UKC

Following a protracted and complex court case, an Italian climbing instructor has been convicted of manslaughter for his involvement in the death of 12 year-old Tito Traversa in 2013, according to Italian magazine Pareti. The young climbing phenomenon sustained fatal injuries in Orpierre when the incorrectly assembled quickdraws placed in a warm-up route failed while lowering-off, resulting in a 50-foot groundfall. Nicola Galizia, 36 - an instructor present on the youth club trip - was sentenced to two years in prison and faces judicial expenses in excess of 21,000 euros.

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In reply to UKC News:

Ouch. That sounds slightly harsh. Some imbecile does something stupid and he gets canned for 2 years. I unsderstand why.... it was his ultimate responsibility, but still a little annoying for him I guess.

In reply to TheGeneralist:

A little annoying? A kid dies and it's a little annoying? 

F*ck me. What planet are you on?

Stay open minded everyone.  The Italian judicaries' concept of a fair trial based on the scientific evidence might be different to yours:  http://www.bbc.co.uk/news/world-europe-20025626

 

Whoever said there was no such concept as a blame-free accident in Italy nailed it.

 

Presumable all avalanches on the Italian side of the Alps are caused by the Swiss?

In reply to Paz:

Not sure about Italian law but seems pretty clear that there is blame in this case, the equipment being used was unsafe.

If you are providing paid instruction it is your duty to ensure that equipment and work practices are safe. Whether the blame should lie with the individual instructor or his employers is a different issue. in this case the judge decided it was his responsibility.

If you get things so wrong, either deliberately or lack of care then be prepared to go to jail.

In reply to Paz:

But this wasn’t a blame-free accident, was it?  A ‘non-climbing mum’ might have wrongly threaded the draws, but presumably it was a climber who rigged the route and apparently didn’t even look at draws long enough to notice there was anything odd about some of them.  A route being rigged for a child to lead.

 

In reply to Dave Garnett:

Didn't he put the draws in himself on lead?

In reply to Coel Hellier:

I was reading that into the way the first paragraph of the report is worded but, you’re right, the blog post says he was handed a rack of drawers, which is slightly (though not much) more understandable.

In reply to UKC News:

I feel sorry for the instructor, but without knowing any details. If I was unaware that such a thing could happen to quickdraws (which I wasn't till it happened), would I have noticed? I can't say for sure that I would have. And if I didn't notice something which had never been reported before, would that make me criminally responsible? I would say not. But under British law, I don't think I would be.

In reply to :

 

obviously I didn't mean it was a little annoying. I meant it was vastly mind bendingly crushingly calamitous and will stay with him for ever. I'd thought that was obvious, but clearly it wasnt so i apologies for not being clear.

In reply to Andy Nisbet:

This subject used to come up every 6 months or so on UKC.  The first time I read someone far more experienced than me saying “this happened to me” it scared the crap out of me.  I took the hairbands off all my self assembled sling draws there and then.  None of mine were retained by the keepers, there but for the grace of god...   

Should an instructor to a child be held to a higher standard though?  I think so.  But - mitigating - unlike flying there are no central authorities disseminating best practice in the form of accident and near miss reports for climbing, so it’s a lot more random when it comes to proving an instructor should have known something.  No reason for a person in Italy to read UKC, and UKC was the only reason I knew about it; I don’t believe it’s covered in my BMC manuals for example.

In reply to wintertree:

TBH it should be fairly obvious to an instructor that those quickdraws were incorrectly assembled.

Like belaying off a gear loop, I can see how a novice might do it, but I'd expect an instructor to exercise a duty of care to ensure it doesn't happen.

 

In reply to Ridge:

This is why I don’t have a problem with the legal outcome - but if you don’t know about this failure mode, it doesn’t take much complacency to fall foul of it.  But that’s the point of being an instructor in life critical stuff.  You don’t.

 

In reply to wintertree:

OK, maybe it's a well known error nowadays, but I've been retired for a while and it was new to me at the time. Obviously it's well known now, and "crucifying" the instructor will give it more publicity. Maybe it's fair, maybe it isn't.

