TM accident account and learnings

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mokganjetsi
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TM accident account and learnings

Post by mokganjetsi » Tue Jan 09, 2018 1:17 pm

** I have removed the original post after a climber who I respect raised some issues with the account which was posted, and in particular regarding the safety of Arrow Final, and whether the accident was truly unavoidable. I will leave the thread since I think some good come from the discussion of safety best practice, route selection, belay practice etc.**
Last edited by mokganjetsi on Tue Jan 09, 2018 5:51 pm, edited 2 times in total.

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Re: TM accident account and learnings

Post by mokganjetsi » Tue Jan 09, 2018 1:26 pm

**Some worthwhile considerations around belay safety rock quality**
1. when belaying keep your eyes on the climber and stay aware of everything that happens above you.
2. if you can, tie into the stance in such a way that you can move a meter or more to the side if necessary (if not under a roof)
3. make it a habit when you belay to assess your possible courses of action should there be rockfall from above. do this before the leader starts climbing.
4. non-belaying second could keep a third hand on breaking side of rope.
5. never assume a rock is solid just because it was the last time you were there, or because it is an established route.
6. Helmet - always!

https://www.mountaineers.org/blog/rock- ... -rock-rock
Last edited by mokganjetsi on Tue Jan 09, 2018 5:49 pm, edited 1 time in total.

Brussel
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Re: TM accident account and learnings

Post by Brussel » Tue Jan 09, 2018 3:47 pm

The accident seems to have been one of those perfect storms where a sequence of events had to happen for the devastanting consequences of two deaths on a popular route:
  • Rock coming loose on such a well travelled route
  • Climber falling becuase of broken rock (I've pulled a number of handholds over teh years and not fallen)
  • Rock hitting belayer
  • Rock killing belayer
  • Rope not hooking up on something on the stance whilst Ian was falling
It was simply one of those unavoidable realities of climbing. I had a similar incedent in Europe recently where the leader pulled a large 150kg rock off and took a whipper. Thankfully I was looking up when it happened and becuase we were sport climbing I was able to move and avoid the rock whch smashed some of our gear. All this happend at a roadside crag 150m from our car. We walked away with a fractured arm and some damaged gear.

It is the nature of the sport and you can do everything right as Ian seemed to have done and still have accidents happen. Sure there are some devices that would have helped but climbing has always been a game of managed risks and some devices whilst safer are less easy to use. We make hundreds of those risk management decisions everytime we get on the rock.

Kudos to the volunteers rescue team who went up the hill to get Ian and his clients off.

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Re: TM accident account and learnings

Post by mokganjetsi » Tue Jan 09, 2018 5:57 pm

Brussel wrote:
Tue Jan 09, 2018 3:47 pm
It was simply one of those unavoidable realities of climbing.
I think it something that may or may not be true (hence editing original post). It certainly was unfortunate, unexpected and perhaps even unlucky - we however have to reconsider what we think is acceptable risk.

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Re: TM accident account and learnings

Post by Garron » Tue Jan 09, 2018 9:42 pm

Sad unfortunate events.

* Putting the belay stance in a location where you are unlikely to be hit by rocks from above.

* Having slack in the system may not help as the leader falls onto gear this will pull the rope tight possibly causing the belayer to be pulled into the line of the falling rock.

* Maybe writing "Loose" on dangerous loose blocks in chalk may help others(?)

A similar accident occurred in the UK (Swanage).

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Re: TM accident account and learnings

Post by mokganjetsi » Wed Jan 10, 2018 7:49 am

Garron wrote:
Tue Jan 09, 2018 9:42 pm
* Putting the belay stance in a location where you are unlikely to be hit by rocks from above.
probably the biggest factor that caused the tragedy in this instance. always better to not be directly below leader and also pay attention to this when you are simul-climbing.

