Difference between revisions of "Talk:Accident analysis"

Revision as of 09:09, 6 May 2009

Suggestions from Mark Dougherty

Some clear issues emerge conserning management of the hypothermia. This was a great success, but was achieved in the face of some considerable adversity - candles going out, matches running out, sleeping bag hard to put on etc. Equipment needs to be re-thought here. What EVERYBODY should be carrying (in my opinion) is:

• nightlight candles
• small folded sheet of tin foil to make a wind shelter for candles
• piezo-electric lighter
• hat/balaclava
• blizzard survival bag see: http://www.blizzardsurvival.com/product.php/100/blizzard-survival-bag The blizzard survival bags are apparently the business. Everyone should have one in their kit. Yes they cost, but I'm assured by people who ought to know that they are a real life saver.

The sleeping bag for casualty use needs to have a full length zip. Can someone handly with a sewing machine modify the bag we have (which being fibre pile is very good from the point of view of insulating even when damp)?

if a stove is availble (either brought from the surface or at a brew station in the cave), make sure a plastic water bottle comes with it. You can heat water to a little over body temperature and then put a hot water bottle inside the casualty's clothes next to their core. If I think back to Razordance 2007 this was a serious omission from the brew equipment at GLAD and could have made a substantial difference to survivability.

A roll of binbags will waterproof anything in an emergency....

There are obvious SRT training issues. Basically anyone who has not caved regularly with CUCC should be checked out for SRT competence by the leader or other experienced person before being allowed underground. No exceptions, then it's not embarassing to insist on it.

Suggestions from Mike the Animal

• Keep a gas fueled emergency stove at top camp, one with a piezo igniter. Make sure its kept in a waterproof container (along with matches and a couple of ciggy lighters). I got one quite cheap off ebay and use it underground on Upper Flood digging trips, works fairly well [1], its a bit fiddly to control, possibly temperature related, but holding the gas canister in my hands works.

• I've used an Ortlieb dry bag when canoe camping as a stuff sack. The ones I've used are fairly long and thin, so will go into a tackle bag. Actually, one of mine has a tiny hole but would be fine with a thick bin liner inside - air pressure should mostly keep water out anyway; I'm happy to donate it.

suggested "buddy checking" practice

Thanks for doing this, Kathryn. It looks accurate and succinct. The only good thing about an accident like this is what we can learn from it, so I'm glad to see it recorded well.

As for suggestions for change: I spoke with Robert Seebacher after the incident, and he was unequivocal about what he thought should change. He said that on every pitch head of every trip, he always has someone look and check all is well (mallion gate, stop krab gate and attachment, harness straps doubled back), and checks theirs at the same time. This was a partial cause of the accident; I watched as "Caver A" tested his stop, but I did not actually look at his central mallion at the pitch head. If I had, it would have been obvious that Caver A's stop had not been moved to his mallion.

Although this would be somewhat of an inconvenience, I strongly recommend that the club adopt this visual inspection ritual, or at least include it in training. I don't know if the number of unscrewed-mallion incidents has decreased since I left, but that's another reason I think checking is good practice.

I can add this to the "Analysis and recommendations" section, but wanted to put it here for discussion first. What does everyone think of this? -Aaron 03:24, 1 May 2009 (UTC)

Comments from Mark D via email:

What Aaron says about buddy checks (and his report of a conversation with Robert on this subject) is very interesting. We instituted a similar policy in the Swedish Federation some years ago along these lines, with a buddy check before the first pitch. However, I don't think it's realistic to have a check before every pitch because this would tend to slow progress.

Part of the issue is that taking SRT kit off and back on again is a safety risk, just as moving the descender back and forth from the central maillon to a gear loop is also a safety concern. Several aspects immediately spring to mind: (a) There is obviously the risk of loading the descender when it is on the gear loop. (b) Re-installing the descender might be done wrongly, for example crab not done up, put on backwards etc. (c) on the ascent, if you need to change over to going down in an emergency there is an additional risk of dropping the descender mid pitch, or finding that you forgot it in a bag which is not attached to you. (d) Similarly there have been cases of people abseiling down to the bottom of a cave and finding they left their top jammer behind at the surface. That hasn't necessarily happened on EXPO but it's definitely happened to cavers before.

My suggested policy for the future is therefore as follows:

a) SRT kit is either "on" in its entirety or (by definition) it's "off" and a new buddy check needs to be made before getting back on a rope. SRT kit to be "on" whenever on a rope.

b) Buddy check performed whenever SRT kit put "on".

c) Central maillon tightened sufficiently so that it can't work loose (a 7mm long maillon makes an excellent spanner for this purpose).

d) Taking SRT kit on and off all the time to be avoided where possible because of the extra risks involved.

Final food for thought. Buddy checks are much easier and faster to perform if everybody configures their gear in the same way. There is a limit as to how regimented we can get, but it's maybe worth looking at standardising the basic layout of equipment.

Mark

Audience

What audience is this page aimed at?

• Laypeople (unfamiliar with caving jargon)
• Past/present expedition members
• New expedition members
• Cavers unfamiliar with the CUCC expedition
• All of the above

--OliverMadge 11:11, 29 April 2009 (UTC)

I'd say mainly the the second and fourth - i.e. anyone with any useful ideas. Edvin

One of the main reasons for doing it is that it is required by the CUEX expedition people, but I don't think they are that interested in reading it, they just want to know that we have done it (so I don't think it is important that it makes sense to non-cavers). Kathryn

Ah, did CUEX specify the section titles? I just renamed them slightly to make it clearer (to me at least). If so you might have to rename them back. --OliverMadge 11:52, 29 April 2009 (UTC)

The section titles were suggested by Mark D, but I'm sure he won't mind them being changed Kathryn

CUEX were certainly very keen on some sort of analysis. But I think it's a good idea to try and learn some lessons anyway; although keeping it as un-officious as possible is always good! Edvin