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ESPELEO RESCATE MEXICO

Reporte de Accidente en USA

El sábado 30 de Septiembre del 2000 murió en un accidente en cueva en el estado de Texas USA un buen amigo de la comunidad espeleológica de San Luis Potosí Mex. y seguramente amigo de muchos mas en el país. Este es el reporte:

ACCIDENT REPORT ON THE DEATH OF JOE IVY IN O-9 WELL, SEPTEMBER 30, 2000

 Edited by Peter Sprouse.

Contributions by John Fogarty, John Ganter, Rebecca Jones, Dr. Jay Kennedy, Bill Mixon, Alan Montemayor, Bill "Carlos" Nasby, Matt Oliphant, Peter Sprouse, Tim Stich, Bill Storage, George Veni

Cause of death: Injuries sustained during a fall of 12-18 meters

Time of  incident: approx. 1900, 09/30/2000

AID CLIMB PROJECT BACKGROUND

O-9 Well is one of the deeper caves in Texas, around 100 meters deep. From the bottom of the 39 meter deep entrance drop, the downstream section continues down 5 more rope drops to a sump. In March 2000, Joe Ivy and Tim Stich made plans to do a dome lead in the bottom of the downstream passage above the sump, about an hour from the entrance. Joe had seen what looked like an infeeder in the ceiling that he felt might lead to more cave passage. Joe had done some bolt climbs in the past, including one in Pozo de Montemayor which led to a considerable amount of cave.

To begin the climb in O-9 Well, Joe and Tim went to the sump room and set up their gear on tarps at the base of the climb. Joe brought a 12-volt Hitachi cordless hammer drill and several types of protection in addition to expansion bolts. First, Joe drilled and set two bolts at the base of the climb. Onto the hangers of the bolts, Joe attached a Kong Slyde. This shock absorbing mechanism is a small metal plate with holes drilled in it. Then the rope is threaded through the holes such a way that as to create friction (see this device at www.kong.ie). The purpose of the Slyde was to turn the 9mm static rope they were using into a dynamic system capable of absorbing the energy of a falling climber. Threaded through the Slyde was approximately one meter of accessory rope terminating in a stopper knot. Under normal static load this cord would not travel through the Slyde, but upon dynamic load it was set up to slip through the device for up to one meter, at which point the stopper knot would end that travel. Click here to see a comparison of this self belay system to a normal belay.

 As the bolt climber made upward progress, the rope connected to the Slyde went up through the protection carabiners and then down to the climber. The ascender (or in some cases two ascenders) of the lead climber were the attachment point to the lead rope. An ascender was used in order to conveniently adjust the length of the belay rope, something that in a normal belay system would be done by the belayer. On the first climbing trip Joe and Tim both took falls onto this rigging and it easily absorbed the energy of the fall. On average, the falls were around 4.3 meters including movement through the Slyde. Tim says that in the case of his fall there was around 7 meters of rope below the top piece, making his fall somewhat less than a factor 0.6 fall (see discussion of fall factors below). In both cases they were using a new piece of protection called a removable bolt (RB). These are reusable wired camming devices designed to be inserted into a drill hole, the use of which would reduce the number of bolts that they would have to place. These come in a variety of sizes. Joe and Tim used both 3/8 inch and 1/4 inch RBs on the first climb. Tim took a fall when a 1/4 inch RB pulled unexpectedly, and Joe took a fall on a 3/8 inch piece, which he felt he had placed poorly. It was extremely difficult to avoid getting some water and mud on the RB before it was inserted. This may have adversely affected the performance of the protection. They decided to abandon using the 1/4 inch size RB and stay with the 3/8 inch ones.

THE DAY OF THE ACCIDENT

Joe and Tim made a total of five trips to continue working on the climb over three weekends. On the last weekend (30 September), they had cleared a muddy section that had made progress on the second weekend unusually difficult. Thick, clinging mud made manipulating gear almost impossible. The final section to the very top of the bolt climb, which was about 50 meters off the floor, was relatively mud-free and on what appeared to be good rock. Joe took the first shift on the climb, as he usually set up the Slyde rigging at the belay point.