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Re: TM accident account and learnings

Post by PeterHS » Wed Jan 10, 2018 10:03 am

mokganjetsi wrote:
Wed Jan 10, 2018 7:49 am
Garron wrote:
Tue Jan 09, 2018 9:42 pm
* Putting the belay stance in a location where you are unlikely to be hit by rocks from above.
probably the biggest factor that caused the tragedy in this instance. always better to not be directly below leader and also pay attention to this when you are simul-climbing.
Usually yes but remember 'spotting' a leader at the start of his/her lead if at all possible.

I owe my life to landing on my belayer after a serious fall due to unique equipment failure. Fortunately, he was directly below me and cushioned my fall as I would otherwise have hit the ground. Fortunately too, he was not badly injured.

It goes to show that there are no 100% hard and fast rules. Every situation is unique and balances of judgement and risk have to be made.

Ciao,

Peter

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Re: TM accident account and learnings

Post by Justin » Wed Jan 10, 2018 11:00 am

Re: belayer position
You don’t want clients wandering around on ledges. If they move off to the side (especially when the leader starts off), the ability to catch the leader (on the rope) is compromised.

They can also be pulled badly (sideways)in the event of a fall (which can lead to injury).
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mokganjetsi
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Re: TM accident account and learnings

Post by mokganjetsi » Thu Jan 11, 2018 11:11 am

Justin wrote:
Wed Jan 10, 2018 11:00 am
Re: belayer position
justin, your take on best and worst places to build a stance on Arrow Final, given the route's characteristics?
PeterHS wrote:
Wed Jan 10, 2018 10:03 am
remember 'spotting' a leader at the start of his/her lead if at all possible
yes, there is of course exceptions - i should not have said "always". generally avoid belaying directly below climber on on-angle routes.

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Re: TM accident account and learnings

Post by Justin » Thu Jan 11, 2018 1:09 pm

mokganjetsi wrote:
Thu Jan 11, 2018 11:11 am
Justin wrote:
Wed Jan 10, 2018 11:00 am
Re: belayer position
justin, your take on best and worst places to build a stance on Arrow Final, given the route's characteristics
For AF I could not say exactly! It depends... wherever possible (on any route) in a place where objects/people will not hit the belayer.

Then you also have the option to put the belayer on a longer leash (needs to be able to absorb a shock load) in case the belayer needs to sidestep a projectile.

Belayer placement is subject to a number of variables. For instance on a hanging belay (where the route goes straight up), there is nothing that you could do.

As mentioned before, one generally doesn’t want clients to be able to be moving around on a ledge - I often have clients sit down (so they can’t fall off!).
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Re: TM accident account and learnings

Post by SNORT » Fri Jan 12, 2018 10:15 am

I read this on Times Live:

https://m.news24.com/SouthAfrica/News/c ... n-20180103
“Ian did EVERYTHING by the book. All systems were solid. The deaths were the result of a piece of fate that sadly are part of these sports‚ incidents that are unavoidable‚ unseen and just random life events.”
This is a rather unfortunate quote in the public space as aspirant climbers of Arrow Final my infer that this was a freak accident and out of context with the nature of the route. I cannot in good conscience with regard to the safety of future ascentionists abstain from detailing the dangerous nature of Arrow Final.

This post in no way is intended to question Ian's competency or methodology on that tragic day, but rather to inform people of the inherent dangers of climbing Arrow Final.

If one cares to search the Climb.co.za website there are many posts alluding to the danger of climbing this route whether following correct climbing and mountaineering principles or not. Arrow Final is by any measure a very dangerous route objectively and as evidenced historically in relation to the accidents that have occurred. It has claimed the lives of no less than 2 people that my peer group not only knew but knew well and were friends. Namely Ian and Beverley Opperman some 30 years ago.

As far as I know all the accidents that occurred prior to 2018 involved experienced climbers!

The objective dangers that are particular to Arrow Final and that are less so on other comparable routes on Table Mountain like Frazers Variation are elucidated below.

