Andrew Bisharat said it well here:

http://eveningsends.com/...tito-traversa-death/

I don’t know anyone who has ever inspected a rack of quickdraws.

Look at the differences between the draw that is incorrectly racked, and the one that is correct. They look almost identical.

I would’ve taken those draws, put them on my harness and not thought twice about it. And you know what? You would have too.

Of course, setting up the draws in that wrong configuration is an incredibly stupid error to have made, obviously one born of inexperience. It’s something I can’t possibly imagine anyone ever doing. Obviously the person who made this mistake looked at a properly racked draw, and tried to recreate what she or he saw. It was a horrible mistake. But it was also a freak mistake—something none of us could’ve ever predicted.

But this was an accident that could’ve happened to any of us...

Sorry, but nope. This wouldn't have happened to me. I may succumb to some other error, but climbing on another person's gear always involves at the very least a cursory look. I'm especially wary of brand new gear due to some experiences...

It started out well enough, but the factual errors just kept piling up.


I have. But then when climbing a route with 4 bolts per 100 ft, you tend to consider the pro.


No they don't


Nope


Petzl predicted it, and warned against it.

Also, how the person did this is far from obvious. IMO it was racked by someone fundamentally lacking in curiosity.


Sorry, but nope. This wouldn't have happened to me. I may succumb to some other error, but climbing on another person's gear always involves at the very least a cursory look. I'm especially wary of brand new gear due to some experiences...

The bottom line is that like any dangerous activity like driving or shooting, experience counts the most (followed by attentiveness and intelligence/curiosity.)

I'd take issue with one other comment, namely the one that says Petzl predicted this, suggesting that the rigging flaw was something people should have known to look out for. I don't think it is true that Petzl knew about this before Tito's tragic accident, and here's why:

Tito died, after several days in the hospital, on July 5 according to most on-line reports. The Petzl report identifying the problem has, at the bottom, the notation PRODUCT EXPERIENCE - STRING_M90-PE-01A(100713). I believe the part in parentheses denotes (in the European style) July 10, 2013, which would be five days after Tito died. Moreover, the document says, at the beginning,

This “Product Experience” document is a supplement to the Instructions For Use, which provides feedback from field experience and tips for using your product.

Taken together, these two items suggest very strongly that Petzl was not aware of this problem and produced the "product experience" bulletin in response to Tito's accident. It would follow that this was not a known issue that anyone would have thought to check for.

It would be nice if you actually included the names of people you are responding to, if you are copying from multiple posts. It appears that you are responding to me, but other than the first part, I haven't actually made any of the statements you are responding to.

Hasn't there been at least one accident similar to this in the past though?

Hasn't there been at least one accident similar to this in the past though? I could have sworn that someone used a draw to secure himself or herself to an anchor not knowing that the draw was only through the rubber band and the band broke.

Even if what I'm remembering is not a petzl thing (I believe it was a homemade rig to copy what petzl does), it seems to me they would have known that this could have happened based on other accidents.

I can't remember the specifics unfortunately. Sorry.

This one?
http://www.rockclimbing.com/...post=2348841#2348841

no that was a different type of failure ... with an open sling and a rubber band ...

MANY intrawebbers believed this was the same type of failure because no one could conceive of someone clipping ONLY the rubber keeper on a quickdraw

you can see this on the first page of this thread and others ones around the intraweb

UKclimbing perpetrated that error by posting up a video of the open sling failure in their article on Tito's accident ... not even they could conceive that someone could only clip the rubber band of a quickdraw despite quotes in the press showing that was exactly what happened

as the firefighter accident above shows ... even the best trained people have real issues preventing things that they dont know what to look for

any RCer thinking otherwise is just deluding themselves ...

Hasn't there been at least one accident similar to this in the past though? I could have sworn that someone used a draw to secure himself or herself to an anchor not knowing that the draw was only through the rubber band and the band broke.

I don't think there's been another such incident. There was indeed an incident in which a woman died when her tethers failed, but that was attributed to the use of rubber retainers with open slings. The possibility of accidentally clipping one of the open strands and thereby creating a sling that depended only on the rubber retainer has been known for a few years I think, and I believe that possibility was illustrated in a previous Petzl warning and is included in the current warning. But the open sling situation is completely different, even if the failure in both cases is the same. The major difference is that the open sling retainer failure can't happen with (properly assembled) closed-sling draws, so there would be no reason to even think about or such a failure or inspect for it in the context of a sport draw.

