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Mistakes + Synergy = DEATH
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passthepitonspete


Jan 22, 2002, 5:44 AM
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Mistakes + Synergy = DEATH
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Less than a year ago, I read about a chap named Joe Ivy who died in fall in a cave in Texas while attempting an aid climb.

As I read the article, a mixture of emotions overwhelmed me.

The first feeling was a combination of amazement, outrage and shock - this guy was an accident waiting to happen! I couldn't help but think, how could he have been so frickin' STUPID?!

Insensitive? Undoubtedly! But that was my gut reaction.

The next feeling was one of helplessness - if only I - Dr. Piton, or someone like me with a reasonable amount of rock climbing experience had been there, then that someone could have saved him from his mistakes. I read the accident report with a lot of head shaking.

I was finally left with a feeling of sadness, because he paid the ultimate price for his own mistakes.

What killed Joe was not so much any single fatal mistake, but rather a combination of "small" mistakes. While it is unlikely that any one of these "small" mistakes was serious enough to have killed him, their summation surely was.

There was a time when I was caving where I nearly died in a flooded passage. It was the same story - a bunch of stupid "little" mistakes very nearly did me in.

Before you read any further, may I ask you to please click here to read where Dr. Piton NEARLY DIES in a cave! This is highly relevant to the rest of this post, and you will "get it" much better if you read where *I* nearly blew it.



Mathematicians and engineers have a term for this effect, whereby the whole is greater than the sum of the individual parts.

We call it "Synergy"

If you ever end up dying while you are climbing, chances are you did more than one thing wrong. For instance, if you were to die by rappelling off the end of your rope, there was a probably a synergistic effect which included such things as you being tired, your failing to double check your anchors, and so on.

You could also be too stupid to be a climber.

Please note that not everyone is cut out for this sort of stuff, eh? Just because you can pull down hard in the gym does not mean you belong in the mountains.

Even Scuffy the Tugboat knew that he belonged in a bathtub, though it took him a near death experience to figure it out!

If you are like Scuffy the Tugboat, then maybe you should go home now, before you end up dead.

Dr. Piton strongly endorses NOT ending up dead. Perhaps you really belong someplace like this, and you should consider staying away from places like these.

It might be a better idea for you to simply stay at home and look at the pictures. Note that the dude who took that last photo is quite dead, because he blew it.

[ This Message was edited by: passthepitonspete on 2002-11-13 15:10 ]


passthepitonspete


Jan 22, 2002, 6:11 AM
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Even death by objective danger such as storm, avalanche or altitude sickness may be more than merely a case of "bad luck."

Did you ignore the weather forecast? Did you cross beneath that serac at the wrong time of day because you were too lazy to get up early? Did you fail to properly acclimatize?

When you start adding up mistakes, the synergistic effect may kill you!

At the bottom of this post, you will find the link to the accident report on the death of Joe Ivy.

I would like you to read it, and I would like you to think. The purpose of your homework assignment from Dr. Piton is so that YOU do not end up like Joe.

I would like each of you to phrase your answer along the following lines. If a Hoser like Alex Trebec can teach you Merricans how to phrase your answer in the form of a question, then surely a Hoser like me can get yous guys to like answer this way, eh?

Use some bold text and answer it as I have done below. Let's try to apply some craft to our writing, eh?

At least one of you will have to hunt down on the internet and tell us all about a Kong Slyde.




Please read the article. After you are finished reading it, read it again. Then think hard.

Tell us how you felt when you read it.

Then tell us all ONE [and]only one!] mistake that contributed to Joe's death, and what you in your wisdom and climbing experience would have done differently.

When I say one thing, it could be a technical point, a systems point, a way of thinking, an attitude. There might be a dozen things wrong that we can find here.

I ask each of you to point out only one thing in order to make you think, and in order to involve as many people as possible. I could simply tell you, but you would not learn so much.

The idea behind this is so that you can learn the easy way, from someone else's experience, rather than learn the hard way, like Joe did.

Please be sure you have climbing experience if you are going to answer this question!