1. Rock fall is inevitable from time to time.

The upper penultimate pitches of Arrow Final follows a broad ramp that is mostly frequented by inexperienced climbers (friends, family kids and clients) often "guided" either commercially by professional guides or by friends or family members of various degrees of competency.
The nature of it being a less than vertical ramp with multiple little level or almost level ledges rather than a ridge, smooth friction slab or steep face is that that there are always unstable rocks, pebbles and even boulders on or above it. The stability of the rocks and other debris is altered all the time by rain (or drought) and also by individuals climbing on and over them and by rope drag. As a result, it is inevitable that a stone, pebble, rock and even boulder will be dislodged from time to time. When this happens climbers below (and potentially even hikers on the trail below) are at significant risk of being struck. Belaying out of the line of rock fall is a basic principle of all climbing but this is, historically not commonly practiced by climbers (including me) on Arrow Final. But even in so doing once a person does start climbing they are at risk from rock strike either from climbers above or inadvertent rock destabilization by rope drag.

2. As it is a ramp with ledges rather than a smooth ramp, a leader fall will in most cases result in a ledge strike that will most likely cause injury of various degrees. The longer the fall the more serious the injuries are likely to be as there is no point that it is vertical for long enough to allow a fall into air and only onto the rope.

3. As it is a ramp and not very steep there is no real exposure as one would feel on a route such as Africa Crag. Human nature, being what it is, then negates the fear factor and climbers are often, if not usually, less careful and diligent in following the basic principles of rock climbing and mountaineering with less gear placements that are available and so on.

4. There are a some other reasons that it is dangerous but these are not particular to Arrow Final such as the fact that there are often multiple parties on it.

Be warned Arrow Final is a very dangerous climb and in my opinion the most dangerous climb for individuals of all levels of competency to climb as proven in this latest tragedy. Think carefully about taking inexperienced climbers up it.

Below are some quotes from the past. I think I have comprehensively answered the question in the first quote.
it seems that arrow final is never short of victims. why is this? It's an easy climb. any other notorious climbs on TM? I know of fatalities on Africa Cracks, Jacob's Ladder etc... Africa cracks is understandable. There's no pro in the chimney, but Arrow Final?
2006
I think you will find routes graded with the “S” bit in the 1982 MCSA journal. It does not really stand for “serious” but rather “Severity” which I suppose is almost the same thing. I tried to introduce this method all those years ago and it never caught on. In the US and elsewhere you have X and R.

S0 is super safe and easy to protect with back-up pro. I would consider very few bolted climbs as S0 as the 3rd bolt which is often at 4m is not backed up and failure of that bolt would usually result in a deck fall.
S1 Excellent pro, easy to place but needs some care as do bolted routes. Steep rock with no deck fall possible. An example on TM is Magnetic Wall or Bombay Duck and most of the steeper routes on TM
S2 Excellent pro, not so easy to place, requires careful belaying, not easily backed up, perhaps a run out…..An Example on TM is Touch and Go.
S3 Dodgy pro, high fall factor, deck fall potential, dodgy rock: Sanitorium on TM. (Most of the routes on Yellowwood amphitheatre are S3. Fun Time and Smallblaar are S1/S2.
S4 = x Probably not death but possible Example on TM is, believe it or not, Arrow Final. I know two people who have fallen on Arrow and one died, one had serious injuries
S5 = X. You fall or pull of a block you are Xed
With little gear and long long runouts. Treat it like real climbing. Arrow Final has an unacceptable accident and fatality ratio because of being treated with less respect

2009
I have maintained for some time now that, IMHO, Arrow is arguably 1 of the most potentially dangerous routes on the hill. Now THAT statement must, surely, garner a host of heated replies...but I'll elaborate: Arrow is often (almost universally) recommended as THE route to do as ones 1st trad route - generally because it is *easy*. But, again IMO, it's got poor gear (yes, even tho it’s easy) – certainly to the 1st timer - and the exit is horrendously loose (with even less gear).
So what often happens is that by the time leaders get to the "top" / Exit ramp they are a very, very long way out and the assumption is that a: they'll find gear or b: just "walk" to the top. And we know what happens when one takes flight from up there.
.

In conclusion

A leader fall or rock fall exposes inexperienced, ill-informed climbers in a party to a very high risk of injury or death whether leading or following.

