Difference between revisions of "Accident analysis"

Latest revision as of 13:54, 10 May 2009

Fall down pitch in Steinbrückenhöhle, Expo 2008

Synopsis

During a two man tourist trip to Steinbrückenhöhle (Loser Plateau, Austria), one caver fell down a 30m pitch near the entrance, sustaining serious injuries. He was subsequently rescued from the cave by members of the local cave rescue organisation, with assistance from CUCC.

History of the trip

Caver A and caver B went underground at 9:30 am on 25th July 2009. They planned to do a "tourist trip", looking around the upper levels of Steinbrückenhöhle, entering via ‘E’ entrance, with the possibility of exiting via ‘D’ entrance. No other expedition members were at the Stone Bridge (the bivy site near the cave) on the day of the accident. Ten other expedition members were at basecamp (a 20 minute drive and 2hr walk away), with the intention of walking to the Stone Bridge later that day.

Who it happened to (their experience, training, etc.)

Caver A was a 54 year-old male. He had caved some years ago in America, using different vertical techniques to those typically used by CUCC. Prior to the expedition, he had a 4 hr practice session above ground to familiarise himself with the new techniques. The day before the accident he went caving with caver B and descended the same pitch as where the accident occurred without a problem. On this occasion caver B waited at the rebelay to watch caver A change over, which he did confidently.

What actually happened in the accident (how they came to fall, injuries sustained)

The accident happened at the ‘E’ entrance pitch of Steinbrückenhöhle. The pitch is approximately 20m from the surface, and is approached by a short section of constricted horizontal passage. The pitch head itself is also constricted.

Caver A prepared to descend first, closely followed by caver B. Caver B watched caver A test his stop descender and abseil out of sight. A few seconds later, he heard caver A fall and shout. He urged him to clip in to the rope, but shortly afterwards he heard caver A fall again. Caver A was conscious immediately following the accident, and remained in verbal contact with caver B.

Prior to entering the cave, caver B noticed that caver A had his stop attached to a gear loop on his harness, rather than his central maillon. Caver B assumed this was a deliberate choice to aid passage through the awkward crawl just before the pitch head. Following the accident, the harness worn by caver A was found to have a broken gear loop. It is assumed likely that caver A abseiled with his stop attached to his gear loop, which broke, causing the fall. Caver A recalls that he had indeed moved the stop to the gear loop the previous evening and did not move it back before abseilling. In fact, he noticed an unusual pull before abseilling, but ignored it after he tested his stop.

See rigging diagram.

Incident response

Approach to the casualty

Caver B abseiled down the pitch to caver A, a few minutes after the accident. Caver A was found lying at the bottom of the pitch, with the rope about 1m behind him.

Initial first aid

Caver B assessed caver A for signs of bleeding and injuries that required immediate attention. No treatment was given at this point but steps were taken to prevent heat loss (see below). Caver B noted that caver A had sustained cuts to the hands and had pain in the lower spine/pelvis.

Management of hypothermia

Caver B covered caver A with a survival bag, and gave him a balaclava before going to raise the alarm. On returning to the casualty, Caver B bought a karrimat, and attempted to place this under caver A –- this was difficult because caver B found even very small movements painful. The karrimat was torn into small pieces to allow it to be pushed underneath caver A. A second survival bag was also brought to cover caver A, and the two survival bags were gaffer taped together. Candles were lit underneath the survival bags to generate heat, but they kept extinguishing when caver A moved. Later, further steps to manage hypothermia were taken by the CUCC rescue party (see below).

Raising the alarm

Caver B prussiked up the pitch and returned to the Stone Bridge to raise the alarm. He phoned base camp at 10:30am, and got an immediate response. He passed on the details of the accident and the injuries sustained by caver A before returning to the site of the accident with a karrimat and first aid kit. The Austrian cave rescue organisation was then contacted by phone by a native German speaking expedition member.

