Manslaughter charges in the death of climber Tito Traversa

Certainly there are, but Petzl identifies how to setup a GriGri correctly (and I suspect judging from their generally excellent documentation, that installing it in reverse is dangerous), harness manufacturers identify the correct way to tie in, etc. Tying in with an improper knot, putting a cam behind a loose block etc, are where the "Climbing is dangerous and may result in injury or death" and the assumption of risk clauses come into play.

Reading the DPM article, it sounds like there was no assembly guide for this piece of rubber. to me, that screams product liability. It really comes down to ensuring that the end user is very aware of the risks inherent in the product they're using. Assuming the customer knows how to do things is a very dangerous fall back, especially with new or slightly different products.

As to the parents responsibility, I'd guess my parents wouldn't know how to check a quickdraw if their lives depended on it, and would trust the guide services to ensure it was done properly.

PatCleary, while I appreciate your points about adequate design and disclaimers from an engineer's perspective, there's also got to be some common sense involved. If I buy a new chalkbag, I don't think the manufacturer is responsible if I decide to use the chalkbag belt as a sling and it breaks. You can't cover every scenario, and I wouldn't expect them to warn about something as obvious as "don't use your chalkbag belt as a climbing sling." I don't expect BD to put a disclaimer, "do not use your ATC as a piece of pro." When I buy a pair of shoes, I don't feel like the shoelaces need to be labeled as "body weight only." Similarly, I find it to be fairly obvious that tiny rubber o-rings shouldn't be used to catch a fall. It sucks that it happened, regardless, but I don't think it's the engineers' fault for failing to tell people you can't take a whipper onto a tiny rubber o-ring.

I think what bugs me most about them wanting to press charges is, what's the point? Prosecution is often a means to prevent others from committing the same crime in the future, but what is it going to help to prosecute anyone involved in this tragic accident? This isn't just a rhetorical question: can anyone think of a way that this helps the situation?

kids are not responsible for their own actions until they are the magic age of 18.

Shoelace's aren't designed as part of a quickdraw, ATC's aren't designed as part of a cam. I'm not talking about "off-label" use of things, but about proper assembly. These things are included with or sold for a quickdraw. And from the sound of it, there was no information on how to use them.

Yes, we should be able to expect certain things, except for the fact that if you do this long enough, you'll eventually see customers using things in ways you'd never expected. And ways that indicate a lack of commonsense that's staggering. BD (I think) has warned explicitly about a very similar concern with trad draws, suggesting it's happened at other times.That's why companies perform risk management, test product, and carry insurance.

Patrick

Abram Herman wrote: This isn't just a rhetorical question: can anyone think of a way that this helps the situation?

i think the major upshot would be that entities that promote themselves as guide services or similar would see that there are consequences for being incompetent/negligent.

PatCleary wrote:I'm not a lawyer, but an engineer. When we release new product, we go through careful risk analysis. Included in that is looking at improper assembly. If we make a product can kind of go together, fail, and injure a customer, we'd (rightfully) be liable. A quick draw that can be assembled without the carabiner going through the dogbone while seeming to be assembled properly is improperly designed. Certainly it should have been documented in a way that you couldn't miss. Looking at the concept of product liability in the climbing world, I don't want to have to play the "guess the failure mode" game at the bottom of a climb while going through a buddies pile of climbing gear and racking up. There are enough risks to address without wondering if my gear was built right. Patrick

'Guess the failure mode' isnt a game. You need to KNOW how your gear can fail in order to lead safely, there should be no guessing. If you are using a buddies gear, you should inspect it to make sure its functioning properly and is safe, as you are trusting your life to it. If you don't know how to do that, then you shouldnt be leading because of the risk involved.

I know I am just one noob voice among a crowd of experts, but as I see it if you are tying in on the sharp end you should be able to (among other things):

inspect gear for safety issues***Understand how gear can 'fail' (know proper vs. improper placements)
Build an anchor
self rescue from any situation you may find yourself in
assess the competency of your belayer (as best as you can)

Leading is serious, the gravity of which seems lost on many people. You are responsible for your life and the lives of those that are following you.

My 2 cents on this deal: its a shame no one involved caught it. It's a shame he was so young. Leader is responsible for all gear and its placements.

slim wrote: the grade the kid isn't really an indicator of whether he has the skills to evaluate the draw. i climbed with a 5.14 sport climber, who has also climbed some long hard scary ice routes at the creek several years ago. he was laybacking up a corner and his first 2 cams fell out of the crack. no joke.

