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Analysis of fatal accident in Joshua Tree 3/15/09
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jt512


Apr 5, 2009, 8:51 PM
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Analysis of fatal accident in Joshua Tree 3/15/09
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[This accident was originally reported here. However, the facts of the accident should be reported at the start of the thread, not buried on Page 4. Hence, I am starting a new thread with a factual summary of the accident.]

[Edit to add:] Summary of accident posted by Al Kwok later in this thread.

The following post by Clint Cummings, copied verbatim from supertopo.com, is the best factual summary of the accident posted to date.
    "1. Woody Stark led a 100' climb on The Great Burrito formation (Real Hidden Valley). He placed an anchor on top.

    "2. Al Kwok followed the climb, trailing a second rope for the third person (Wendell Smith). The second rope was attached to the back of his harness.

    "3. 65' (approx.) of slack in the second rope was pulled up, to prepare for belaying Smith, and a knot was tied in the second rope at this point (65/100). This knot was clipped to the anchor by Stark. Smith was tied into the second rope at this time.

    "4. Before Smith started climbing, Stark requested that Kwok lower him to the ground. At this point, Kwok probably believed that the second rope anchored him closely to the belay anchor, but there was in reality 65' of slack in between.

    "5. Kwok began lowering Stark. [Edit:] After Kwok had lowered Stark about 35', Kwok probably shifted his weight forward, expecting to be held by the second rope. Due to the slack in the second rope, Kwok kept moving forward and fell along with Stark.

    "6. Kwok fell 65' (approx.) and was held by the second rope at this point (the haul loop on the back of his harness was strong enough). [Edit:] During the 65' fall, Kwok did not lose control of the lowering device. Stark fell 100' total to the ground, receiving a fatal head injury.

    "7. Smith untied Stark from the lead line, to relieve pressure on Kwok."

Additional references from supertopo.com:
Various clarifications to TGT's post by "Locker," a close friend of Woody:

Jay


(This post was edited by jt512 on Apr 8, 2009, 4:39 PM)


potreroed


Apr 5, 2009, 9:14 PM
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Re: [jt512] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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This is another sad reminder that no matter how experienced you may be you can still make a fatal mistake by assuming that something is so that isn't so. Be careful out there and don't assume anything--take the time and effort to check and double-check.


Dirka


Apr 5, 2009, 10:14 PM
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Re: [potreroed] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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Very sorry about all this. Stay safe. Double check each other!

R.I.P.


asellers98


Apr 6, 2009, 12:24 AM
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patto


Apr 6, 2009, 3:32 AM
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Re: [jt512] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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Great summary jt512. Thanks! Smile

(Interpretting Locker's posts in particular is quite trying. His excessive use of capitals make him sound aggressive, though I'm starting to think that is just his style)

In terms of 'Analysis' I don't know how much can be discussed, basic safety at anchors doesn't seem to be adhered to. What surprises me is that Al was never made safe before being taken off belay. Surely that is the first thing you do when you reach ANY anchor. And I'm sure we all know the problems associated with lowering.

Mistakes were made. RIP Woody.


billl7


Apr 6, 2009, 4:57 AM
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Re: [asellers98] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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asellers98 wrote:
I am curious, I didn't see the time of day of the accident? Was it fatigue, rushing, or was the anchor rig hidden by the way they drapped the rope slack?
A comment in one of the ST.com threads indicates that rushing was a factor and that daylight was not an issue.

Bill


(This post was edited by billl7 on Apr 6, 2009, 5:14 AM)


king_rat


Apr 6, 2009, 5:55 AM
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Re: [jt512] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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I find this kind of accident both very sad and very scary. I can think of a number of occasions where I have done similar things, (thought I was tied in when I was not, or thought I was on belay when I was not), but luckly i have allways caught myslef in time. It is scarily easy to make this kind of mistake. This kind of accident should remind us to check and double check both ourselves and those who climb with us.


scrapedape


Apr 6, 2009, 6:20 AM
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Re: [patto] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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There doesn't seem to be a lot that can be learned from the specifics of this accident, other than the importance of being constantly attentive to your and your partners' safety systems.

This report also offers a reminder of the added complexity that comes with adding a third climber to the party.


dingus


Apr 6, 2009, 7:59 AM
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Re: [scrapedape] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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I'd suggest there is alot to learn from this accident.