If you are not absolutely certain that you know what you are talking about, then please do not attempt to answer this question. We have any number of qualified experts available, so let's listen to what they have to say.

Joe did not have proper climbing experience, and look where it got HIM!

Yours et cetera,

Dr. Piton



Accident Report on the Death of Joe Ivy



How I felt:

Gut reaction: How could he be so stupid! This was followed by "I wish I could have been there to help" and was later followed by sadness. But it took me a full day to get over my anger before I was able to feel sad.



One mistake:

Joe quite simply did not know what he was doing! Clearly.

He was out of his element in very many ways. Joe tried to "reinvent the wheel". His design did not work. His design was flawed from the start. He did not replicate his design under controlled conditions, and instead tested it in the field.



What Joe should have done differently:

Joe should have sought out proper instruction. Aid climbing, especially when compounded by the darkness, wetness and muddiness of caves, is not the place for the inexperienced.

If you are going to put your neck on the line, you had BLOODY BETTER KNOW WHAT THE HELL YOU ARE DOING!!

Learn to walk before you run.



I am Dr. Piton,

and I am just a bit luckier than Joe.


cryptoboy


Jan 22, 2002, 5:49 PM
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first off i do not know what i am doing when it comes to aid. i would like to some day, but until then i try to learn all i can.

The obvious problems:
1. static rope. should have used dynamic, and if cuts were a possibility, maybe they should have used double ropes. (i don't know if aid climbers do this, though)

2. zippers instead of kong slydes. if they need some kind of shock absorber, zippers at least wouldn't be messed up by dirt and mud

3. normal harness

4. regular belay

Just my quick guesses.

Something, though, strikes me as a larger underlying problem. One of the great attractions of aiding is the mechanical problem solving. The search for the "better way". It seems Joe Ivy was a bright guy who had some clever ideas mixed in with some not so clever ideas. Maybe part of the challenge of aiding is coming up with the more clever idea that won't get you killed. Maybe that's the real lesson to be learned. Be clever, but not too clever

c


passthepitonspete


Jan 22, 2002, 7:35 PM
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Nice rant, Stu. Good points with an "s", Chris.

Both you guys would lose at Jeopardy because you did not properly phrase your answer!

I am trying to create a TEACHING POST where people can scroll down and quickly pick up the mistakes. [Hint: You could edit your posts.]

Please point out one mistake and what you would do to correct it. Leave ideas open for other people.





Around here, Dr. Piton teaches the BETTER WAY.

Please note the difference between the BETTER WAY and a CLEVER IDEA.

Clever ideas belong to BIG WALL THEORISTS.
Clever ideas should remain in the parking lot with their creators.

Joe Ivy was a Big Wall Theorist who should have stayed in the parking lot!

If you do not know what a Big Wall Theorist is, then you should click here and wait for the smilies to load.

[Note: Please hit CONTROL + R if the link above loads too slowly.

Good work. Please carry on pointing out one clever idea that Joe used.


cryptoboy


Jan 22, 2002, 8:12 PM
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One clever idea:

using Kong Slydes and static rope instead of dynamic rope(s)

Lighter and possibly more durable, but prone to jamming and probably nasty on falls.

c

p.s. http://www.kong.it/doc408.htm
the kong slide. looks like it might be ok for a runner to a sketchy placement. In warm dry weather. If you felt lucky.....

zippers seems to be the way to go...

[ This Message was edited by: cryptoboy on 2002-01-22 13:01 ]


bmsullivan


Jan 23, 2002, 5:42 AM
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How did I feel?

Maybe i'm to cautious but it definetly seemed that many flaws were ignored. I know in climbing "balls" and determination are a key factor, but I can't help but feel that there was some carelessness involved as well. I am very sorry for those who know Joe. I'm sure it was devastating to them all. I do think this will help some of us to re-evaluate our own climbing methods.

One mistake:

Using a belay system with a known flaw. Quote:"Planning an ascender belay that was believed would "only" result in the stripping of the rope sheath was poor judgment from the start. Joe's death was due to his own actions and the judgments he made in designing his belaying system."