I get where you're coming from, but we're not talking about a 5.14 sport climber placing a tri-cam wrong. Young sport climber using sport gear that wasn't checked by him or any other person.

But yes, I agree in the same way a grade is not a good determination point, neither is age. It's tricky for sure... and ultimatley why the responsibility should be on the guide/leader for the groups' safety. I know when I guided hiking trips I personally inspected all gear before it was used because, I was taking these kids out and would be responsible if gear didn't work.

How many people would have guessed that the crimps performed on an Alien might fail? Or that a GriGri that you pulled to hard on would lockup and fail to close? I'm not just talking about the simple stuff. But where do we draw the line? There's a reason that product liability law exists.

Yeah, the parent, instructors, or kid should have caught it. Unfortunately, from the sound of things the parent assembled it wrong and there wasn't even a warning about it that he/she maybe would have seen.

At the end of the day I'd much rather chuckle at the ridiculous users manuals (don't take the toaster in the bathtub?) than watch a friend die because he grabbed the wrong draws.

Pat

This is tragic. Not manslaughter... just tragic.

If it's a guided group, then the guides assume liability as they should be giving their client a gold standard of safety. However, I'm hesitant to call a group of parents and friends and kids a "guided group", even if we invoke that one of the kids was a minor, and adamantly against holding anyone in the group accountable (if any punishment is necessary, the suffering of seeing their friend die is "time served"). Here's a scenario, very similar to this tragic case, that shapes my view:

Suppose I am a too frugal for my own good, and I like climbing on my 20 year old rope which has only one or two viable strands remaining, and all the rest are shit. The rope has miraculously held my body weight (the quickdraws that broke on Tito held the body weight of the person who set them in, no?) and some kid who is not mine comes and asks me if he can climb on the toprope we set up with my horrible rope. I'm also very shitty at setting up anchors - the bolts are not clipped (the gate is stuck on the hangar) and the rope is running through a single non-locking carabiner with a hair-trigger gate. The kid hops on my rope, all shit hits the fan, and the kid dies. Am I responsible?

Saying I am responsible for this puts a dangerous burden of liability on anybody lending out any gear at the crag, and swapping ropes is quite standard for busy crags - we assume that the other people, in our party or not, have set up the anchor correctly and are using ropes that won't break on this climb (due to a combo of shitty quality, failure to protect sharp edges, or what have you).

But wait! The kid is... well... a kid! The minor is below some arbitrary threshold of age below which we do not deem them capable of making responsible decisions. So... I should check ID's before allowing somebody to hop on my TR? Well then, all you high-schoolers hoping to hop on the TR I have set up will just have to wait another couple of years, and those of you who didn't bring your IDs on a multi-pitch climb will have to rappel down separately because I don't want to be held responsible if I failed to tie stopper knots and you slide off the rope.

As I said above, this is tragic. However, I don't think that this is manslaughter (at least not anywhere that I'm in the jury). I think that this just plain sucks. If parents want the ability to hold someone accountable for not providing a gold standard - using good ropes, clipping quickdraws correctly, building ERNEST anchors with 3 pieces of gear on only bomber cracks/features (and on separate features where the features are suspect), tying stopper knots, and all the other nuances that are needed for a gold-standard day of climbing - then the parents should hire a guide or require the person taking their kids to sign a contract saying that they will be helping the kids climb with the highest standard of safety.

If I send my kids off-roading with some unlicensed friend, and the car rolls over because the friend turned too fast and my kid dies, my friend is not responsible (so long as they did not break any laws about the speed limit/maximum angular velocity while off-roading...). I am responsible for sending my kid off to perform a risky activity with an unlicensed group.

EDIT: I realize that Tito went with a club, and the degrees of formality of a club correspond to different degrees of liability. For instance, whenever I go climbing with my favorite trad buddies, we call ourselves the "Too-Much-Fun-Club"... should we be liable for anything that happens (see above rant for my answer: No)? However, if this club is associated with a climbing gym, then there is probably a waiver somewhere which explicitly or implicitly contains a promise by the gym to hold up their end of the bargain and provide a safe experience. Details matter...

Alex Washburne wrote:Here's a scenario, very similar to this tragic case, that shapes my view: Suppose I am a too frugal for my own good, and I like climbing on my 20 year old rope which has only one or two viable strands remaining, and all the rest are shit. The rope has miraculously held my body weight (the quickdraws that broke on Tito held the body weight of the person who set them in, no?) and some kid who is not mine comes and asks me if he can climb on the toprope we set up with my horrible rope. I'm also very shitty at setting up anchors - the bolts are not clipped (the gate is stuck on the hangar) and the rope is running through a single non-locking carabiner with a hair-trigger gate. The kid hops on my rope, all shit hits the fan, and the kid dies. Am I responsible?