Most of us have "I almost got it today' stories. I'm sure Woody Stark had a pile of em bigger'n most - he climbed pretty hard for 40 years.

Complacency in dangerous industrial or military environments is deadly. This has been proved over and over and over. In those settings, the workers religiously use and adhere to safety protocols and checklists. It has again been proven repetitively, that these safety rituals save lives.

Yes we all have close calls sooner or later. And we all will be rushing along at some point, to make matters potentially worse.

Reinforce the rituals. Make these habits so ingrained that it is literally taboo to ignore them.

"What? You didn't check your partner's knot? What, are you sleeping with your daughter too???"

Even still, what happened to Woody could happen to one of us too. Climbing is a complicated rig played out in a deadly environment, for free. No one is paying us to be rigorous with our safety procedures.

Cheers
DMT


curt


Apr 6, 2009, 8:20 AM
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Re: [dingus] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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Dingus, I agree. Also, most climbing accidents can be attributed to "something silly" being done by one or more of the parties involved. I suppose it's not so different from airline disasters, where "pilot error" is the most usual cause. In both cases the equipment has become so reliable that human error (apart from much more rare objective dangers) ends up being the weak link.

Curt


scrapedape


Apr 6, 2009, 9:13 AM
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Re: [dingus] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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DMT,

I realize I was being unclear. I totally agree with what you are saying.
My point is that no single thing that they did was especially unsafe. There is no lesson analogous to "such and such knot is dangerous," or "don't thread your grigri backwards." That's what I meant by saying there's little to learn from the specifics.

It was complacency, plain and simple, that was the problem here. That is a big reminder for all of us.


moose_droppings


Apr 6, 2009, 9:24 AM
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Re: [jt512] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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Again I'd like to restate my condolences to the family and and all close to him.

Maybe we could start a simple universal checklist much like pilots use before they can take off. Someone could come up with a good acronym that is taught and ingrained into every climber to the point that no matter who you climb with its automatic to go through the acronym. Something like:
C-check your knots
H-help check your partners knots
A-are all anchored properly
D-double check everything.

I'm not advocating to use CHAD, just tossing it out there as an idea. Then everyone, instructors included, starts teaching such an acronym as a rule that before you can climb you must do a universal checklist to be used every time two or more people starts a pitch or meets at a belay, you will run through such an acronym religiously. I know we should should do checks all the time anyway and that vigilance should be second nature, but unfortunately its not. If everyone had to do it verbally with each other and check off every letter of an acronym with a partner each time, it may make it less likely to to start becoming complacent with some of our rituals.

It might not fly as climbers on the whole don't like rules, but would it be worth a try? Any other ideas?
Complacency is not an option, any help deterring it should be.


majid_sabet


Apr 6, 2009, 9:28 AM
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Re: [jt512] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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very confusing report.someone needs to rewrite the entire report like how its done for ANAM..


notapplicable


Apr 6, 2009, 9:29 AM
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Re: [asellers98] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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asellers98 wrote:
(NOT PART OF THE ACCIDENT-->)?Using the wrong device for the same lowering situation. A regular ATC, instead of an ATC guide/reverso/etc in this situation had you lost your stance and fell over the edge, rendering the lockoff unlikely. So even if there was only 10 feet of slack, you may have lost control of the belay.

etc.

A regular (non-autolocking) tube style device is not the "wrong device" for lowering a climber.


billl7


Apr 6, 2009, 11:13 AM
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Re: [dingus] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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The obvious possibility is that both persons missed that the anchor person was not really anchored. A possible variation on this is that the person being lowered expected to be lowered solely from a stance but the other not. Perhaps a partner of Woody's would know of the likelihood.

I have lowered a person from a stance for shorter distances. And I do not care to discuss in this thread the merits of lowering from a stance.

Still, it is possible that the accident might highlight a mismatch in expectations.

Edit: This 'stance' idea now seems even more unlikely given information provided later in this thread - namely, anchor reconfiguration and weight difference between the persons.

Bill L


(This post was edited by billl7 on Apr 6, 2009, 7:51 PM)


dingus


Apr 6, 2009, 11:30 AM
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Re: [jt512] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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I couldn't read or understand what was posted on the taco Jay. I tried but there is too much emotion in those threads and I can't deal with that AND an analysis at the same time.