After making at least 6 meters of progress, Joe descended to the fixed line below him and rappelled to the base of the wall. He remarked that he was going to eat and get something to drink. From time to time during that day's climbing other cavers on the trip visited the bottom room. Some were still there when Joe descended the standing line. Tim got a wrench and some carabiners from Joe and also his adjustable one stirrup etriers, which he had designed himself. Tim preferred these to the standard multi-step ones Joe also had on hand. Tim climbed up to the anchor for the fixed line and then attached himself to the lead rope. The rope had been passed through a vertical line of  3/8 inch bolts to Joe's last protection, a bolt. During this part of the climb they used both wedge and sleeve type bolts of 3 inch length. Tim switched his ascenders to the end of the rope that came down from the carabiner in Joe's last bolt and climbed to where the lead continued.

Along the way he cleaned carabiners and hangers from the protection Joe had placed, leaving the last two bolts. When he reached the top bolt, he transferred the hammer drill and bolt kit that were hanging on the bolt to himself. From there, he continued the climb by the method they had established. This involved clipping his cow's tail into the bolt hanger of the topmost bolt. He then attached the etriers to the bolt carabiner which also contained the rope. This allowed him to then stand and attach a Fifi hook to the bolt hanger. The Fifi hook is a flat metal hook attached to his harness with a short piece of cord, allowing him to get as close to the bolt as possible.

From there, he adjusted the etriers to a position that allowed him the highest comfortable step from which to drill a new bolt hole higher up. After setting a new bolt, he then hung a carabiner from it. He put one etrier on this carabiner to use it to pull up on. This allowed him to thumb his chest ascender and get slack from the lead rope. Tim then stood up, clipped the rope into the higher carabiner and moved slack down through his two ascenders. Then he could remove his cow's tail and Fifi and climb up to the new, higher bolt. This technique does create a loop of slack not normally seen in a standard belayed climb, where the belayer would be paying out slack as needed by the climber's ascent.

Joe performed these same actions while he climbed. However, earlier in the climbing project Tim had decided to use both of his ascenders on the belay rope, while Joe continued to use only the seat Croll to attach himself to the belay rope. Tim also had decided to use 3/8 inch expansion bolts exclusively. Although the 3/8 inch RBs appeared sound to him, he had enough expansion bolts with him to use for all of his placements. Joe continued to use the 3/8 inch RBs and had placed one on his first shift. At no time had they placed two RBs in a row, always placing a bolt above an RB.

When Tim finished his shift, he was within 4.5 meters of the top of the climb. A hole 2 or 3 meters diameter could be seen at the summit of the climb. A low crawlway appeared to go off in one direction, although it was possible that it was merely a flat roof with a slightly hollowed out ceiling. He drilled two final bolts and tied a double figure 8 knot to make a standing line. At this point, it looked like the lead rope might not reach the top. In any case, Tim had run out of hangers and was exhausted. He decided to end his shift and let Joe finish the final pitch. At most, it would take 4 more bolts or pieces of pro. This left the two bolts at the top for Joe to climb up to. As he rappelled, he removed hangers and carabiners to give to Joe.

Joe had gotten rest, food and water and was in good spirits. Tim told him he had two bolts at the top of the lead rope and might need another rope. Joe coiled one and attached it to his harness. Joe ascended the rope and disappeared from view into the darkness of the upper dome. The other cavers sounded like they were again visiting the bottom room, and Tim heard some voices and saw flashes of headlamps. He could occasionally see the dim glow of Joe's LED array high above him. Then, Tim heard what sounded like a brief exclamation from Joe and then a loud, resounding crash. Many times in the past, large chunks of mud and some rock had fallen on the climb, but this was much louder. Tim called up to Joe, but there was no response. More alarming still, Tim could no longer see any light above him. Joe must have had an mishap, Tim decided.