In reply to Andy Nisbet:

But he's not being "crucified"; as the article explains, he's probably not going to serve any jail time at all.

You can still argue whether it's fair that he should be held legally responsible at all (it's unclear from what I've read whether he'd seen the quickdraws before they were used). But what he's getting seems to be the equivalent of a suspended sentence (and legal costs).

In reply to Ridge:

 

There were 10 climbers in the the group - would you expect the instructor to check every q-d that had been brought along?

 

Chris

 

In reply to Chris Craggs:

Exactly Chris, and quickdraws are things that nobody really scrutinises either. There is another factor in this case that may well have an impact on the decision. In France anyone who has a qualification - guide, instructor etc - is deemed completely responsible for a group or an indivdual, full stop, and so has to assume responsibility even if it was someone else who committed the error. Even if they have no direct link to that group or person, they have in the eyes of the law obligations/duties to everyone else present that we as Brits don't have. This group was Italian, so it would seem logical to assume that either the Italians have the same view in law or that because the accident happened on French soil that French laws prevail. I tend to think it's the former.

I should add that I don't know if the above has a bearing on this case or if indeed the instructor was more responsible or more involved than I'm assuming. I'm also not sure to the absolute degree of involvement the guide/instructor has to have with someone for this law to apply - for instance if I was at the other end of a crag, out of view and earshot when there was an accident I'm sure I couldn't be held responsible in any way or form but I don't know where the demarcation lies. I do however make a point of pointing things out if I see potentially dangerous practices going on - as we all would and should - even if I'm met with an angry reply of 'why don't you go f*ck yourself...' Which is just what happened on one occasion. There are often threads on here on exactly this subject, and I'm quite clear in my mind here where my duties lie.

In reply to Chris Craggs:

Yes.

If you are instructing children who bring their own safety equipment, you absolutely should be checking that equipment before they use it. I'm not sure how that could even be a question? If you have to many kids to check them all, then you don't have enough instructors for the group.

 

In reply to Andy Nisbet:

Many of us became more aware of the thing that can happen when using a 'keeper' with an open sling in the aftermath of the death of Tito Traversa, but that was not in fact what killed him. 

Tito's quickdraws were not open slings, they were 'dogbone' slings with the bar tacks sewn through both sides to leave a relatively small loop for the carabiner at either end.  It isn't possible with such a sling to assemble the quickdraw correctly and then have it jiggle about so the carabiner ends up attached only by the keeper - in Tito's case the only way for that to happen was for the 'instructor' to assemble them that way in the first place.

In reply to deepsoup:

Or indeed the mother of one of the other kids.

 

In reply to jon:

Oops, yes, quite right.  My mistake.

I should probably have said: "the only way for that to happen was for them to be assembled that way in the first place".

In reply to jon:

As I understand it (without being a lawyer, but having read stuff on the subject issued by the DAV)  under German & Austrian law a significantly more experienced person who offers advice & guidance to the less experienced thereby de facto takes on the role & legal responsibility of a guide, even in an entirely voluntary, non-commercial context.

Strikes me as an obvious way to inhibit the sharing of advice & general willingness to help - although it hasn't stopped me from offering a friendly word to obvious beginners doing daft things a couple of times.

In reply to UKC News:

I don't understand why the mother isn't being charged here?

In reply to oddrune:

Presumably because she could not be expected to be competent to assemble/inspect safety equipment, whereas the instructor could?

In reply to UKC News:yes, because a the instructor in charge of a group of children you are explicitly in charge and held responsible for the safe working condition of equipment and that safe practices are followed.  In this case the instructor did not and has been found to have caused through negligence.

the arguments/discussion above about whether or not he/i would have noticed are irrelevant - as an instructor you should know this! 

 

In reply to AlanLittle:

i believe she took on this responsibility the moment she chose to assemble the quick-draws. as a side note: who the hell assembles quick-draws? they are generally bought preassembled.