The risks on Arrow Final can be mitigated as follow
s:

1. Embarking on a concerted and co-ordinated project to clean off the loose rocks and debris or at least attempt to stabilize as much as possible.
2. Making fixed belays that entice or invite climbers off to the (right) side of the ramp and that will keep individuals out of the fall line of
objects. This can be effected with traditional protection such as threaded nuts and pegs rather than bolts. (There is an old belay peg level
with the start of 5th pitch of Africa Edge that is in a safe place and that can be improved further right.)
3. Making a fixed belay in a safe place that avoids loose debris on the large rubble covered exit ledge that avoids rope drag over loose rocks.
3. Having two experienced climbers in a party.
4. Belaying with locking devices like the Grigri, Edilred Joule or Alpine-Up.
5. A dedicated regularly up-dated website or forum that not only publishes problems on the route but also publishes when conditions are good and
where parties can inform other parties of their intention to climb the route.

These measures will not “dumb down” the climb at all and may go a long way to prevent further injury or death. Fixed stances are conventional practice in the developed climbing world and also will facilitate rescues as and when needed. Whether these should be bolted is open to debate but if there is any chance of avoiding the death or serious injury of one of my mates or anyone for that matter, I would not object to it.

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Re: TM accident account and learnings

Post by henkg » Fri Jan 12, 2018 11:36 am

Not taking anything away from Snort’s comments as they are all valid. But there are a great many pitches especially on easy trad ground and country climbs with similar objective risk levels.

Scrambling and easy trad carries more risk than steeper roped climbs. Unfortunately most multipitch country climbs has a pitch or two which is really easy, but really risky.

With AF being climbed (and soloed) so often, one might neglect to treat it with the respect any trad climb demands.

A good habit as one climbs is to tap and test holds, flakes etc, maintain three point contact and visualise response to unexpected failure.
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Re: TM accident account and learnings

Post by SNORT » Fri Jan 12, 2018 12:50 pm

Henk, what you state goes without saying as it applies to all rock climbing in one way or another.

However, there are very few and I mean very very few routes that pose a similar or comparable risk that Arrow final poses to climbers and especially to inexperienced climbers in a comparable context. In fact so few that I cannot think of any popular "bucket" list route that I have done or am aware off anywhere in the world that would qualify for a S3 or S4 severity grading!

At the risk of repeating myself

1. Arrow Final is one of the most accessible AND popular world class climbs of its grade anywhere that I know of in the world.
2. Nowhere on it is there any real degree of exposure that I said negates a lot of the fear factor potentially leading to complacency and short cuts with regard to belay and gear placements and so on.
3. All the pitches are easy and require minimal fitness and limited climbing ability making it very desirable and user friendly to guide friends, family and clients. Over 40 years I must have guided more than 50 people up one way or another and soloed it up and even down as many times with takkies or approach shoes.
4. It is a ramp with small ledges all the way that collect stones and debris. This is unusual if not unique for a world class (easy) trad route that would usually follow a ridge, a crack line or a slab or be mostly steeper.
5. The exit ledge is actually blasted rubble loosely held together with climbers' friend and dirt that is always unstable to some degree.

It is this combination of risk factors that is directly and by and large unique to Arrow Final that makes it so dangerous.

6. Then there is the mid-set of doing country and most other routes that invariably requires a much greater degree of commitment and due process and climbing fitness and competency and just "head". So climbing a route like Africa Crag requires all these attributes as it is much "scarier' but technically not much harder than Arrow Final. It may be more strenuous but that's it really. However it is a very safe route until one gets off the true rock climbing and even then there is much less unstable debris and the like compared to Arrow Final. Belaying out of the fall line is also more intuitive and the overall protection is better. This is the nature of climbs as they get harder, steeper and more remote.

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Re: TM accident account and learnings

Post by PaulB » Fri Jan 12, 2018 11:20 pm

For me the big take-away, especially for guides, is to put your clients on auto-locking devices...