What the nature of that mishap was, he didn't know. Tim shouted up to Joe several more times. One of the approaching cavers by the name of Sarah Springer heard  the shouting and spoke out to Tim. He told her that he needed help. Sarah passed the word up and in seconds someone was making their way to the surface. At this point, Tim began to hear Joe moaning and trying to say something. Sarah continued descending into the room where Tim was. Tim quickly put on his ascending gear and got onto the standing line. Joe's moaning was coming from a point well below the lead, which frightened Tim. When he finally saw Joe, he could see that he was wedged within a slot above a muddy ramp they had discovered during their previous trips. Joe's legs were slightly raised, his helmet was missing (it was later found and put back on his head), and smears of blood were on the left wall. Joe continually complained of difficulty breathing. It appeared that Joe had taken a fall anywhere from 12 to 18 meters, hit a steep, sloping ledge on the left and then wedged into the slot above the muddy ramp. Tim climbed above the slot and then down climbed to Joe from behind.

Tim noticed that Joe was not attached to any rope. That was the first thing he decided to attend to, as it was very possible that Joe could slip down the ramp and off the wall. He made a quick overhand knot in the rope below him and attached Joe's harness to it. He then asked Joe about his injuries. Joe said, "Can't breathe. Left arm fucked". Tim tried to pull Joe through the slot, grasping his right arm. Joe yelled in pain and Tim asked if that arm hurt as well. "Everything hurts. Do it anyway." With that, he pulled Joe and ordered him to kick if he could. He did, and he eventually came out of the slot and slid down onto the top of the muddy ramp. There is a very uneven ledge at the top of the ramp that is barely large enough to sit on. It is not possible to lie prone, but Tim reasoned that this was the best place to attend to Joe's injuries. The only other alternative was to pass him the 3 or so meters through the slot and immediately rappel to the bottom of the wall. Joe was loudly complaining that breathing was difficult, so Tim focused on that problem first.

The primary reason Joe seemed to be having trouble breathing was that his seat harness had somehow ridden up onto his chest. This was a butt-strap type of harness without leg loops. Normally this type of harness, of a design that Petzl once produced but no longer carries (the Rapide), utilizes an additional strap that goes between the legs, around the butt strap, and comes back through the legs to fasten to a buckle on the harness. Joe deleted this strap from his own harness when he made it, or removed it at some point.

Tim was wary of  removing Joe's harness since Joe was in danger of falling of the ledge, but he needed to breathe. As it turned out, Tim could not have cut if off in any case as he couldn't find Joe's knife. Joe was still somewhat lodged in the lower recess of the slot, so it obscured the gear hanging from his harness, which included the knife. The angle of the ramp was too steep to allow him to pull Joe up onto the small ledge. Time was short, so Tim decided to get him off the wall altogether, but noticed that there was weight on the rope below him.

Even worse, from where he had down climbed the rope had rested on two rocks jammed into the top of the slot. These rocks were  holding the weight of the climber on the rope. He repeatedly pleaded for the climber to get off of the rope, but she replied that she couldn't. Sarah was not familiar with the process of changing over to rappel while on rope. Tim then told her to just keep climbing up, as he reasoned that he couldn't describe how to do a changeover successfully. He then left Joe and climbed the 3 meters to get out of the slot. Once above, he could meet Sarah and let her change over to his part of the rope. This proved impossible, as the rope was deeply jammed within the chock stones and it kept Sarah from climbing to him. Instead, he pulled her through a wide part in the slot below the chock stones and Sarah eventually got onto the small ledge behind him.

Once there, he had Sarah attach herself to the rope above Joe with her cow's tail. By this time, Joe had lost consciousness but still seemed to be breathing sporadically. Sarah and Tim again tried to move Joe to the ledge so they could take his weight off of the harness and allow him to breathe, but Joe's body was covered with slick mud and the only place to grab him was his harness. Tim managed to stem the sides of the small ledge and pulled Joe up several times with his legs alone. This only worked for a time to relieve some weight from Joe's harness, but he would again slip down into a lower position in the slot.

Once again, Tim made preparations to get Joe off of the wall entirely instead of continuing the futile effort to get him onto the small ledge. The rope needed to be removed from the chockstones and passed through the back of the slot and down the ramp. He did that, and then rappelled below Joe and clipped him into his cow's tail with two carabiners. By now it seemed painfully obvious that Joe was not breathing. It would have been very difficult to administer CPR in Joe's awkward position, and so they didn't attempt it. Sarah is an EMT, and she confirmed that Joe had no pulse and was not breathing. See Tim's illustration of the fall scene.