Probably, yes. The elements of involuntary manslaughter are: (i) an act that causes death, (ii) the act is inherently dangerous or done with reckless disregard of human life and, (iii) the actor knew, or should have known, that the act could cause death. Your conduct satisfies all three elements.

PatCleary wrote:I agree that everything probably has weak links in it. Documentation is an important issue. It may be that the documentation provides ample instruction on how to assemble these, and meets the minimum requirements to get the customer to review the documentation before assembly. In that case they may not be liable (seem my note about documentation in the last post). In my line of work we sell to professionals, not consumers, so I'm not entirely sure of the changes in requirements. I suspect they're more stringent when selling to consumers as I suspect many take that piece of paper out of the back of the shiny new whatever and chuck it. Risks also come in various levels of severity and likelihood. High severity, high likelihood, and a combination of both need to be addressed. I can't speak to how BD would rate an ATC used in guide mode, to me it sounds rare, and somewhere middle of the road in severity (unless you absolutely can't lock it off). A carabiner being attached by a thin slice of rubber sounds like an extremely severe risk to me. As to identifying the problem, I have a hard time believing they wouldn't come up with this problem. What could cause the product to fail -> Improper assembly -> Not putting the carabiner through the nylon loop. These are generally fairly formal processes, and I'd hope for a company designing personal protective equipment, thorough ones. Additionally, there's been discussion about not using rubber bands on trad draws for exactly this reason. .

BD warns of this ...

BD ATC

petzl does not ....

petzl.com/files/all/technic…

if someone in the gym should thread it through like this ... which EVERY climber who has taken any sort of belay test should know not to do ...

is it Petzls fault??? ... or the retailer who sold it, whose job it isnt to teach people how to belay

tons of other examples one can go and "find" ...

VARMENT wrote: Sorry bearbreeder but the misuse is super obvious in this example as it would have been to anyone fit to lead a group of climbers outdoors. Firefighters or not this seems totally obvious to me as dose the Tito case.

from the USFS report on the failure of FOUR people checking the system


Blindness

A misconfigured harness is a very rare event. Wolfe et al. (2005) demonstrated that when a target is rare, participants are surprisingly poor at detecting it. The rarity of the target leads to “disturbingly inaccurate performance.” Rich et al. (2008) explored some of the possible mechanisms for why we miss rare targets, one of them being ending the visual search prematurely. Research in visual attention has also revealed several ways that people don’t see what is in their visual field. This is simply how the human visual system works.

Inattentional blindness is the “looked-but-failed-to-see” effect. It occurs when attention is focused on one aspect of a scene and overlooks an object that is prominent in the visual field and is well above sensory threshold.

[...]

Change blindness is a failure to notice that something is different from what it was. Large changes to a visual scene are very likely to go unnoticed if they occur during saccades (eye movements) because visual analysis is suppressed during that time.

[...]

Confirmation Bias

Confirmation bias is a tendency to search for or interpret information in a way that confirms our preconceptions/expectations and to ignore, not look for, or undervalue what contradicts our preconceptions. Hollnagel (2004) states that this feature of human thinking (a strong tendency to look for confirming evidence) is an example of the Efficiency-Thoroughness Trade-Off (ETTO) principle. Klayman and Ha (1987) state that some confirmation bias results are due to over-application of a positive test strategy. A repeated review of an established condition (e.g. a correctly configured harness) reinforces the expectation that the system is in that specific configuration. This is an example of reinforcement through experience which leads one to miss potentially critical anomalies.

The existence of inattention and change blindness, as well as the influence of expectations on vision (confirmation bias), helps us make sense of this tragic event.



wildfirelessons.net/documen…

From a design perspective, they've addressed many of the risk factors. If you put the rope into the device without clipping it with a carabiner, the rope doesn't end up trapped in a way that it looks like it's actually in. Once you tried to pull any slack out, the rope would pop out. The device will catch a factor 2 fall. It'd be remarkably hard to set it up upside down in guide mode. There are no sharp edges to cut a rope on.

Beyond that they recognize that it's a complex device and provide a lot of documentation on using it. Look at the documentation on setting it up in guide mode.

To address your example, in the document they clearly indicate how to setup a Reverso in both graphics and text. I'm a little surprised they don't show a warning similar to BD's. Especially considering the fact that they show the gate needs to be locked, etc. Apparently they've decided the belay device being setup gratuitously wrong is either low enough risk (when you pull the first batch of slack the rope will pop out, low enough frequency (most users will know how to set these up), or that the text indicating to get training on it is enough coverage.

