normal accidents and the sand pile effect - Mountain Buzz

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Old 06-05-2005   #1
Join Date: Apr 2005
Posts: 8
normal accidents and the sand pile effect

i've been quite captivated by the posts regarding the recent (and tragic) incidents on the river. indeed the whole topic of survival and death is a fascinating passion for me. i'm a seasoned class-iv boater with my normal share of stories and an experienced outdoorsman. i'm also a wfr and was first on the scene of the climbing fatality in boulder canyon on april 2nd...and it was the first time i had actually seen someone die. the topic of survival and wilderness accidents is something that i'm quite passionate about.

there have been some questions and comments in the threads about the increase in the incidents this year and i want to add my perspective on it. please note that i'm a math teacher by trade and that inherently makes me a bit of a geek, but i think what i have to offer is valuable in this context.

first off, the book deep survival by laurence gonzales is one of the best books i've ever read about why some people survive and some people don't. although the book is more about ocean survival, wilderness survival, and mountaineering accidents, i strongly strongly recommend it to any boater. it made me a better paddler because of what it did for my pysche and my own mental self-awareness during those occasions of meandering on the wrong side of the border between safety and danger.

some quotes from the book that i think relate...

"what we call 'accidents' do not just happen. there is not some vector of pain that causes them. people have to assemble the systems that make them happen. even then, nothing may happen for a long time. that is how mountains such as hood, mchkinley, and longs peak, and others get a reputation as milk runs. many people who get into the worst trouble on such nontechnical peaks are those who have climbed more difficult mountains elsewhere....they are hijacked by their own experience combined with ignorance of the true nature of what they're attempting to do.

perrow's normal accidents, first published in 1984, is a work of seminal importance because of its unusual thesis: that in certain kinds of systems, large accidents, though rare, are both inevitable and normal. the accidents are characteristic of the system itself. his book was even more controversial because he found that efforts to make those systems safer, especially by technological means, made the systems more complex and therefore more prone to accidents.

in system accidents, unexpected interactions of forces and components arise naturally out of the complexity of the system. such accidents are made up of conditions, judgements, and acts or events that would be inconsequential by themselves....perrow's point is that, most of the time, nothing serious happens, which makes it more difficult for the operators of the system [like paddlers]. they begin to believe that the orderly behavior they see is the only possible state of the system. then, at the critical boundaries in time and space, the components and forces interact in unexpected ways with catastrophic results.

[get ready for the geeky stuff...]

small collapses are common on sand piles. large-scale ones are rare. but collapses of all sizes do happen with an inevitability that can be described mathematically as inversely proportional to some power of the size...similarly, fender benders are common, while sixty-car fatal pileups are rare. the so-called power law is found extensively in nature. it's more precise way of saying what perrow was saying: large accidents, while rare, are normal. efforts to prevent them always fail."

it's human behavior for all of us to believe that past outcomes will justify future outcomes... but most of us have paddled our favorite river run dozens of times without incident, and then something happens...and all of a sudden, we may be fighting for our survival. the run down sbc is a classic example that many boaters have cited as something they've run before without any awareness of the severity of the outcome. we can become lulled into a sense of safety...we can easily forget that the system (paddler's mind and body, river flow, hydraulics, condition of the boat, weather, water temp, etc) is complex and never fully predictable. furthermore, stories are not note-worthy, tragedies are. there are thousands and thousands of tremors in california every year, but it's only after the big ones every decade or so that we pay attention to the power of the earthquake. i think the same is true for us boaters and the river.

every seasoned boater has a catalogue of hairy stories on the river...they're quite common and happen all the time...many happened today and went unposted...the stories of boaters dying are more tragic and therefore, far less common. but like the big earthquakes, we stop and listen and re-evaluate our choice to paddle only after one of us dies on the river.

but all of this is normal. tragic, yes...very tragic...and my heart goes out to all those who were close to him, especially his wife. but this boater wasn't the victim of the was not a "freak" was normal. he was caught between "the critical boundaries in time and space [where] the components and forces interacted in unexpected ways with catastrophic results."

like i said at the top, i agree with much of what has been posted on the topic of this tragedy. i just want to put a different spin on our perspective on accidents as paddlers in an effort to add to this conversation, not tear it down. i also don't want to sound like a know-it-all or like i have all the right answers. i only offer this piece to the topic as a piece, not a solution or end all on the subject.

i'd be interested in hearing your feedback and thoughts.

peace, chase

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Old 06-05-2005   #2
Steamboat Springs, Colorado
Paddling Since: 1983
Join Date: Apr 2005
Posts: 86

What always gets me is the statistic which always gets thrown out following one of these tragic accidents. That is that you are more likely to get killed driving to the river than actually boating.

If that is statistically the case as so many claim, then why have I never known anyone who died driving to or from a river trip or while on shuttle and I've know almost 20 boaters now who have passed away?