Regardless of Joe's condition, they were committed to getting him down at this point. Once on the ground, CPR could be given easily. Since the slot was very tight, it was difficult for Tim to see his mini rack, much less manipulate it effectively. He knew that he wanted it locked off when he took on Joe's full weight. He had to guide Joe down the muddy ramp, frequently pulling his legs out from under him and getting him unstuck.

Eventually, Joe slid out and onto Tim's cow's tail. Tim then rappelled with Joe to the base of the wall. The rack held both cavers' weight well and the rappel felt safe. When Tim got to the bottom, he got Joe to a somewhat flat area and quickly looked for a knife to cut his harness off. Charley Savvas and Frank Delgado appeared at that moment and came to assist. Tim knew that Joe was probably dead, but said that he was trying to get his harness off and needed a knife. Charley produced one and they moved Joe to a better spot and cut off his harness and cow's tail. Frank, also an EMT, examined Joe and concluded that he was dead. CPR was briefly given, but it was too late to matter.

Other cavers arrived from the surface with a Sked litter and other rescue gear, and the body was packaged up for hauling. Patrick Lynott directed the rigging of haul systems that were used not only on drops but also in the canal areas. They moved the body up four rope drops to the bottom of the second drop, then left the cave to get some rest at around 0300 on the morning of 1 October.

Calls for assistance had gone out to cavers in central Texas at around 2300 on 30 September, and cavers began arriving at the site before dawn the next day. Law enforcement authorities had been notified during the night, had visited the site, and had closed the entrance with police tape to keep anyone from reentering the cave until the Justice of the Peace arrived in the morning.

After clearance was received from the authorities, trained cave rescue personnel led by John Green, South Central Regional Coordinator of the National Cave Rescue Commission went in to finish the recovery just after 1200. Besides John, these were Tim Comer, James Davis, Rod Dennison, Tommy Gillis, and Monty Strange. The body reached the surface at 1610, and was loaded into an official vehicle for transportation.

For details on the body recovery, see the report compiled by John Green.

At 1700 Andy Grubbs, Bill "Carlos" Nasby, Peter Sprouse, and Kevin Stafford entered the cave to de-rig ropes and collect and study the equipment left at the bottom from the lead climbing activities. They found much of Joe's equipment laying on the floor, but some had to be located by fishing around in muddy pools. The hammer drill was in the mud bank where Tim had tossed it from above. While Kevin and Andy gathered gear, Peter took photos, and Carlos climbed up the bottom fixed line up the dome to have a look at the ledge area where Joe landed.

From Tim's description they knew this rope was tied to two bolts that had not been affected by the fall. The rope passed up a narrow crack to a steep, muddy slope about a meter wide. Carlos saw Joe's elbow pad and a bolt laying in the mud. The rope went up over a rounded hump to the side, and was fixed to two bolts about 8 meters above the mud ledge. From that point, a smaller diameter rope went straight up out of sight. The bottom end of it was tied to one of the two anchors, the top end was presumably to the two bolts that formed the belay point that Joe was using. The Slyde was not present at the bottom. Carlos tugged on it, and it felt solid, but at that time there wasn't any assurance that this rope would be safe to climb.

On 2 October, John Fogarty, John Green, Rebecca Jones, Missy Lynott, Patrick Lynott, Charley Savvas, Jessica Snider, Peter Sprouse, Kevin Stafford, Tim Stich and Carlos met to analyze the gear that had been retrieved from the base of the climb. Some of this gear was in an abnormal condition, and is categorized below according to what seems to have happened to it.

ITEMS THAT WERE INTENTIONALLY CUT DURING THE BODY RECOVERY OPERATION:

1. The seat harness was cut to remove it from his chest, where it had slid up and was compressing him.

2. The cow's tail was cut for the same reason, it was tangled on his body, and due to the heavy mud it was easiest just to cut it away.

3. The stirrups, and presumably the back up safety line, were cut off of his handled ascender for use in the recovery hauling system.

ITEMS THAT WERE DAMAGED IN THE FALL

1. The belay rope was completely cut in two, half of which was recovered, the other half of which is presumably at the top of the climb.

