FALL ON ROCK, IMPROPER PROCEDURE, INADEQUATE BELAY, FATIGUE, MIS-COMMUNI CATION

Illinois, Crab Orchard National Wildlife Refuge

On May 31, 1989, an experiential education program was involved in the fourth day of a five day course being conducted in southern Illinois in the Crab Orchard National Wildlife Refuge.

The curriculum called for rock climbing and rappelling at an area called Panthers Den, which offers an excellent site for beginning climbers and rappellers because of the height of the bluffs—roughly 10 to 15 meters. This had been a program site in the past.

After all the students had completed their climbing and rappelling, some staff expressed an interest in doing a climb. The Program Director allowed a few staff to do so, while other staff took the groups back to camp to prepare for dinner.

Rob Newcomer (27), one of the instructors, wanted to attempt a climb at the current rappel site. He wanted to rappel down without belay, and then climb back up the rock face where the rappel was set up.

Program Director Michael Leach was supervising the climbing site. Michael noticed that Rob was preparing to rappel without a belay. Michael told Rob that it was against policy and that he needed to have a belay line attached before his rappel. Rob asked if he could be lowered down (single line) by the belayer. Michael gave him permission to do so.

Rob Newcomber at this point did not change his tie-in to conform to a lowering belay system. He kept his rope through a figure-eight device as is commonly used in rappels. Rob’s belayer, Rick Solomon, was sitting at the tree anchor clipped into the girth hitch and was getting ready to belay. Rob asked his belayer, “On belay?” Rick responded by saying, “Belay on.” Rick was still preparing to belay and was anticipating additional commands (communication) with Rob as is the program’s policy in which they had both received training through their High Ropes course certifications. At this point Rob walked back over the edge attempting to rappel without finishing up the sequence of commands. As Rob stepped over the edge, he fell to the bottom of the rock face as the rope fed through the belayer without arrest.

Rob was reached by Michael and Rick about one minute after the fall. Rob was not breathing. They repositioned him in order to clear his airway, which enabled Rob to start breathing again. Rob fought off efforts to immobilize his spine initially, but after gaining easier breathing, became cooperative and was immobilized.

After a secondary survey was completed by Michael, he made evacuation plans. Rob Williamson and Rick Soloman began to construct a litter. Keith Bealke, leader of the school group, selected students to help in the litter evacuation. Karen took charge of taking care of the remaining students. Michael maintained contact with Rob monitoring vital signs.

The evacuation took approximately two hours to cover two-and-a-half kilometers with the litter. Rob was then transferred to the white van. All staff returned to the program, except for driver Robb Williamson and Michael, who stayed with Rob. They drove to the nearest farm house and called for an ambulance which arrived 30 minutes later.

Rob received excellent emergency medical care, which was coordinated by Michael Leach, an Emergency Medical Technician, and later by medical professionals. (Source: David Cady)

Analysis

Staff are hired based on experience with the activities designed in the program, with attention paid to attracting the highest quality staff available.

In this case, both individuals were skilled belayers, certified by the program and hired as belayers for the rock climbing-rappelling portion of the program. They each had previous climbing and rappelling experience, and were graduates of courses offered by the National Outdoor Leadership School. They had both been hired for previous programs and had received high quality references from contracting organizations.

Lack of training is a factor that cannot be overlooked. Both Rob and Rick had been trained as belayers, but not for the activity in which the accident occurred.

The accident occurred on the fourth day of the program late in the day. Staff had admitted that they were fatigued. In addition, there was lack of consistent use of climbing signals by the staff, inspection of harness and set up by belayer prior to saying “belay on,” and the climber’s personal ownership for his behavior prior to descent. Allowing staff to engage in personal recreation while on a program should not be the norm. The evacuation could have been quicker if a litter and backboard had been at the site. In this case a litter was constructed of wood and rope. A runner could have been sent to notify hospital personnel and to summon help, which also would have sped up the evacuation. (Source: David Cady)