In reply to oddrune:

I completely disagree. If you are in charge of a group of children and a parent ties their child in it's still your responsibility to check the knot. The responsibility for that child is still on you even if you let another person tie their knot, put their harness on ect. If they turn up with their own kit it's your responsibility to check it's safe to use.

I'm my opinion the instructor should have checked the draws before they were used. Especially if they were assembled by someone who was not an experienced climber.

In reply to RBonney:

Agreed.

...and would you even let a parent assemble safety critical kit like that in the first place,  regardless whether its "checked". Hindsight is a wonderful thing and this is such a sad story for all, instructor included, but really, would you leave doing that to a (seemingly) unqualified parent unless you were totally sure of competence?

In reply to oddrune:

I'm always swapping and mixing and matching my quickdraws.  Removing krabs and putting them back facing the opposite direction (so that they sit on the bolt hanger better), lengthening with extra extenders, putting a revolver krab on etc.  If you are working a project long-term, it's worth making sure that all the clips can be made as easily as possible.

In reply to :

 

in which case she shouldn't have done it.  He's been prosecuted for something which she did that he did not want or ask her to do. I understand why, but I still think it's quite harsh on him.

 

f

In reply to UKC News:

Would you hand some unassembled quickdraws to someone's mum and then climb on them yourself without checking them? I wouldn't!

As an instructor, would I give any crucial responsibility like that to someone who wasn't technically responsible for the group without double checking it myself? Never.

In reply to thebigfriendlymoose:

Swapping krabs and slings on a quickdraw is something many of us do from time to time. What I find a bit odd is why so many quickdraws needed made up from a supply of component parts, rather than being already made? And of course, why someone with no climbing knowledge saw fit to decide to do it themselves, and not think to get someone to check them?! 

I understand the legal reasons of the instructor being responsible, but I agree with those who think it seems pretty harsh on him. 

In reply to Michael Gordon:

I am led to believe that, in Italy, it is quite common to buy quick-draws as self assembly kits.

The instructor had assumed responsibility for the group and therefore should have ensured that the group was safe. He should have been checking all safety aspects, including quick-draws. He can't have the role of instructor and not take the responsibility when shit happens. 

In reply to johncook:

How strange!

As I say, I'm aware of and understand this argument. It still seems harsh to me considering that in my eyes he is less at fault than the person who actually set up the quickdraws in such a stupid manner.

In reply to Michael Gordon:

Indeed!

The parent in this case must have been aware of *what* these things were, i.e. safety-critical equipment, but chose to assemble them DESPITE being obviously not competent to do it! In my eyes, this is a punishable offence, and I feel she should have been prosecuted as well. Has this been my kid, I would have gone after her with fire and fury, that's for sure. Though I'm not even sure I would have let my kid climb on other people's gear; though I do it all the time myself so that might be hypocritical...

I agree the coach has responsibility, but I do not agree he has the sole responsibility and as such, the ruling is unfair.

Where I live, it is quite common for parents to volunteer to be 'instructors' and what not, free of charge as a 'service' to the community. I find it unjust that these people now should come under scrutiny because some mom effed up the assembly of some piece of kit. 

In reply to johncook:

Had he? One of the articles about this incident implies he was just someone on a club trip who happened to be an instructor. Tito, as I understand it, was young but also experienced and not someone who would need what is normally described as "instruction". 

 

In reply to Dave Heaton:

While I agree with your point about checking equipment it does seem that what should have been almost a foolproof piece of equipment, that is the ubiquitous quickdraw, has been enhanced to make it possible to assemble incorrectly.

If I give anybody off the street a sling and two karabiners they'll probably assemble a quickdraw.

Throw in that rubber keeper thingy and god knows what you get.

Is this incident a perfect example of why we should be keeping it simple?

https://www.climbing.com/news/the-quickdraws-that-led-to-tito-traversa-deat...

 

 

In reply to baron:

What someone in the street would do with a quickdraw, harness or pair of crampons is irrelevant to their safety as climbing equipment.

 

In reply to Pero:

Barons point is a good one, the hairband complicates something simple that works, the parent would have struggled to assemble it wrong without it. But ultimately the instructor was responsible and is culpable.