2. The frog chest loop was cut at the point where it goes through the Croll.

3. The auxiliary hammer drill gel cell battery had a broken case.

4. Joe's Leatherman knife had a broken lanyard cord.

A removable bolt (RB) was found that showed wear; however, Tim felt that this RB was not being used by Joe at the time of the fall and that the wear on it was from normal use and not fall damage. It was loose and had no carabiner attached to it. When the removal tool is used to pull these out of the drill hole, sometimes strands of wire get cut. They had two more of these in use on the climb, so one could have been involved in the fall.

Unfortunately the Croll was not found. This seems to have been lost in the mud as his body was being prepared for removal. No one specifically remembers removing it when the gear was removed from the body, but the body was covered with heavy mud at the time. It would be useful to inspect the Croll for fall damage or rope fibers.

The cut lead rope was immediately seen as the cause of the fatality. The damaged area on the rope had 80 centimeters of exposed core, though due to stress on the core the actual length of this section of core prior to the damage may have been less. The core was puffy, bundles are separated, and there were lumps where it melted. The sheath was shoved down the core and had noticeable compression for 90 centimeters. Symptoms of this compression were regular raised rings, and reduction of spacing of the red marker strand to 60 percent of the original spacing. It is assumed that the Croll cut the rope under a catastrophically heavy load.

GEAR SELECTION AND BELAY SYSTEM

Joe always looked for ways to improve caving techniques, and for this climb had developed a direct aid self-belay technique. In Joe's experience, more than one of his belayers on dome leads had fallen asleep or dropped him a long way during the many hours a climb typically takes. Self-belayed aid climbs are more common in outdoor rock climbing, but not as common in caving.

One of components that Joe decided to use was the shock absorbing Kong Slyde. This device should have been most effective in a short fall such as the one Joe took, and had worked in previous falls in the dome, however the performance of friction devices of this type is unpredictable due to variables such as mud, orientation of the device at the time of  loading, and the amount of friction added by protection pieces and rock rub above the belay.

Rappelling devices work because you can vary the friction on them, but the Slyde is nonadjustable. It should be pointed out that the safety of this system would have been increased if the rope had been tied directly into the anchor as well as into the Slyde cord, so that if the cord failed, which apparently did not happen in this case, the rope would still be attached to the anchor.

In addition to the belay rig, Joe fabricated his own style of adjustable etriers. They employed an adjustable cord looped through the multiple eyes of the Fifi hook in a similar way to the Slyde, instead of sewn foot loops every foot or so. It is worth noting that adjustable etriers are not desirable when used on shaky anchors, because if the adjustment slips, the resulting shock load may cause the anchor to pull out. There was no direct attachment between the etriers and the seat harness.

Joe also had used an unconventional seat harness. This harness was of a type that did not employ individual leg loops, but rather was made up of two sewn webbing bands, a waist band and a butt strap. This explains how the harness was able to ride up his body after a shock load. In this case, the movement of the harness up his body may have been of some help in absorbing the shock of the fall and is not seen as the cause of death, but could have had serious consequences had the rope not broken and left him hanging.

In rigging ropes and belay systems in caving and climbing it is essential to understand the nature of dynamic loads and to consider the fall factor (FF) in any given situation. Fall factor is a simple formula, length of fall divided by length of rope absorbing the fall. If a climber or caver falls from the height of her belay, the length of the fall is the same as the length of the rope, resulting in a 1:1 ratio or a factor 1 fall. If the climber is 2 meters above the belay with no additional protection and falls the 2 meters to the belay point and the additional 2 meters to the end of the rope, this is a factor 2 fall. The climber has fallen twice the length of the available rope, the most severe fall possible.

Factor 2 falls put a tremendous amount of strain on equipment and climber and should be avoided if possible. In multi-pitch lead climbing, the beginning of the pitch can be the most dangerous because the danger of a factor 2 fall is greatest. If the climber is above the belay point and falls without benefit of a higher piece of protection, she can fall twice the length of the distance between herself and the belay. Even when additional protection has been placed above the belay point, if there is sufficient rock friction in the system, as around a corner, the belay point is effectively raised and the fall factor increased. It is essential when beginning a lead climb to put in the first pieces soon, and make them bombproof. Although counterintuitive at first glance, short falls can in fact be the most dangerous. In rigging drops while caving, it is essential to design and rig anchors with a dynamic load in mind, so that if either the primary or back-up anchor fails, forces greater than fall factor 1 will not occur.