What would I do differently?:

I would have followed manufacturer's guidlines for the gear used. The article stated that it was believed he read the chart about forces on the Croll using a static line. All known possibilities should be taken into account when climbing, especially when developing new methods.

[ This Message was edited by: bmsullivan on 2002-01-22 21:46 ]

[ This Message was edited by: bmsullivan on 2002-01-22 21:48 ]


anth


Jan 23, 2002, 6:39 AM
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one mistake:

every piece of climbing equipment i've ever bought comes with instructions that say, "do not modify this gear in any way".

modifying the harness is, in my opinion, a serious no-no.

what would i do differently? follow the instructions... if the harness is too uncomfortable or whatever, then get a new one.

how do i feel? bummed. i just looked at a climbing accident report that covers the years 1951-2000. of the 3000+ accidents listed, less than 10 are due to gear failure. about half are due to slipping while walking and the other almost half are all due to user errors. you know, harness incorrectly buckled, knot incorrectly tied, poorly built anchors, no redundancy in the system, etc, etc...

so nearly half of the accidents were clearly preventable. joe's seems like one of those accidents.


thanks for all the info, pete. really appreciate it.

-anthony

[ This Message was edited by: anth on 2002-01-22 22:54 ]


coach


Jan 23, 2002, 4:44 PM
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Dr. Piton,
I read the report closely and like you felt both sadness and some anger. It reminded me of a previous thread where I saw several people touting the virtues of climbing on static lines. I may not be the brightest bulb but I follow the advice of people like John Long and Bruce Padgett when they say Never climb on a static line where even a short fall is possible. The forces exerted in a short fall can be sufficient to kill or cause serious injury. When you add to that the use of a belay system that is questionable you are asking for trouble.

I know that we all except danger but don't add to it! Appreciate the thread and link. Thought provoking and informative. Keep it up.

Climb On


passthepitonspete


Jan 24, 2002, 8:07 PM
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Carry on, lads. Good comments. Unfortunately Joe made so many mistakes this thread can keep going for quite some time.

Thank you for the proper "Jeopardy format".

Next, please.

C'mon everyone, LOTS of stuff left!


caveclimber


Jan 25, 2002, 8:24 PM
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I first read about Joe in my NSS news. First off I would like to say I am sorry for his family. How it happen was all in God's hands. I believe that there is a purpose for everything that happens. How many times have you climbed and got to the point you were going to your first bolt and fell. One wrong turn of your head or rock you did not see and it is all over. Climbing is not full proof it is dangerous and we can only try to make it safer for all by learning from mistakes. To bad we have it take a mistake to fix it. Caving in itself is very dangerous you never now when you are going to push a lead and fall down a crack or pit. I have not climbed long enough to say he did wrong all I know is every one I have talked to said he was very careful sometimes to careful.


passthepitonspete


Jan 30, 2002, 1:07 AM
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C'mon, y'all. Have another read.

I am trying to TEACH YOU STUFF SO YOU WON'T DIE!

Please read the title of the post - it refers to a synergistic effect that caused a death. Let's get some dialogue happening here!

This is the best teaching post you will ever find!!

READ IT.

Dr. Piton's "medical skills" are limited to those who are STILL ALIVE.

If you don't believe me, then ask Tom Patey.


veilneb


Jan 30, 2002, 2:52 AM
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Okay, I will give it a try. I have never used ascenders, but to me, it sounds like the use of an ascender with exess force (like during a fall) may damage the core of the rope, compromising its integrity.

What is: the incorrect use of an ascender as a belay device?

V


veilneb


Jan 30, 2002, 7:40 PM
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Shack Exley was a prominent cave diver and explorer. I think his statement may apply to this situation.

Exley's Razor: a proposal for discussion involving the nature of limits. One never truly knows one's limits until they are encountered. Once a limit is reached and exceeded, return is not always possible. This razor is dangerously sharp. It divides those seeking the knowable end from those who have found the ultimate destination.