If you did manage to injure someone by not clipping the rope it'd be possible to sue Petzl and maybe (depending on laws, charge the responsible parties with negligent homicide), although based on the documentation I suspect Petzl would win.

The difference is Petzl addressed a lot of ways their product could fail and either fixed them (design) or warned the customer (documentation). The quickdraw manufacturer (according to reports) didn't fix the issue (they sold a keeper that didn't force the carabiner through the dogbone) or document the problem (no assembly instructions provided).

PRRose wrote: Probably, yes. The elements of involuntary manslaughter are: (i) an act that causes death, (ii) the act is inherently dangerous or done with reckless disregard of human life and, (iii) the actor knew, or should have known, that the act could cause death. Your conduct satisfies all three elements.

I disagree. Not sure where you got your "elements of involuntary manslaughter", but wikipedia explains that for "criminally negligent manslaughter" (the category of involuntary manslaughter in which there is not unlawful act committed):

"Criminally negligent manslaughter occurs where there is an omission to act when there is a duty to do so, or a failure to perform a duty owed, which leads to a death. *The existence of the duty is essential because the law does not impose criminal liability for a failure to act unless a specific duty is owed to the victim.* It is most common in the case of professionals who are grossly negligent in the course of their employment. An example is where a doctor fails to notice a patient's oxygen supply has disconnected and the patient dies (R v Adomako)."

I personally believe that random climbers at the crag do not have a legal "duty" to provide you the highest standard of safety. I think they should, and I think it's a dick maneuver to express undue confidence in your safety systems ("yeah dude, this anchor is fine.") which could become constructive manslaughter if the person presses that "it's fine". I'm not one to make claims of a slippery slope, but ruling that this death is involuntary manslaughter because random people at the crag have a legal duty to provide others with the highest standard of safety would radically alter this past-time. (note: details matter, these people in Tito's case were part of a "club", and not just random strangers at the crag). If everyone at the crag had the legal duty to provide the highest standard of safety, then I wouldn't see why we stop there and don't require people at the crag to have "climbing licenses" (like a driver's license), and people caught climbing beyond the scope of their license should be held accountable for climbing outside of their expertise (like someone with a normal driver's license driving a semi truck or a train).

I don't like that train of thought one bit. The only line in the sand for liability in climbing that I see as defensible and stable is to say people are either guides (and therefore have a duty) or not guides (and therefore have no duty) and you choose who you and your kids climb with.

It's easier to sue someone else than be confronted with your own complicity in a tragedy. I'm sure the father knows, deep down, that his son's safety was _his_ ultimate responsibility. Regardless of how talented the kid was, the father let his son partake in a dangerous sport outside of his own purview. He shouldn't have let the kid climb without his supervision without having absolute confidence that Tito was fully equipped with the knowledge and ability to assess gear systems and safety _himself_. And what 12 year old would instill that confidence?

Our local phenom, Kai Lightner, with the exceptions of competitions, pretty much only gets belayed by his mom. When she realized her son had preternatural abilities, she took it upon herself to learn everything she could about climbing and made sure no one else would be responsible for her sons safety (or lack thereof).

Alex Washburne wrote: I disagree. Not sure where you got your "elements of involuntary manslaughter", but wikipedia explains that for "criminally negligent manslaughter" (the category of involuntary manslaughter in which there is not unlawful act committed): "Criminally negligent manslaughter occurs where there is an omission to act when there is a duty to do so, or a failure to perform a duty owed, which leads to a death. *The existence of the duty is essential because the law does not impose criminal liability for a failure to act unless a specific duty is owed to the victim.* It is most common in the case of professionals who are grossly negligent in the course of their employment. An example is where a doctor fails to notice a patient's oxygen supply has disconnected and the patient dies (R v Adomako)." I personally believe that random climbers at the crag do not have a legal "duty" to provide you the highest standard of safety. I think they should, and I think it's a dick maneuver to express undue confidence in your safety systems ("yeah dude, this anchor is fine.") which could become constructive manslaughter if the person presses that "it's fine". I'm not one to make claims of a slippery slope, but ruling that this death is involuntary manslaughter because random people at the crag have a legal duty to provide others with the highest standard of safety would radically alter this past-time. (note: details matter, these people in Tito's case were part of a "club", and not just random strangers at the crag). If everyone at the crag had the legal duty to provide the highest standard of safety, then I wouldn't see why we stop there and don't require people at the crag to have "climbing licenses" (like a driver's license), and people caught climbing beyond the scope of their license should be held accountable for climbing outside of their expertise (like someone with a normal driver's license driving a semi truck or a train). I don't like that train of thought one bit. The only line in the sand for liability in climbing that I see as defensible and stable is to say people are either guides (and therefore have a duty) or not guides (and therefore have no duty) and you choose who you and your kids climb with.