Would you let someone untrained pack your parachute or fill your scuba air bottle? Of course not. But you might let your mates mate, in an informal setting, maybe distracted, not thinking to ask if they were trained.

It should be an alert to all of us who take responsibility, and for instructors a 'gotcha' part of training. Complacency is human and hard to reduce, it's just such a tragedy for everyone involved.

In reply to UKC News:

I believe European legal systems also have something similar to the concept of strict liability in English law.  What this means is that some things may be so serious that the person in charge can be held responsible even if they were not personally at fault.

In this case, the instructor was held to have overall responsibility.  He may not have been responsible for assembling the quickdraws himself, but because he was the experienced climber, and presumably in charge of the group, the buck stopped with him.

Actually, I don't agree that he was not morally culpable.  He was the expert, there with adults who were not climbers, and in my opinion he had a moral as well as a legal responsibility for safety.  In some respects I find it harder to blame the person who actually did assemble them - as a non-climber she can't be blamed for not understanding the risks associated with these rubber bands, however she should have thought to get it checked by an experienced person.

As in so many climbing accidents, the cause of this tragedy seems to have been complacency - on the part of the non-climber who failed to appreciate her lack of knowledge or consider the possible consequences, and on the part of the instructor in not checking everything himself.  Hindsight is easy, but we've probably all been complacent at times and got away with it.

 

 

In reply to UKC News:

Very interesting thread. If it's clear cut in this case that this was a freelance instructor being directly paid to be in charge of the whole group then I think he should probably be held responsible in this case. Whether or not the punishment in prospect is harsh or lenient is a second consideration but a suspended sentence plus a substantial contribution to costs might be appropriate if this is a first offence on an otherwise unblemished record.

But it has been suggested that this was not a clear cut case - that this might have been more of a club family outing with one leader happening to have an instructor qualification. 

I've just returned from my own club's beginners gritstone weekend. 40 members involved. 10 groups out on various Peak grit crags, each group with a club-recognised "leader", an "assistant leader" and two beginners. All the leaders are experienced (40+ years in my case), all volunteers of course, but only three have a recognised qualification (SPA in each case). One of those is me. I'm also club equipment officer and a member of our club safety committee that decides which members are recognised as "leaders". There are a number of circumstances in which I would feel "responsible" or "partly responsible" if an accident were to happen on one of our beginners meets but I would not I think expect to be facing a criminal charge, a prison sentence or heavy legal costs in these circumstances. (In the event of a civil claim, I believe I would be covered by BMC insurance).

Another scenario would be where a customer books a day with a company or centre offering climbing opportunities and the company then deploys one of their staff to supervise the group. There would be circumstances when the company or a senior individual in the company should be considered fully or partly responsible, for example if an inappropriately qualified instructor had been deployed.

Martin

 

 

In reply to Howard J:

But as an adult she should surely have realised that climbing is a potentially dangerous sport, that she did not know what she was doing, and thus that she should not have done it. 

At the time the suggestion was that it had been a non-climbing teenage girl friend, not an adult, which is more excusable.

But, it's still the case that the adult climbers in charge bear most responsibility for lack of adequate supervision.

In reply to Dogwatch:

Though Tito was experienced and able, in the eyes of the law he would still be a child and can't be deemed capable of making an informed decision. A bit like Lewis Hamilton being great at carting aged 12 but not allowed on the roads. As such, though he probably had little to learn about moving over rock, wouldn't/shouldn't be trusted to ensure his own safety. Instruction probably wasn't required but oversight of safety issues probably was.

In reply to ditchy:

Sure but whose job was it to provide that oversight? For example, were his parents present? Just because there was someone qualified as an instructor in the group, does that automatically make him "in charge"?

I don't know the answer to that but there seems to be a working assumption here that because there was an "instructor" in the group, he must have been "instructing". The accounts of what took place don't actually seem so clear-cut. 

In reply to Dogwatch:

Where the accident happened, yes. And quite possibly also in his native country too.

 

In reply to Dogwatch:

No they weren't.  Indeed, one of the sad things is that this was the very first day he had ever climbed without a  parent there.