Be Safe
V


amethyst


Jan 30, 2002, 9:02 PM
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Why did Joe not stay home and quilt that day?
(Obviously should not have been where he was.)


anth


Jan 31, 2002, 5:15 AM
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looks like nobody else wants to play, so i get to go again.

the problem you're alluding to, ptppete, is that it is a combination of mistakes which led to the unfortunate result of joe's accident.

taken individually, each error can be the cause of a bad accident, but that's why we build redundancy into the safety system, right? to cover for a mistake (or a misstep). taken together, however, those mistakes overwhelm the safety system and the situation becomes desperate.

what i keep coming back to when i think about this accident is this one question: "why did he tinker with everything?"

there's a difference between tinkering with something and improving something. improving a safety system is, at this point in the game, quite difficult.

climbing companies and mountain rescue groups are continually improving the gear and methods, but it's a hell of a lot of work. more than anything, it requires lots of testing. the only way to find out how much the gear will withstand is to break it, and measure what you're doing carefully. and do it many, many times.

a lone climber usually doesn't have the resources to evaluate a change to a piece of gear. especially one that's part of an interconnected safety system.

so, basically what i'm getting at, is that i don't understand why joe didn't follow established - and safe - procedures. i don't understand the tinkering mentality. i especially don't understand tinkering with a safety system.

and i especially really totally don't understand how someone so obviously interested in gear and the ways you can put it together could have such a total disregard for the results of his handiwork. you don't need a degree in math or engineering to spot the glaring errors here.


amethyst


Jan 31, 2002, 5:27 AM
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Anth

Some people are just too smart for their own good.


passthepitonspete


Feb 27, 2002, 3:06 AM
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Climb Tech Removable Bolts do not hold well in muddy and wet conditions such as those commonly encountered in caves.

What exacerbated the problem is that Joe already knew this!

Nnnnnnnnext!



P.S. Sheck Exley was without doubt the World's Greatest Cave Diver.

He pushed the limits, and died doing so.

Dr. Piton recommends you click here to read of Sheck Exley's death.


passthepitonspete


Feb 28, 2002, 1:37 AM
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On Friday March 1st, I will be making an aid climb in a cave, that cave being Roppel Cave which is part of the Mammoth Cave System in Kentucky.

With any luck, the World's Longest Cave will become longer still!

I do not intend to repeat Joe's errors.

You guys have all missed one critical element.

Think "fall factors" and tell me how he blew it.

C'mon, last one!


thundergoddess


May 10, 2002, 7:41 PM
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I have had several opportunities to climb with Tim Stich. As a beginner I do follow the more experienced wisdom passed on from those who have climbed for some years. I also see many "experienced" climbers pass on good information that they don't use themselves. I have witnessed Tim among others in a group in Texas make many mistakes,dangerous mistakes, that a beginner who has read all the books,knows not to do. However, despite these errors they come off the rock without injury. Good for them but it is this sort of behavior and luck that leads to terrible accidents later. Don't get cocky and don't believe you have all nine lives to spare. So don't be too soft on Tim. Carelessness and cockiness lead to disaster in climbing. There is a disregard for the basic rules,tips,warnings and the newbie is often the the butt of many a heckle but when I read the accident report it was like reading a checklist on what to do to insure a disaster. What were they thinking? I'm saying Tim has a good heart but last I climbed with him ....some people shouldn't be that confident.


thundergoddess


May 10, 2002, 7:51 PM
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There is a chance both guys needed to go home and sleep. I don't doubt that for a minute. Do as the experienced caver/climber says not as he does. I can only hope this experience eventually gives Tim the patience for climbing and other climbers. Set up has always been important to me, again, heckled for the detail I put into set-up. However, I have yet to fall or get injured. I do as they say, I thank all the climbers that have helped me enjoy climbing without injury. I follow their advice to the T.


passthepitonspete


Nov 12, 2002, 8:36 AM
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Every now and then, I read something that absolutely jumps out and bites me.

The death of Joe Ivy was just one of those things.

Recently, I read something else almost as amazing - right here on our very own website!

I found the similarity to be uncanny.

It appears in the General Forum, a place rife with Big Wall Theorists, or whatever their equivalent would be on the crags.

There is an extraordinarily useful lesson to be learned here.