You owe a duty not to let someone climb on your crappy rope on crappy anchors or, alternatively, you have a duty to warn them that your rope is crappy and is anchored improperly. The class of people you owe that duty to is everyone.

PatCleary wrote:The difference is Petzl addressed a lot of ways their product could fail and either fixed them (design) or warned the customer (documentation). The quickdraw manufacturer (according to reports) didn't fix the issue (they sold a keeper that didn't force the carabiner through the dogbone) or document the problem (no assembly instructions provided).

so let us know which manufacturer it is ...

you DO realize that petzl didnt update their technical materials on quickdraw failure till AFTER the tito accident ..

PRRose wrote: You owe a duty not to let someone climb on your crappy rope on crappy anchors or, alternatively, you have a duty to warn them that your rope is crappy and is anchored improperly. The class of people you owe that duty to is everyone.

so you now you have to tell everyone if you used two opposed draws??? ... as we know tons of people will scream UNSAFE at that even though many of the gyms around here use it

bearbreeder wrote: so you now you have to tell everyone if you used two opposed draws??? ... as we know tons of people will scream UNSAFE at that even though many of the gyms around here use it

The scenario under discussion is a rope that the owner knows is unsafe, as well as objectively unsafe anchors.

I have no idea who it is or what keeper is in use. I'd love to know, as to avoid that product. Lifted directly from DPM's site "The owner of the company that produced the rubber keeper is charged for not including proper instructions for assembly in the packaging."

Good for Petzl to change it. However, after buying a couple Strings last week I tried to assemble one wrong. When assembled with the carabiners I use the very base of the String made it over the edge of an Express draw. Their solution, to the limited extent of my testing, was to design a keeper that won't solidly hold a carabiner to an improperly slung draw.

PRRose wrote: The scenario under discussion is a rope that the owner knows is unsafe, as well as objectively unsafe anchors.

"unsafe" is a relative term ... i know tons of people who would consider anything less than a fully SERENE anchors with lockers unsafe ... there are climbs i consider "safe", but someone else may think "dangerous" ....

its irrelevant for this case anyways ... its not like the people at the store, at the manufacturer, the club or the people around knew specifically that the draws were "unsafe" ...

PatCleary wrote:I have no idea who it is or what keeper is in use. I'd love to know, as to avoid that product. Lifted directly from DPM's site "The owner of the company that produced the rubber keeper is charged for not including proper instructions for assembly in the packaging." Good for Petzl to change it. However, after buying a couple Strings last week I tried to assemble one wrong. When assembled with the carabiners I use the very base of the String made it over the edge of an Express draw. Their solution, to the limited extent of my testing, was to design a keeper that won't solidly hold a carabiner to an improperly slung draw.

its very possible that the company is Kong ... it and camp are based in the area mentioned, and as far as i can tell camp doesnt sell a "string" type of device

kong.it/instructions/FAST_N…

remember this is the FIRST TIME in 20+ years of quickdraws that something like this has happened that we know of ... if the same accident had happened before someone would have brought it up by now ...

bearbreeder wrote: "unsafe" is a relative term ... i know tons of people who would consider anything less than a fully SERENE anchors with lockers unsafe ... there are climbs i consider "safe", but someone else may think "dangerous" .... its irrelevant for this case anyways ... its not like the people at the store, at the manufacturer, the club or the people around knew specifically that the draws were "unsafe" ...

There is no reasonable climber who would consider the quickdraws that killed Tito to be safe, so the fact that different climbers might judge other kinds of anchors to be less than desirable is irrelevant.

The legal question does not turn on whether anyone knew specifically that the draws were unsafe. Someone can be liable for acting carelessly or negligently. This is an Italian issue, so I don't know exactly what legal standards apply, but liability could potentially attach for:

-assembling the draws without having the requisite knowledge or training;
-providing guides or trip leaders who were not adequately trained or supervised
-selling the strings without instructions (particularly if there were forseeable ways to misuse them);
-manufacturing the strings in a way that allowed them to be misused in a forseeable manner if there was a way to manufacture them that did not allow them to be misused.