Testing conducted by Petzl shows that an FF2 fall on dynamic rope will generate a force of 9 kilonewtons, assuming a typical climber weight of 80 kilograms. A kilonewton (kN) is defined as the force which gives to a mass of 1000 kilograms an acceleration of 1 meter per second squared. In Joe's case he weighed approximately 114 kilograms with his gear, which would increase that load to 13 kN. Factoring in the fact that static rather than dynamic rope was used, and the force doubles to 26 kN. A paper by Bill Storage and John Ganter suggests that these forces may be MORE than doubled by the use of static rope, which would increase the kN even more. The fact that the belay rope was not in new condition, and was wet and muddy likely reduced its strength.

FATAL FLAWS IN THIS BELAY SYSTEM

The data in the preceding paragraph makes it clear that using a static rope for a leader belay, where high fall factors are by definition expected, is simply unacceptable. The lead rope Joe and Tim used was 9mm PMI static line. PMI calls this rope 8mm, but since they measure rope diameter under a load, which some other manufacturers don't do, it is actually more like 9mm unloaded. Standard lead climbing practice usually only employs 9mm rope in a double rope system, and even then dynamic rope is to be used. Rope choice comprises one of the miscalculations made in the design of this belay system.

The second problem with the belay system used was connecting the climber to the rope with an ascender. Ascenders are designed for ascending, not belaying. Looking at the Croll on Petzl's website, there is a valuable chart under Croll Technical Notice, Loading figures. It shows the load under which a Croll will cut ropes of various types and diameters. The Croll will cut a 9mm static rope under a load of 4 kN, which would occur in a very moderate fall. Although Joe may have been aware of the data in the Petzl chart, he did not believe the failure mode of the Croll with the rope diameter he selected would be the complete cutting of the rope. Joe had expressed to Tim that he believed that the rope sheath would be ripped and bunched while the Croll slid down the rope core. Earlier Joe had an experience using a multi-pulley haul system to drag a truck up a hill where an ascender had cut a sheath in this manner. The core was puffy and separated, but held. In that case, while the pullers did shock load the system by running downhill, they stopped pulling when the sheath failed, while the force in a fall will continue until expended in other ways.

PERFORMANCE OF RBs IN CAVING CONDITIONS

Joe and Tim used both 1/4 inch and 3/8 inch Climb Tech removable bolts on their first trip. Tim took one fall and Joe took one as well when these pulled out. In both falls, they had the benefit of having placed several pieces of protection prior to the RB placement, thereby reducing the fall factor. Tim found the fall he took to be fairly soft. He was able to immediately continue bolting and was not unduly shaken by the experience. As noted earlier the fall factor in this case was estimated at 0.6. Joe similarly was unconcerned about the force of his own two falls and did not see a need to redesign his belay system to handle more energy. Through their experiences of falling, they developed more faith in the belay system, but became more wary of the performance of the RBs. Both Joe and Tim quit using the 1/4 inch variety and Tim quit using RBs altogether, though he blamed their pulling out on mud and water contamination of the hole.

The problem with placing RBs was that it was nearly impossible to keep them clean before inserting them in the drill holes. Muddy hands, random patches on clothing, and the mud and water covering the cave wall made contamination almost assured. The hardness of the limestone varied, as is common, and this effects how well an RB will hold. Whether or not the hole is wallowed out by the hammer drill also affects RB performance. RBs were, however, quick to place and did hold in many cases without trouble. One 3/8 inch RB held Tim's fall in an overhang, which attests to the device's potential performance. This placement was unusually deep in the rock and was very hard to clean once fallen on.

Some aid climbers choose to use some pieces that may only just hold body weight, but marginal pro should only be used with caution and experience. This is especially important at the beginning of a climb when there is the risk of an FF2 fall. Overall, the small time and weight savings in using these devices is questionable, given their unreliability. It takes only a few more minutes to install a bolt.

