Tito Traversa, 12, Fighting For His Life


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Alan Rubin

Jul 10, 2013 - 05:17pm PT
Human error made easier by poorly-designed equipment. Surely on certain types of quick draws it is very difficult to get the biner through both the sling and rubber "keeper"--at least for someone as ham-handed as myself. I can see how someone, not only a child (but obviously more likely with someone young and/or inexperienced) could think they got the "nose" of the biner through the sling material when, in fact, they'd squeezed it between the sling material and the rubber. That is human error, sure, but one that could be less likely with either a better design (and, no, I don't have one)or by having the draws pre-assembled (though this doesn't solve the problem when one has to replace worn slings on still good biners). But a horrible and terribly sad tragedy whatever the cause.
Dr. Christ

Mountain climber
State of Mine
Jul 10, 2013 - 07:07pm PT
I don't think an EXPERIENCED adult would have been nearly as likely...

If you have ever worked in a gear shop you know just how clueless inexperienced adults can be. And if you have ever read the stupidtaco, you know just how stupid some adults can be, even the "experienced" ones.

Ice climber
Pomfert VT
Jul 10, 2013 - 07:15pm PT
No effin way a serious adult climber falls for that setup. saying anything else is simply trying to make the girl feel better.
Dr. Christ

Mountain climber
State of Mine
Jul 10, 2013 - 07:25pm PT
Who said anything about a "serious adult climber?" My impression is that it was a KID.

Are you opposed to making a KID who just lost their FRIEND due to a MISTAKE feel good?

Gym climber
Jul 10, 2013 - 07:40pm PT
Human error made easier by poorly-designed equipment.

I suppose you might say it's poorly designed in retrospect, but I wouldn't really fault the manufacturer--I just don't think it would occur to anyone who has the slightest idea how climbing equipment works to set up the draws that way.
I don't see this as the assembler making a "mistake" in the sense of mis-threading something or forgetting to do a process step; she just didn't understand what the hell was going on at such a fundamental level that it would be hard for a designer to even contemplate that someone would do what she did.
It's like someone who thinks a harness gear loop will hold substantial force and tying into it--you can get a harness that guards against that with fortified gear loops, but I wouldn't say normal harnesses are "poorly designed."

SF bay area
Jul 10, 2013 - 07:42pm PT
The Petzl version without the plastic keeper (first one shown in RGolds post), is very difficult to screw up.
Dr. Christ

Mountain climber
State of Mine
Jul 10, 2013 - 07:53pm PT
I'm confident people can find a way to screw up pretty much ANY equipment, eventually.

Jul 10, 2013 - 07:58pm PT
poorly-designed equipment.

A couple of thoughts:

Do those plastic holders really do anything? Do they make clipping that much easier? Or are they an unnecessary doo-dad bling accessory? Some dog bones I have seen have very tight loops and require a bit of effort to thread the biner. I ask because KISS matters.

At 12 years of age, Tito would have been starting middle school in September if he were local. Hed be four years shy of being able to drive a car. Lack of competent supervision complacency is the cause of his passing. So sad.



SF bay area
Jul 10, 2013 - 08:06pm PT
Do we need to balance the simple convenience needs of many against the deaths of a few?

In the end I guess it just depends on insurance and litigation costs. Seems like one litigation would wipe out any possible profit from such cheap devices.

Jul 11, 2013 - 11:06pm PT
Those rubber keepers are not needed. Isnt their purpose to keep the gate of the biner that gets clipped from wobbling? Just sew the dog bone loop tight so that it takes some effort to thread the biner. Done. The keepers are a gimmick a solution looking for a problem. Am I missing something here?

Credit: Gene

[Note that the picture has the gizmo on the wrong end of the draw as was pointed out previously. My arrow should be at the other end of the draw.]

Why market a product that is not needed and is just another link in a chain of what could and did go wrong?


Trad climber
Poughkeepsie, NY
Jul 12, 2013 - 12:22am PT
The following report, posted by daysleeper on UK Climbing and then by bearbreeder over on rc.com, indicates that even when people check for problems they can miss them.


Four experienced people checked this set-up and failed to detect the problem, which is far more obvious than the problem with Tito's draws. The rappeller was killed.