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Re: TM accident account and learnings

Post by SNORT » Mon Jan 15, 2018 10:58 am

Paul, auto-locking devices are pretty standard use for professional guides belaying up clients following a pitch.

This was not the problem in this accident.

On the other hand auto-locking devices when belaying the leader is very rare unless a single rope and grigri is used. If indeed a locking device was used such as a Grigri, I have little doubt that Ian would be alive but his client not as she was struck and instantly killed by falling rock.

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Re: TM accident account and learnings

Post by henkg » Tue Jan 16, 2018 4:58 am

Snort, I am not disagreeing with your assessment of AF. I am pointing out that easy sections on trad should ALWAYS be done with due care. And no, this does not go without saying.

Objecive risks are beyond the control of a climber and so many instances of blocks dislocating and causing harm can be poninted too.

A constant reminder of those famous words of Edward Whymper is in order.
You may still be here tomorrow, but your dreams may not. Cat Stevens

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Re: TM accident account and learnings

Post by SNORT » Tue Jan 16, 2018 9:46 am

I have been acutely concerned about Arrow Final as a “route-to-do” for as long as I can remember and there are several posts and threads relating to the objective dangers of climbing this route on the www.climb.co.za website. I first alluded to it in 2006 when I rated it as a severity 3 or 4 or “X” and “R” rated route which if accepted as such should be considered a death trap for climbers which it has proven to be. There are many trails closed around TM from time to time as they are considered to be too dangerous and yet Arrow remains unconsidered in that way.

By any objective measure it is the most dangerous route of its kind anywhere in the world – at least that I know of - and rock fall in particular is unavoidable and inevitable from time to time.

I have inspected the accident scene twice now and from the objective evidence I am 99.9% sure that Ian stood on a large block that gave way under his feet leaving some debris behind that I cleared away and stabilized in a crack on Sunday.

This is what the debris looked like:
Debris.jpg
Debris.jpg (91.53 KiB) Viewed 524 times




Where the yellow outline is there is a “stain” against the rock face and there was a large rock or boulder there before. I have been aware of it for years and avoided standing on it. However to do so required quite tricky feet. Bear in mind that Ian had both ankles fused that would make smearing difficult for him and thus standing on a block that has been there “forever” would have come naturally.

My analysis is as follows, that Ian being taller than me was also aware of this block and he placed gear in the crack above as can be inferred from the position of the ropes in the photo taken from above. Something like this perhaps?
Gear.JPG
Gear.JPG (56.82 KiB) Viewed 524 times


However, unless you have a hand jamb in the crack, and the gear placement would interfere with this, there are no positive hand holds and no positive feet to prevent a fall if the block gave way.

As a result Ian took a leader fall and the block struck his belayer resulting in his fall not being arrested. On discussion with Dion Tromp he confirmed that this is a most likely scenario.


On Sunday I found a lot of unstable debris that was left behind and I carefully moved it by wedging it in the crack at the back and using small stones to lock the rocks in.

The ledge after I cleared it as much as possible looking down. You can see the sandy or dried mud “bed” where the now missing rock was positioned.
Rock bed.JPG
Rock bed.JPG (98.78 KiB) Viewed 524 times

The thing is that the whole route is a crap-shoot with literally hundreds of stones rock and even boulders precariously positioned to be knocked off by inexperienced and even experienced climbers and rope drag.

The only way to mitigate this risk is to belay away from the fall line of rocks and to using locking devices when belaying the leader like a Grigri, Alpine Up or Edelrid Joule.

However this does not protect climbers below from rock fall and this route often has multiple parties on it.

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Re: TM accident account and learnings

Post by SNORT » Tue Jan 16, 2018 9:53 am

Anyway, I spent several hours getting rid of the most obvious loose rock and stones yesterday. Below is what it looked like all over the place.
Crap shoot.JPG
Crap shoot.JPG (80.99 KiB) Viewed 521 times


I made two fixed permanent belays off to the right away from the fall line of rocks and debris.