One hopes we can learn it without letting one of our own die in the process.

Please click here to read an amazing parallel to the death of Joe Ivy.

I would love it for those of you who really do know and understand solo belay systems to comment on the post linked above. Perhaps you might like to comment on the striking similarities between the two stories.

Let's remember we are TRYING TO STAY ALIVE.

Read, absorb, and don't fricking blow it.

Like Mike nearly did.

Cheers,

Pete


timpanogos


Nov 12, 2002, 11:04 AM
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Pete, just as this death deeply affected you – the following death affected me. I assume it is because it involves your styles (caving/aid) of choice and the gear/techniques involved. Where for me it was a trad route.

You can click here Death at the Coulee
and read about the death of Goran Krop (famous alpinist) who had 4 of 5 pieces of pro blow on him starting 20 meters up a trad lead and ending up on the choss below the belay station. This was once again a high fall factor which broke a biner and was potentially on a static rope.

But in both cases it was the synergy of many marginal things (in Joe’s case, wrong things), which compounded to a fatal ending.

Not being an aid climber, I can only comment on what I recently read about “moving systems” by none other than PTPP. I know I will always remember those exclamation points!!!! (Heavy bounce testing) along with the aid head verse trad head of clip the darn thing ASAP). So I guess my 1 item that I will mention that was a mistake that added to the disaster was he was only using one set of aiders (and funky ones at that) which would not allow for a safe testing (one foot in each set, balanced incase of pop) of the new placement.

There are several things I learned from the Krop thread above, but one that might be of use in this thread deals with static ropes.

So here is my question:

How can you tell a static rope with out even touching it?




Answer:

A static rope will only have a single colored Stripper threads in the sheath, whereas a dynamic rope always has a multicolored striper threads.

Get used to visually checking your lead ropes – in the gym, crag or wall, on your buddies ropes or your own etc. as part of your tie in practice and make darn sure it has multicolored strips on it!

You might be leading on a static and not even know it!

Chad

edit: fixed link

[ This Message was edited by: timpanogos on 2002-11-12 08:04 ]


lazide


Nov 12, 2002, 2:02 PM
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WARNING: THERE ARE STATIC LINES ON THE MARKET IN SOLID AND BRAIDED COLORS NOT READILY IDENTIFIABLE AS STATIC LINES BY FEEL OR COLOR!



ptpp: I saw that thread, and immediatly thought the same thing you did.

WARNING: SOLO CLIMBING IS NEVER SAFE!

With the proper training and equipment, the risk can be lowered - BUT IT IS NEVER SAFE.

Now, to properly respond to ptpp original post:

How I felt:
After I read the part about him using a static line to lead on (even with a load limiting device), and with an ascender for chrissake, I felt like I was watching a train wreck, but powerless to stop it.

The lesson I learned
NEVER LEAD ON A FRIGGEN STATIC ROPE!


twrock


Nov 13, 2002, 4:22 PM
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I did go and read the post on the death of Joe Ivy. Chilling. Like a suspense movie where you know that each step forward brings the victim closer to the ultimate danger. Yes, so many cumulative mistakes.

But what really spells it out so plainly is the last paragraph in the conclusion. And the very last sentence sums that up:

"Overconfidence kept them from continually questioning their system and methods."

Yes, unfortunately it does sound like Mike.


bagwhan


Apr 20, 2003, 6:29 AM
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Joe Ivy [In reply to]
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It's a rule of mathmatics (and life, as Joe Ivy found out) that as you increase the number of variables in a system, you exponentially increase the complexity of said system. So, by fiddling with all number of his gear (the stupid ascender belay, using the Kong Slyde, the static rope, his "customized" harness, etc.) he monumentally increased his odds of having something go wrong on him. So what was his single mistake? I don't think it's worthwhile to speculate about what single factor killed him. The system as a whole killed him--it is very unlikely that any single part of the setup he was using would have killed him if he'd had everything else the way it should have been. Joe contracted a bad case of the clevers, and he just didn't know when to stop "improving".

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Forums : Climbing Disciplines : Big Wall and Aid Climbing

 


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