In the last post I discussed an accident we had on a job site a couple of weeks ago. Similar to back in 2018 when Florim had his accident, I believe that when things go wrong, in view of the fact that word is going to get around anyway, it is important to provide people with full, complete and correct information – how and whether they read it and what they make of it is then up to them.
After posting on social media there was a wide range of reactions and comments. Many were supportive and positive, others made me pause and think. This is to be expected and is part and parcel when laying oneself open by communicating about situations gone wrong. Yet indulge me, allowing me a couple of observations here…
I was somewhat taken aback by how many people seemed to think this could never happen to them. In our team we cultivate an active safety culture, including safety briefings and training, risk assessments and ensuring an over-all high level of competence. Complacency and cutting corners were not part of this incident. As I already described, it was really due to a compilation of small factors, culminating in a system failure. This could happen to anyone. The other day Chris reminded me that when we used to work together, we would use the image of a traffic light to assess where our form was during the course of a day. While one moment you might be solidly green, the next instance there might be an external factor having a negative impact, resulting in your form reverting to orange or red.
Some external factors are foreseeable: feeling a bit spinny and light-headed late morning after having skipped breakfast? That one is easy to mitigate and should not really come as a surprise: hydrate and keep an eye on an appropriate diet for the work you are performing. Cold or heat are a bit different and more perfidious, they can catch you out, as it is less easy to monitor yourself and recognise the point where your judgement becomes impaired. Monitoring each other, partner checks, seems to me to be one way to nip potential problems in the bud: knowing your work mates, knowing where their strengths and weaknesses lie, anticipating external factors which could be having a negative effect on their form, not working in isolation, in a bubble, checking in with the other members on the team regularly. Communication is part of this, the other part is observational skills, as well as looking ahead, anticipating scenarios. Varying team constellations can make this very challenging. I go into situations like that knowing that in all likelihood I am going to miss points, but trying my very best to make sure that I have the big ones covered off and am not missing the obvious. I do this by taking my time and by being thorough.
A further observation is that a number of peoples’ comments stated how no one touches their lines, that they are their sole responsibility. This had me puzzled. A core concept of how we work revolves around a lowerable access system, allowing for a rapid, efficient ascent, as well as access to the canopy in case of an emergency. So in this instance, these lines are not “private”, on the contrary, they are the responsibility of the whole team, the ground crew as well as climbers. But actually, I suspect the truth of the matter is that teams using SRT for work positioning often will not bother installing an extra access. In case of a canopy-tied anchor point, on top of that, there is no means to lower an injured climber, so I am intrigued as to what the rescue plan is in such a scenario.
In fact I would even go a step further: The mentality that I am the sole person in charge and responsible creates a narrow pyramid of responsibility which could lead to pilot error, a concept from the aviation industry, where checks and balances are put into place to mitigate the risk of a bad call by one person, i.e. the pilot, causing a system failure. This is achieved by spreading responsibility amongst a number of team members. In many ways, this is what I was describing above with the concept of an on-going partner check as an integral part of the work process.
Another couple of weeks down the line, I do not really have any ground-breaking new thoughts to share. One comment that did really resonate with me was by Richard Delaney, a dear friend in Australia who runs Rope Lab, an invaluable resource to all things related to rope and working on it. Richard wrote:
Thank you for sharing this. The more if this rope stuff I do and the more experienced friends share their stories, the more we realise how human we all are. Especially me. I don’t read these reports and think “how could THEY have let that happen, I do this so it would never happen to me”. I read them and realise just how human we all are and how humble and diligent we need to be. I think “wow… that could have been me”.
Diligence and humility are a valuable and rare commodity it pays to cultivate, as well as awareness and meticulous attention to detail. Hopefully this helps to keep us and our team mates safe, in recognition of the fact that sometimes a freak incident, unforeseen event or human error can and will slip through the net, as 100% safety is not possible. But let us spare no effort to mitigate the residual risks down to as low a possible. If this incident drives one lasting message home for me, it is how truly human and fragile we are.