Maybe you can shed some light on that, coming from your math background.

What gets me is how forgiving kayaking usually is. I've watched many people paddle into the most horrendous looking places and come away without problems, places I'd never even consider getting close to out of fear. For example, try sometime going to the Gore race and watching a spot all day, especially after the race is over. You'll see some horrendous mistakes with everything coming out o.k.. It can be the most inconsequential spot, like say the first drop, Applesauce. Someone is sure to paddle straight down the middle onto the rock and come out laughing in the pool below. You'd think it would be bad but nothing happens.

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Old 06-05-2005   #3
ski/kayak bum
Join Date: Oct 2003
Posts: 460
i havent read the first book that your referencing but i have read perrow and he was refering to human created systems not rivers that are as dynamic. His "large accidents" are a result of many much smaller accidents or even better bad conditions. for example the challenger shuttle explosion was the result of many people/systems failing not just some bad O-rings. O-rings by themselves werent the culprit, it was bad engineering/design/manufacturing/safety checks/testing/installation so on and so forth. 9/11 wasnt just some guys flying into buildings it was years of failed foreign policy/bad immigration laws and policies/bad intelligence/bad security at the airport/and numerous other failures along the line. as you "complicate systems" you add powers of possible outcomes and failures. this isnt a critique of your comments just some clarification. and it is only my take on his thesis.

that being said how do you think this relates to boating accidents? and the future of safety systems in kayaking?

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Old 06-05-2005   #4
Join Date: Jan 2005
Posts: 305
to qoute double-a-ron
"that being said how do you think this relates to boating accidents? and the future of safety systems in kayaking?"

That is a very simple outcome.
"take 100 chefs cutting veggies at some point a bandaid will be needed no matter how good they are."
"enough people do the same thing for a givin amount of time a different result will happen, for the good or bad."

The helmet law and motorcycles it is proven to lower brain damage in accidents but some people die from a broken neck caused by the helmet.

In scuba we teach the buddy system in case you run low on air for saftey but if you stray to far from your buddy...

No matter how safe you/we try to be an unexpected outcome will arise.

The causes can be reduced, driving slow in the snow, double checking your buddys gear when going climbing or diving but faliure in a system will happen either human or equipment.
This is why they are called accidents.
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Old 06-06-2005   #5
Join Date: Apr 2005
Posts: 8
dq...good point... i know that many folks traditionally use the automobile statistic to quantify the relative safety of airplane travel... and it seems that you're questioning whether people overuse/misuse this statistic...and i don't know specifics, but it seems to me that the relative dangers of paddling class iv (and v, vi) whitewater are far greater than driving your car. we are an elite bunch of athletes who (like mountaineers, b.a.s.e. jumpers, nascar drivers, and extreme skiers, boarders, whatever) put ourselves on that edge between safety and danger in search of life. we become accustomed to being able to make that choice of position...and paddlers often die as a result of their own decisions rather than many drivers who die as a result of someone else's stupidity. i can't explain your frustration with the overuse/misuse of the statistic...but i think you are justified in expressing it. i know it's easier for me to justify what i do on a river using that same statistic...but i say it for me, to excuse me to myself of my risky behavior...but i doubt if i die on a river that it would make those who love me feel any better about my death.

double-a-ron... i have not read perrow's book, but i do know that he frequently uses the shuttle accidents as examples in his works about how accidents are a result of systemic failures that are as complex as you describe. your comment is spot-on...and is very clarifying. i appreciate the knowledge and perspective you share. my hunch is that laurence transfers perrow's arguments to mountaineering accidents (everest in '96 being a commonly used case)...and personally, i see the connection between that and snapping my skirt on at the riverbank before hurling myself down a class v run that is at (or just above) my ability level. the river is not a system in and of itself...but humans who try to navigate them create their own safety systems (mental, physical, technical, and otherwise) to help increase their own chances of survival...and for the most part, the safety system isn't used. when it is used, it usually works...but like rasdoggy says, put 100 chefs in a kitchen, someone will need a band-aid. put tens of thousands of boaters through deadly whitewater, the human system mixed with the added complexity of the chaos of the river, someone will inevitably die. and that is a normal consequence of the sport we choose...and of the lifestyle that athletes like us choose. tragic accidents are rare, but normal.

i don't know what it means for the future of the sport... i hadn't thought of that until now after reading your question. i guess i was only targeting at changing our perspective on future tragedies that will inevitably happen and how we deal with them as a paddling community. as for the future of the safety systems in kayaking, doesn't perrow state that the more complex the safety system, the more catastrophic the results of that safety system when it (inevitably) fails? i don't know. you probably know more about that having read the book. i'd be interested in hearing more of your thoughts.

thanks for the thoughtful feedback...keep it coming.

peace, c
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