The report goes on to discuss studies highlighting intrinsic perceptual difficulties in detecting unexpected configurations.
patrick compton

Trad climber
Jul 12, 2013 - 08:52am PT
"Inattentional blindness" ...very interesting. If adults performed this poorly I can only guess how a. 12 year old would do.

Gym climber
Jul 14, 2013 - 12:36pm PT
A video demonstrating how hard it is to notice things.

Mark Hudon

Trad climber
Hood River, OR
Jul 14, 2013 - 01:31pm PT
As much as I feel that the adults at the scene should have shown more responsibility, I can't say that I would have been astute enough to notice a 10 year old assembling Tito's draws and then check them critically.

SF bay area
Jul 14, 2013 - 01:36pm PT
They might not have even been assembled on site.

Trad climber
Jul 14, 2013 - 01:38pm PT
Murcy, not sure that video is that useful, saw the gorilla and got the # of passes correct...

When you are climbing, single-pitch, multi-pitch, sport, trad, boulder, you check your gear, every time... whoever was in charge of the gear for that group is in a personal hell the likes of which few of us have experienced...

Like the idiot I saw yesterday and posted about... do not cut corners to save time, do not rush, do not assume things have been done properly... above all, never leave the ground if you don't trust something or haven't checked the set-up personally...

Mark Hudon

Trad climber
Hood River, OR
Jul 14, 2013 - 01:40pm PT
Monolith, true...

Social climber
Jul 14, 2013 - 03:56pm PT
hey there say, rgold...

thank you for sharing...

it is THIS:

...intrinsic perceptual difficulties in detecting unexpected configurations.

THIS is far more common than folks in ANY field, job, sports, household work, AND--the list goes on...

this is very much similar, and on the same trail, as what i was trying to share:

the BRAIN in new, or fast, or even in 'habit' mode, MAY not always
be telling us WHAT we think we heard, or understood (its override, i think it would be, in this case)--or we may even IGNORE something it WANTED to tell us, by falling susceptible to 'OUR overide, as to what we are busy thinking at the time)'...
*added some edit, in case i did not or cannot seem to explain this proper, it is so complex...

hence, the marvels of teamwork, and double-checking (however, double checking is not always going to do it)...

what can DO it, or helps more is:

either TALKING to yourself about anything that WOULD be serious, as you do it, or looking at it from various angles, ahead of time, etc...

*anyone that proof-reads, etc, know how very easy it is for the brain to
see what SHOULD BE THERE, until you do an 'reverse check' and read backward, page up, etc, or, have someone ELSE read it to you, or if you read it OUTLOUD...

we are HUMANs that need VARIOUS safeguards, and even 'un-habit' type ones, thrown in it, on occasions to 'KEEP the brain on alert'...

dear family, please forgive, i have now become part of 'over doing this'...
but i AM A MOMMY AND GRAMMA AND BIG SISTER type, and i love all my
buddies here and all the kids that want to learn...

the BRAIN again, is a marvelous thing--we really are would be nowhere without it, but:

but--we need to understand 'it's GLITCHES'...
take a survey of MANY of the odd mistakes you've done--many times you will wonder, HOW in the world did i DO THAT????? i KNEW better, :O
or, i've done it right, before, all these years...

SOMETHING new or odd, just triggered the brain to 'GLITCH' into
doing an 'OVERRIDE' of 'your judgement' :(

sadly, in climbing, there is no room for mistakes, or time to fix them...
dear family and loved ones... love and prayers to you as you go forward, without your beloved child...

*won't share anymore now, i just saw something very good shared by

Trad climber
Poughkeepsie, NY
Jul 24, 2013 - 10:56am PT
Petzl has updated their instructions for their "String" products to include the following precautions. The second item down in the right-hand column is the set-up that killed Tito.

"String" precaustions from Petzl
"String" precaustions from Petzl
Credit: rgold

See http://www.petzl.com/files/all/product-experience/SPORT/PE_STRING_M90-PE-01A_EN.pdf for the full document.

Maybe these should be posted at all gyms?

Social climber
Jul 24, 2013 - 11:22am PT
Even the very clear graphics of the image above aren't gonna save people from rigging draws with rubber thingies wrong.

I'm with those who say "Why do we need the rubber thingies?"

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