Thanks for pulling this out.

The only other thing I would add is this:

Personally I am shocked by this accident. Literally shocked. In one breath I say to myself this certainly could have happened to me and mine a few times over the years.

Woody Stark was known for his bold leads. And it was clear to me at least that even into retirement he still climbed hard and more to point, he still climbed BOLDLY.

So I would not have been surprised had he perished in a lead fall. I certainly assumed that, as did plenty of others. That he died from a lowering-off accident ought to really be a wake up call for me and hopefully others as well.

To borrow a Ray Bradbury - its sorta like finding out the Romans died of atheletes foot.

DMT


sspssp


Apr 6, 2009, 11:42 AM
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Re: [scrapedape] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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scrapedape wrote:
There doesn't seem to be a lot that can be learned from the specifics of this accident, other than the importance of being constantly attentive to your and your partners' safety systems.

I also disagree with this. In addition to being attentive, I think this shows that climbers should develop the habbit of "pull testing". For instance, before rapping or lowering someone off your waist, yank on the rope (or sling) that you think is attached to the anchor and see if is. In particular, it seems a little odd that the climber didn't check this because even if he had been clipped in "short" he had no idea how short. It shouldn't have been fatal, but it could have been unpleasant even if there was 3 or 4 more feet of slack than he realized. Or maybe he wasn't really expecting to weight his "anchor" rope, but instead unexpectantly got pulled forward.

Another "pull test". I would like to suggest that climbers get in the habbit of yarding on the lead rope after putting it in their grigri (or other auto-locking). This would reduce the chance of belaying someone with the rope fed the wrong way. And it also gives you a heads up on how easily the rope will catch.

Good habbits (pull test before relying on it), and learning from other's unfortunate mistakes, can help prevent future accidents.


(This post was edited by sspssp on Apr 6, 2009, 11:47 AM)


vivalargo


Apr 6, 2009, 3:13 PM
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Re: [jt512] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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He wrote:
"
My point is that no single thing that they did was especially unsafe."

I think this statement could only come as a result of the partial accident report that is going around - and that's not to say it's anyone's fault, but the details are lacking.

Actually, both the leader and belayer did a few things that were not only sketchy but totally out of the norm, precedure wise.

Most obvious, the belayer failed to tie into the anchor before trying to lower (directly off his waist - a basically unheard of prcedure) a person who outweighted him by 60 plus pounds.

JL


majid_sabet


Apr 6, 2009, 3:44 PM
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Re: [sspssp] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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sspssp wrote:
scrapedape wrote:
There doesn't seem to be a lot that can be learned from the specifics of this accident, other than the importance of being constantly attentive to your and your partners' safety systems.

I also disagree with this. In addition to being attentive, I think this shows that climbers should develop the habbit of "pull testing". For instance, before rapping or lowering someone off your waist, yank on the rope (or sling) that you think is attached to the anchor and see if is. In particular, it seems a little odd that the climber didn't check this because even if he had been clipped in "short" he had no idea how short. It shouldn't have been fatal, but it could have been unpleasant even if there was 3 or 4 more feet of slack than he realized. Or maybe he wasn't really expecting to weight his "anchor" rope, but instead unexpectantly got pulled forward.

Another "pull test". I would like to suggest that climbers get in the habbit of yarding on the lead rope after putting it in their grigri (or other auto-locking). This would reduce the chance of belaying someone with the rope fed the wrong way. And it also gives you a heads up on how easily the rope will catch.

Good habbits (pull test before relying on it), and learning from other's unfortunate mistakes, can help prevent future accidents.


(This post was edited by majid_sabet on Apr 6, 2009, 5:19 PM)


snowey


Apr 6, 2009, 4:28 PM
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Re: [vivalargo] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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vivalargo wrote:
Most obvious, the belayer failed to tie into the anchor before trying to lower (directly off his waist - a basically unheard of prcedure) a person who outweighted him by 60 plus pounds.
JL

Although you are right in that we usually tie into the anchor immediately upon reaching the belay, I think their behavior is not out of the norm at Joshua Tree. When topping out on a climb at Josh with a perfectly flat top out (as was the case here) I am not convinced that everybody immediately ties into an anchor. This is especially true if there is a walkoff from the climb.
When I am at Josh and I reach the belay at the top of a climb I usually just move away from the edge, say that I am safe and untie from the rope to start preparing for a walkoff. I can see how this "standard" Josh procedure might have contributed to this accident.

