The name of the company, based in Lombardy, Italy, was not included in La Repubblica's report. The owner of the gear shop that sold the rubber keepers is charged, though the Google translation of this Italian article provides an unclear cause. Either they were required by law to provide guidance in assemblage or they were required to ensure that the product came with adequate instructions for assembly. The manager of the club that organized the trip and two instructors that were on site are charged for failing to control the correct assembly of the equipment. A sixth person, a relative of the girl that lent the equipment to Tito, is still under investigation but not currently charged.


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