One is where the clients were belaying and there is a scar from a rock strike.
Scar.JPG
Scar.JPG (84.01 KiB) Viewed 511 times
Last edited by SNORT on Tue Jan 16, 2018 10:13 am, edited 1 time in total.

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Re: TM accident account and learnings

Post by Old Smelly » Tue Jan 16, 2018 10:05 am

Thanks for your efforts SNORT. I am pretty sure I have stepped on a block somewhere there and thought it was dodgy...
Really, its not that bad...I think it's my shoes...

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Re: TM accident account and learnings

Post by SNORT » Tue Jan 16, 2018 10:10 am

Belay point 1.JPG
Belay point 1.JPG (119.67 KiB) Viewed 511 times
The other at the next ledge at the start of the last pitch of Africa Edge where there is indeed and old gnarly peg in situ
Belay point 2.JPG
Belay point 2.JPG (142.62 KiB) Viewed 511 times


Both stances would require removal of the pegs to remove the hex and nut respectively. I shall improve the stances soon by replacing the rope with mailons and chain.

I am fully cognizant of the merits and de-merits of making fixed stances but in this instance I feel it is justified and my conscience dictates that this is the best compromise. Fixed belay stances is the norm in the developed climbing world and there are, in any case, very many fixed bolted and trad stances on Table Mountain already.

These include the following trad stances and bolted lower offs for those that do not know them.
1. Uber Huber
2.. Oddshouters Outing
3. Africa Lunch and Out to Lunch
4. No Longer at Ease
5. Cock'nBull Buttress
6. Sanitarium
7. Magnetic Wall
8. Jeopardy
9. Myrrh
10. Don't Squeeze I'll Laugh and Boltergeist
11. Bombay Duck


Both these new fixed stances are "bomber" but nevertheless should always be backed up with cam or nut placements to the right and the belay position must be at or further right of these placements out of the fall line of rocks. The main reason for building these placements is to invite or entice climbers off to right out of the strike zone of falling rocks at least when they are belaying. These stances will not and cannot prevent rock fall from occurring when actually climbing the route and Arrow Final will remain a very dangerous route to climb.

I also very strongly advise that Arrow Final is avoided if there are already climbers on it.

Adhering to this protocol will go a long way to improve the safety of climbing Arrow Final.

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Re: TM accident account and learnings

Post by XMod » Mon Jan 22, 2018 5:04 pm

I have climbed Arrow Final a few times including soloing it and would have to agree with Snort's assessment of it as a potentially dangerous route. The gear is intermittent in sections and any fall would definitely result in injury on the many small ledges. The loose rock, at the top especially, is absolutely horrendous. To be honest I felt more gripped leading it than soloing it!

Well done Snort for cleaning up the crag top and ledges :thumleft: , something that should happen regularly as a matter of course - yet everyone obviously just scrambles past the debris :scratch: without ever thinking of making things safer. We have all failed Ian and his client in this regard!!!

I also second the call for guides and leaders who may be leading people of less experience, to give their seconds auto-BRAKING belay devices to use along with appropriate instruction on their use. Auto-locking belay devices are not common for trad climbing. Devices such as the Reverso or Mammut's Smart Alpine are ideal. They both come very close to auto-locking without actually completely stopping the rope. I dont believe a Grigri or Sum is suitable for trad at all regardless if you are using one rope or not. The locking action of these latter two is too severe and sudden resulting in a high peak load - NOT exactly desirable for trad gear which may not be altogether bombproof. I too have zero doubt that Ian would be alive today if his second had used such a device. Any device that does not include a back up system of some kind should be regarded as undesirable - throw those bugs and ATC's away!

Auto-braking devices for seconds in the professional guiding realm should absolutely mandatory.

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Re: TM accident account and learnings

Post by XMod » Mon Jan 22, 2018 5:15 pm

One last thought (all climbers take note) is that any rock that is pale yellow in colour (as the remains of the loose block are) on TM should be regarded with utmost suspicion. It is VERY often friable and rotten!

Climbing is a dangerous sport please be careful guys and gals - but get out there and have fun (safely).
The get out there bit being a note to self :wink: :lol:

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