In any case, my response was to the claim that Petzl had "predicted" this accident, suggesting that a reasonably informed climber should have known about this danger, and I still do not think that is true.

As for the suggestions of product engineer negligence, I think they are way off the mark. There are millions of ways to misuse climbing gear, and every bit of climbing technology comes with its own unique set of fatal goofs, some of which, sadly, have yet to be discovered. The incorrect assembly of those draws, not one but eight of them, is, frankly, an inconceivable chain of errors. I don't think anyone can wrap their brains around how it could have happened, and I think the suggestion that engineers should have been thinking of ways to prevent it is ridiculous.

My bet is that they knew the risk and didn't think it would actually happen, and that knowing the rubber wouldn't hold a fall wasn't enough of a concern to outweigh the advantages of putting it on the draw.

...As for the suggestions of product engineer negligence, I think they are way off the mark. There are millions of ways to misuse climbing gear, and every bit of climbing technology comes with its own unique set of fatal goofs, some of which, sadly, have yet to be discovered. The incorrect assembly of those draws, not one but eight of them, is, frankly, an inconceivable chain of errors. I don't think anyone can wrap their brains around how it could have happened, and I think the suggestion that engineers should have been thinking of ways to prevent it is ridiculous.

"Negligence" is probably going too far, but this is clearly poor product engineering.

This is clearly a case of user incompetence and most definitely not "poor product engineering". That's like saying a Ferrari is poorly engineered because it doesn't float when you drive it off a road into a lake.

I honestly don't think it is poor product engineering, and I don't think the end-marks are a good analogy. The end marks are used and have to be recognized for what they are in the field, possibly under stressful circumstances by climbers who may be very fatigued. But no one assembles sport draws mid-pitch. You do that at your leisure, in a comfortable environment, when you have every opportunity to pay attention to what you are doing and double-check everything you've done, with the full realization that an assembly error could lead to your or a partner's death.

I just don't see why product design needs to take into account the fact that someone will, under these circumstances, assemble draws incorrectly. Yes, we know it can happen, the USFS firefighter fatality makes that clear. And of course, a child should never be alllowed to do this, surely that is the primary lesson of the tragedy. Would you jump out of a plane with a parachute packed by a twelve-year-old? One can think of other classes of people who should not be given such responsibility. But I don't think it is the job of product designers to anticipate and protect against such extreme instances of inattention and incomprehension. Climbers ought to have some responsibility for proper set-up and handling of their equipment, and I think that installing a rubber O-ring in a way that makes it a load-bearing component of a draw is firmly within the boundaries of personal responsibility.

By the way, if we stipulate that the rubber keepers are useful for sport draws and that at some point climbers will assemble their own draws, then how do you redesign this product? The fatal assembly was one that was clearly visible to anyone capable of looking at it without preconceptions. How could you make that any safer?

I think the lesson of the tragedy ought to point in a different direction, one that keeps the responsibility where it belongs and doesn't even suggest that such problems should be solved by product engineering. Things like sport draws and knotted slings should be bounce-tested before use, because simple inspection may not provide an adequate check.

Well, I guess we're just going to disagree on this one. I realize that operator error was the proximate cause of this particular accident and I fully realize that engineering around all imaginable forms of product misuse and stupidity is impossible. But, when I was out climbing today I looked at several different quick draw designs--and there are some out there (with rubber keepers) that are designed such that this type of accident would be impossible.

Since this accident did happen, it's my personal opinion that Petzl and others should redesign their quick draw products so that a known failure mode is eliminated--much in the way most harness buckles these days can not fail to be doubled-back.

Curt

How would patents figure into this? Is it possible that Petzl can't do it the fail-safe way because of patents? I really hope that is not the case.

How would patents figure into this? Is it possible that Petzl can't do it the fail-safe way because of patents? I really hope that is not the case.

Well, I guess we're just going to disagree on this one. I realize that operator error was the proximate cause of this particular accident and I fully realize that engineering around all imaginable forms of product misuse and stupidity is impossible. But, when I was out climbing today I looked at several different quick draw designs--and there are some out there (with rubber keepers) that are designed such that this type of accident would be impossible.