It IS a break in procedure, however, to not tie into the anchor before lowering someone.

RIP Woody.


(This post was edited by snowey on Apr 6, 2009, 4:31 PM)


asellers98


Apr 6, 2009, 5:27 PM
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vivalargo


Apr 6, 2009, 5:49 PM
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Re: [asellers98] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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I wonder why the leader (WS) didn't secure the lead rope to the anchor and rap off, instead of having the much lighter (125 lb.) belayer try and lower him to the ground directly off his waist - a pretty much unheard of descent tactic (this basically only happens when someone seconding a pitch cannot follow and the leader must lower him to the deck or the belay below).

Another factor which possibly saved the belayers life (gathered from what the belayer told me) is that when said belayer got to the top, the leader let it be known that he was not especially pleased with the anchor. Using a piece of gear cleaned from the pitch just climbed, the belayer added a third piece to the two piece anchor, and equalized the whole set up as well. Note also that this equalized, three piece anchor was set in a horzontal crack.

I consider it fortunate that such an anchor withheld a 70 airball whipper. In my experience, anchors set in horizontal cracks - in grainly Josh rock, to boot - are much more prone to rip when shock loaded than are anchors that are vertically aligned (set up to withstand downward, rather than outward, forces).

JL


(This post was edited by vivalargo on Apr 6, 2009, 5:50 PM)


mojomonkey


Apr 6, 2009, 5:55 PM
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Re: [jt512] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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I am having trouble visualizing one aspect of the accident. After lowering Stark some distance, Kwok fell the distance of his long tie in. He was held by his haul loop tie in. Was Stark on the ground after the fall, or still above it? The write up says Stark hit the ground, but also that Smith untied him because he was exerting pressure on Kwok. Perhaps the distances and rope stretch worked out such that he was on the ground and only lightly weighting the rope. It seems it would be hard to untie if there were much weight on the line. And is there a reason Kwok couldn't/didn't just release the belay to relieve pressure? (Maybe as simple as shock)

Also, can someone give a brief description of the climb / lowering line? Face/slab/vertical? Would Stark have hit anything on the way down?


notapplicable


Apr 6, 2009, 6:23 PM
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Re: [vivalargo] Analysis of fatal accident in Joshua Tree 3/15/09 [In reply to]
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vivalargo wrote:
Another factor which possibly saved the belayers life (gathered from what the belayer told me) is that when said belayer got to the top, the leader let it be known that he was not especially pleased with the anchor. Using a piece of gear cleaned from the pitch just climbed, the belayer added a third piece to the two piece anchor, and equalized the whole set up as well. Note also that this equalized, three piece anchor was set in a horzontal crack.


JL

Based on the original report, I got the impression that Kwok assumed Stark had anchored him to the belay and Stark assumed Kwok had anchored himself in. Given what you just said, it is very strange that Kwok rebuilt the entire anchor and didn't realize he was not adequately attached to the power point. Perhaps he did realize it and simply forgot to attach himself after completing his rebuild of the anchor.

It happens all to easily and I've done something very similar myself. Luckily I walked away with just a broken arm and a severely bruised ego. Unfortunately Woody was not so lucky.


vivalargo


Apr 6, 2009, 6:47 PM
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Bryan wrote: "Given what you just said, it is very strange that Kwok rebuilt the entire anchor and didn't realize he was not adequately attached to the power point. Perhaps he did realize it and simply forgot to attach himself after completing his rebuild of the anchor."

Hard to imagine taking the time to rebuild an anchor, equalizing it, then not tying in. But my sense of this is that the belayer felt rushed - and when pressure is applied to any of us, we can start spacing out even the most obvious things (in retrospect).

All in all this is a totally bizarre accident, including the surreal way that the facts were kept private and only partially disclosed, how the disclosure of an "accident report" was mixed with emotional confessionals from friends and next of kin, blaming and taking sides on what should and should not be said, and when it should be said, and lastly, the confusing medly of oversights that led to the accident.

I'm afraid that the only thing we may take away from all this - and it is significant - is: never rush.

JL

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