Response (CUCC and Austrian rescue)

Following the call from caver B, a meeting was called to pass on the details of the accident to all expedition members. It was decided that a group of 5 people would immediately drive to the Loserhutte car park and walk as quickly as possible to the stone bridge. Other expedition members would follow after collecting supplies and liaising with the Austrians. At this point it was assumed that no immediate help would be available from the Austrian cave rescue team, and so plans were made for a rescue by CUCC.

The two members of the first party reached the Stone Bridge at ??, shortly followed by three others. A tacklesack was packed with a karrimat, stove, food, drinks and sleeping bag. This took quite some time, as items were distributed around the stone bridge, and it is surprisingly difficult to stuff a sleeping bag into a tacklesack (the emergency sleeping bag that was at the stone bridge was a ‘buffalo’ type, and was not in a compression sack). Three cavers went underground, two with the intention of marking the route underground to ‘D’ entrance and beginning to think about bolting pitches for rescue, and one to stay with caver A. ‘D’ entrance was the proposed rescue route at this point, assuming no help from the Austrian rescuers, as it was thought that the available expedition members had insufficient experience to attempt to haul caver A out of ‘E’ entrance (which has a constricted pitchhead, a rebelay and two deviations). Caver B exited the cave at this point. Caver A was moved onto the 2nd karrimat (much easier with lots of people) and partially into the sleeping bag. However, the sleeping bag was much too small, and the zip only extended a short way down, so this proved difficult. All of the matches in the first aid kits had been used up (lighting the candles that kept going out), so there was no way of lighting the stove at this point.

Meanwhile, on the surface, one member of the advance party was appointed surface coordinator. She kept a list of what gear and cavers had gone underground. The fifth member of the advance party marked the route to ‘E’ and ‘D’ entrance from the stone bridge with reflective cairns (the accident happened early in the expedition, and so this had not already been done).

A second party, which included all of the remaining expedition members (5 others) gathered gear, first aid equipment, map and surveys and left base camp 30 mins after the 1st party, to set up a ‘base camp’ at the bergeresturant, which is at the beginning of the walk to the caving area, and has a large tarmaced area where it is possible for a helicopter to land. Twenty minutes after the CUCC party arrived, they were joined by two members of the Austrian cave rescue organisation, followed by 10 members of the Austrian mountain rescue. The Austrians were shown a cave survey, and the cave entrance and the stone bridge bivy was pointed out on a map (which was difficult, because of the lack of landmarks in the area where the cave and bivy are situated). A police helicopter arrived and began to shuttle the rescuers part of the way to the cave (to where the terrain becomes too rough for a helicopter to land). However, before everyone could be transported, cloud came down and helicopter could no longer fly, so some expedition members and mountain rescue personnel had to walk all of the way. Equipment was carried to the cave to allow a stretcher carry, which would have been necessary if the weather had not improved.

The first two Austrian cave rescuers arrived at the bottom of E entrance pitch at 2.30(?) pm with a stretcher and hauling gear. They quickly decided to haul caver A out of E entrance rather than via D entrance (as was the plan up to that point). A petrol drill was used to bolt the top of the pitch with through bolts, and a hand winch was used to haul caver A. A pulley arrangement allowed the hauling team to operate well back from the constricted pitchhead. Caver A reached the surface at (7??)pm, and luckily this coincided with a break in the weather, which allowed the helicopter to fly, and he was airlifted off the plateau.

Aftermath

Underground first aid kit not dried out nor restocked nor labelled as not suitable for use.

Outcome (did the person survive and/or make a complete recovery?)

Caver A was transported by helicopter to hospital in Bad Ischl where he was diagnosed with an "open book" pelvic break, a pelvic fracture, and one vertebra fracture, but no organ damage. He underwent surgery to insert a metal plate in the front of the pelvis and a plate into the vertebra. He remained in hospital for two and a half weeks, before he was in sufficiently stable condition to be transferred to a hospital in Virginia, USA. He is recovering well, and is fully ambulatory, although he is still affected by his injuries one year later.

Problems encountered

Analysis and recommendations

(what were the underlying causes of the accident? What can we do to make sure such an accident doesn't happen again? If there were problems in managing the accident, how could we do better next time)