POSSIBLE ACCIDENT SCENARIO

Joe was alone when he fell, and no one knows exactly what he was doing at that moment. The scenarios presented below are speculative, based on the evidence currently available. If and when it is possible to inspect the actual fall site, a more accurate account may be possible.

When Joe climbed the second standing line to Tim's two-bolt anchor, he had two choices. One was to tie his additional lead rope to the end of the one on the wall, which was anchored at the base of pitch 2,  to make a longer rope capable of easily reaching the summit. They had done this in the past in places where they felt they could safely remove pro pieces in the area where the rope-joining knot would be.

The other option was to move the Slyde self-belaying device setup to the highest two-bolt anchor. Joe apparently did this, as evidenced by the absence of the Slyde at the base of the second pitch. Given the short interval of time between the beginning of his ascent and his fall, approximately 30-45 minutes, it is probable that he was only able to drill and set a maximum of two pieces of pro. It is believed that he set one piece, perhaps one of the 3/8 inch RBs, and may have drilled a second hole. Joe had set the RBs in between bolts on the previous pitch, so he may have continued the practice.

Joe's hammer was on his seat harness in the carabiner that held it. His hammer drill was in its pack, which Joe used like a holster to keep mud off of it. An accessory cord secured the drill to Joe's harness. Based on this evidence, it seems likely that Joe was not drilling at the time of the fall. One possibility is that Joe drilled and placed one 3/8 inch RB, put a carabiner with etriers on the RB, and stood up to pass a loop of slack from the lead rope into the carabiner. He ascended to the RB, put his Fifi hook into it and then readjusted and stood in the etriers. He then drilled a second hole, put a bolt in with a hanger and carabiner and may have again thumbed his Croll to get slack in the rope. The RB below that he was hanging on then pulled out and Joe took a fall with very little rope out. This would result in a short fall of great force that may have reached a fall factor of 2, depending on whether or not he had already pulled out some slack to clip the second piece.

An alternative scenario is that Joe was still hanging from his Fifi hook on his first pro placement, the 3/8 inch RB and it pulled out before he got his drill out of his bag to drill his second hole.

As Joe reached the end of his rope and began to decelerate, the first thing to fail was the chest harness, which cut at its attachment point to the Croll. This chest harness, more properly called a lift harness in the Frog system, was of thin webbing not intended as a life support component by design. It was likely cinched up tight to hold him as upright as possible while climbing, and since it was thin and subject to a sharp angle where it went through the top eye of the Croll, it cut quickly. Joe's body then slipped through his seat harness, which rode all the way up to his chest. Since the fall site has not been visited, there is no way of knowing how much of the one meter accessory cord, if any, traveled through the Slyde. The somewhat wet 9mm static rope may have stretched as much as 3-4% or more. However, not enough energy had been lost in these events, so the remaining energy caused the cam on Joe's Croll to cut the lead rope he was attached to. He then fell 12 to 18 meters.

CONCLUSIONS

A mechanical ascender should NEVER be used as a primary part of a belaying system, no matter how many subsequent devices are added to absorb the energy of falls. Dynamic rope of 10mm or larger diameter should always be used for belaying leader climbs, static rope is unacceptable.

RBs, if used at all, should be used with extreme caution, as they seem to perform poorly under the often wet/muddy conditions of a cave.

The fact that some falls of  lesser force had occurred before the accident led the climbers to feel that the belay system was adequate, however these falls were too few to actually validate the technique. Planning an ascender belay that was believed would "only" result in the stripping of the rope sheath was poor judgment from the start. Joe's death was due to his own actions and the judgments he made in designing his belaying system. No piece of gear failed in a way that was not known to happen. The belaying system design was perilously flawed in that it did not allow for the force of a fall factor 2 fall. A belay system should be designed to handle the maximum fall possible, which is an FF2 fall. The good performance of the belaying system on gentler falls prior to the fatal fall helped foster a sense of complacency in the climbers. Overconfidence kept them from continually questioning their system and methods.

Los restos de Joe Ivy descansan en LAS GRUTAS DE LA PUENTE, localizada en la Sierra de Álvarez, Mpio. Villa de Zaragoza, San Luis Potosí, S.L.P., México.

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