But, in any group taking kids climbing, there should be a clear understanding among the adults as to who is supervising which kids. 

In reply to UKC News:

Looking at the photos of the actual draws used, they look like the elastic stopper was used to secure silver carabiner to the draw, rather than the red one with the curved gate? 

Forgive me if I'm being thick here, but the red draw with the curved gate looks like the one that should be used for the rope end (curved for easier clipping) and the silver for the rock end.  So if the rubber stoppers were used at all, they should have been on the red (rope) end to hold that one tight for easier clipping and leave the rock end free to move on the dogbone as they were climbing?  

Somebody could have noticed something was amiss when the dogbones were stiff at the wrong end as they wouldn't have behaved correctly during the climb, warranting a closer look as to how they were assembled.

Not sure what I'm trying to say here, but the authorities' picture of how the draw should have been assembled looks wrong to me.

Either way this is a tragic story... 

 

 

In reply to Iamgregp:

But the non-climber who assembled them would have been oblivious to this.

But the only person who used them is Tito himself, on that first climb of the day.  So if you're saying he should have noticed then maybe he should, but he was only 12. 

In reply to Coel Hellier:

No, I deliberately didn't use the "should", nor say Tito himself. He 12 years old and should not be blamed in any way.

 

In reply to Pero:

My point was that, from a safety angle you can't get much simpler than either a sling or a karabiner.

I couldn't think of any useable way to assemble these items that wouldn't be safe, especially for lowering off from which is what Tito was doing.

It's when people try to make simple things 'better', as in the addition of the rubber keeper that things go wrong.

But hey, keep those informative comments coming.

In reply to UKC News:

What do folk think the conviction would be if the person (climber) legally responsible had been the one to set up the draws incorrectly, due to ineptitude? Presumably also manslaughter. This in comparison seems to me more like gross negligence. 

In reply to UKC News:

Not sure if this point has been made.. but I will make it anyway via an anecdote... I remember standing next to a novice belayer at a wall that was in the process of dropping someone from the top of the wall on a top rope because they were belaying in an unbelievably (to experienced climbers) incorrect way... I managed to grab the ropes and saved what could have been a horrible fall. I told the person to take some more instruction on belaying... I think there is a real issue in using inexperienced climbers in any critical part of climbing without 100% double checks. I am sure there are lots of examples of inexperienced climbers making countless silly mistakes because they were perhaps embarrassed to ask if they had got it right.

A very very tragic incident involving someone so young, which we must learn from.

 

In reply to Coel Hellier:

Well, yes.  Or if she was going to do it, she should have been more aware of her lack of knowledge and checked it with the instructor.  But as everyone keeps pointing out, clipping krabs to a sling is an apparently simple process .  I'm certainly not suggesting she is blameless, but the ultimate responsibility lies with the experienced climber who was in charge of the group.

There seems to be some question over whether he was formally in charge, but whether or not this was the case I would say his experience and qualifications effectively made him so, in a group made up of non-climber adults and kids.  It has been  suggested that in that jurisdiction the law imposed that liability on him and the court's decision followed that.  There is something called 'strict liability' which means that someone who is in charge can be held responsible even where they were not directly at fault themselves

As I said before, it appears to have been due to complacency over preparations which, because they are so routine, often don't get the close attention they should.  It's an easy trap to fall into, which I suspect most of us do from time to time.

 

In reply to Michael Gordon:

Gross negligence resulting in death could be manslaughter under English law.

 

In reply to Chris Craggs:

I don't think we've got enough information to understand the verdict.  

For me, if the instructor knew, or had asked, a non-climbing parent to assemble/fiddle with quickdraws they should definitely have checked them.

If, as far as the instructor knew, it was a bunch of quickdraws they had seen before coming out of a club kit bag or personal equipment they had seen before from someone they knew then there is less reason to check.  

 

In reply to Dave Heaton:

I'm clearly missing a vitally important piece of the puzzle here.  Wherabouts does it say he gave unassembled quickdraws to somebody to assemble?

Apologies for missing that.  It does indeed put it in a different light.

 

In reply to Howard J:

OK, fair point!

In reply to TheGeneralist:

At first the instructor's sentence may sound harsh to some, but if it makes other instructors think twice, check their equipment and as a result saves lives in future it seems perfectly reasonable.

In reply to Dave Heaton:

I doubt it'd even cross my mind that there was any way to get dogbones wrong, if they looked right at a glance I'd think they were right because how couldn't they be...

I think those being overly judgemental should probably have another think about what they don't know they don't know. Sad story.

jk

In reply to Dave Heaton:

A better question would be this: If you arrived at the crag with a sack full of quick-draw parts and you assembled them into complete 'draws YOURSELF, would you not ask your buddy to check that you hadn't made a mistake before using them for the first time? I certainly would. You only assemble them once -- excluding tweaks as mentioned by a moose, above -- and checking them is sensible and doesn't take long.

Another thought-vector: most of the kids in a guided climbing group probably bring their own harnesses and I doubt any guide simply accepts that without question or inspection. Guides: do you check your charge's harnesses before climbing?

Personally, I rather agree with the outcome, here, and I even agree with the fact that the jail time will probably not be served. I think that the guide was responsible and he was negligent. Someone died and the correct charge is manslaughter. However, he is surely remorseful and exceedingly unlikely to prove a repeat offender and so rehabilitation is essentially achieved: jail would serve no purpose.

 

In reply to UKC News:

How awful. No matter how it happened or who or what is to blame the loss of that little boy is just terrible.

In reply to Xharlie:

I think it's important to remember that he happened to be an instructor, and from what we know, happened to be present with the group. From memory I don't think there's evidence he was actually working at the time and therefore responsible in the normal sense. 

In reply to Xharlie:

I wouldn't dream of it. I've stripped them apart and reassembled them a thousand times or more, I could do it blind. They're quickdraws.

It probably wouldn't be manslaughter in the UK. Would that also be correct?

jk

In reply to jon:

The reporting on this still seems to be incredibly vague.  It's not at all clear to me if the instructor was paid and employed, or merely present, and it's also unclear whether he knew the draws had just been assembled or not.  So both these (extreme) cases appear to be possible:

1) an instructor was being paid for his services and knew he was the only competent adult on the trip.  He was aware of a parent in the back of the minibus struggling to put some new draws together.  He didn't bother to check them (or just checked one, which happened to be fine) and allowed the child to climb on them.

2) this was a trip from a climbing wall where a number of people had got together to share transport.  One of them happened to hold an instructing qualification but was in no way in charge, certainly not being paid.  After they arrived at the crag, he was dimly aware of one of the parents (who he'd seen at the wall a hundred times) giving one of the children some draws from a bag.  He had no idea they were new and had only just been assembled, and felt no need or obligation to go over and check them.

I would feel that 1) should involve jail time, and 2) should never go anywhere near a court room.  But without knowing what the actual specifics were, probably somewhere between these two extremes, we're doing nothing but guessing wildly.

In reply to jkarran:

I don’t know the specifics of this case, but if a person under instruction died in an accident and the instructor was found to be grossly negligent there are 3, I think, types of manslaughter charge the police could consider. The level of negligence has to be very high though. It’s more likely to be dealt with as a H&S section 3 offence (certainly at an indoor climbing wall, I’m not so sure about outdoors). 

In reply to UKC News:

http://eveningsends.com/climbing-instructor-sentenced-in-tito-traversas-dea...

 

Says here that he was the "unofficial" instructor... 

I like to think i would have checked the draws.... but if the kid was climbing 8b+ on the regular it's quite conceivable that i wouldn't drop what i was doing and dash over to check his quick-draws before he started climbing, especially if i didn't know they were new draws and wasn't even on the job, surrounded by other parents. This guys only crime could be having a qualification  

In reply to duncandarnell:

'Unofficial instructor' could either mean he was teaching/helping for free, or that he wasn't and really just happened to be at the crag at the time. The first sounds much more serious than the latter to me, and again, pretty harsh if it was just the latter.