NO such thing as "freak" or "fluke" accidents

[vineyridge]

In the cursory statistics published in the FEI report, it stated that the fall rate at CCIs was over 26%; the fall rate at CICs is about 17%, IIRC. One wonders why the discrepancy, except that 4* would tend to distort the figures. (I will admit that I didn’t read the whole power point presentation/report.)

The surface reaction would be to eliminate CCIs to make the sport safer, but I don’t think that is the correct answer.

In response to the above post, there was an option at Badminton this year for the Vicarage Vee; very few riders took it. CMP’s comment on the carnage is that the riders rode it wrong; that some of the tracks were a yard off the only correct line.

[ise]

I was at Jersey Fresh all three days. I had two horses competing - one in the CCI3* - he won his division and a mare in the CIC2* she finished 5th. I walked the course and saw all the obstacles. The footing was excellent. Weather conditions were also excellent. My background in in Statistics and Analysis.
It was horrible when the accident happened and the event was stopped for close to 2 hours to accommodate the air lift of the young woman who eventually died. It was also distressing when one horse was injured and has to be put down. While it is a situation that will stay with everyone there forever, I saw no obstacles that were obviously dangerous. If I had - I would have pulled my horses - I not only own them, I bred them. I realize the possibilities for all my horses in various disciplines when they compete. But I also know from a statistical basis - there will be accidents. Some of them horrible and heartbreaking. There will always be a probability and it’s rarely zero.

[snowrider]

[QUOTE=Paks;8665260]
Rotational falls occur when the front end is stopped by the fence and the horse had enough momentum that it still continues. This usually happens when the one or both of the front legs hit the fence above the knee. If the hit occurs below the knees the lower legs usually just gets a good rap and folds clearing the obstacle. However with a table the folding of the leg may not be enough as the surface of the table provides friction slowing the front end down as the backend airborne continues faster than the front end and the flip occurs.[/QUOTE]

I also think that the kind of rotational fall that proves fatal for the rider is more likely to occur when the horse flips straight over, which is more likely to happen with even resistance along the pivot surface. So a jump where a horse who has failed to clear it with one or both front legs is pivoting on it a chest or upper foreleg over a level, fixed, smooth and even surface.

If you watch rotational falls on YouTube, which I did last night with an engineer buddy, it’s quite predictable imho which jumps have the potential to see that kind of fall. Does that mean they “cause” falls? No, the horses failure to clear it is the “cause” and even then falls are rare and there are variables that determine if the horse lands on the rider or not. But the mechanics of what happens after seem to be well described in this thread.

Also there are a crapload of rotational falls on YouTube! I had no idea it happened so often. We only saw a couple filmed in a ring with show jumps and they seemed to all be associated with a horse falling to its knees and tipping over. Still scary but not predictable.

[alicen]

[QUOTE=hldyrhrses;8665415]
I would like the riders get together at an event with a dangerous jump and say they aren’t going to jump the fence b/c its too dangerous![/QUOTE]

They could do that and choose to take the longer route, but not all of the more dangerous riding fences cause traumatic horse and/or rider injuries.

[JP60]

[QUOTE=vineyridge;8665425]
In the cursory statistics published in the FEI report, it stated that the fall rate at CCIs was over 26%; the fall rate at CICs is about 17%, IIRC. One wonders why the discrepancy, except that 4* would tend to distort the figures. (I will admit that I didn’t read the whole power point presentation/report.)

The surface reaction would be to eliminate CCIs to make the sport safer, but I don’t think that is the correct answer.

In response to the above post, there was an option at Badminton this year for the Vicarage Vee; very few riders took it. CMP’s comment on the carnage is that the riders rode it wrong; that some of the tracks were a yard off the only correct line.[/QUOTE]

This the heart of the matter. Horses, humans, they are going to make mistakes. We do it all the time, but we build around us a tolerance factor to try and avoid the worst bad potential when we F up.

General Aviation airplanes are designed with positive lateral stabilization which is a fancy way to say that if put into an unbalanced position, the plane will self correct. It is less efficient fuel wise, but it helps cover many minor mistakes some pilots may make. On the opposite side, modern fighter jets are design with almost negative lateral stability which makes them very maneuverable, very fuel efficient, but requires a computer to keep them in the air.

The sport of Eventing should not be allowing Course designs or Fences that are such that a yard one way or another results in the potential for inury or death. Looking at Rolex, DeGracia designed a course with positive lateral stability. Glance offs, refusals, run outs the still impacted the team, but did not put them in immediate peril. Badminton was more the opposite with the worst being the V Vee.

The fundamental question we want to answer is what do we want out of this sport, a rare few that have the aptitude to be almost perfect as we hold our breath for those who don’t, or one that rats out the weak without creating harm to either while still presenting challenging rides.

Boyd did not take the option thinking he had the skill to be almost perfect. He was lucky to walk away and not have his horse damaged. Not everyone will take the option when they think they know how to Ride, they are too stupid to understand the consequences, or have too much ego to back down. That is not how we should be thinking about course design.

[poltroon]

[QUOTE=ise@ssl;8665437]
I was at Jersey Fresh all three days. I had two horses competing - one in the CCI3* - he won his division and a mare in the CIC2* she finished 5th. I walked the course and saw all the obstacles. The footing was excellent. Weather conditions were also excellent. My background in in Statistics and Analysis.
It was horrible when the accident happened and the event was stopped for close to 2 hours to accommodate the air lift of the young woman who eventually died. It was also distressing when one horse was injured and has to be put down. While it is a situation that will stay with everyone there forever, I saw no obstacles that were obviously dangerous. If I had - I would have pulled my horses - I not only own them, I bred them. I realize the possibilities for all my horses in various disciplines when they compete. But I also know from a statistical basis - there will be accidents. Some of them horrible and heartbreaking. There will always be a probability.[/QUOTE]

I want to highlight this comment, because I think there’s a myth that we have the information today to know which these especially dangerous obstacles are going to be in advance, and that somehow riders, trainers, and course designers are ignoring this data. It has seemed to me that the data show that we don’t.

There are additional factors that are hard to control and understand - how the horse sees the obstacle, how careful the horse and rider will be at a particular situation. My trainer once told me to always beware fence #5, regardless of what it was. Paraphrasing badly, “It’s right when you stop thinking ‘oh shit this is really scary’ and have started thinking everything is going well and it will all be fine.”

I agree. It’s crucial for the health and future of our sport that we figure this out. I love eventing, I love the camaraderie among riders, I love the discipline of working out the three elements, I love the opportunity to play with my horse. But, it stops being fun when horses and riders die on course.

Some kinds of accidents will always happen. But, truly, we need to keep looking for a way to mitigate or prevent rotational falls from being catastrophic so often.

[MtnDrmz]

[QUOTE=vineyridge;8665425]
In the cursory statistics published in the FEI report, it stated that the fall rate at CCIs was over 26%; the fall rate at CICs is about 17%, IIRC. One wonders why the discrepancy, except that 4* would tend to distort the figures. (I will admit that I didn’t read the whole power point presentation/report.)

The surface reaction would be to eliminate CCIs to make the sport safer, but I don’t think that is the correct answer.

In response to the above post, there was an option at Badminton this year for the Vicarage Vee; very few riders took it. CMP’s comment on the carnage is that the riders rode it wrong; that some of the tracks were a yard off the only correct line.[/QUOTE]

17%, let alone 25%, is clear stats that show this is not a “freak Accidnet”. IMO as long as something can be replicated, it is not freak, unlikely perhaps, but not freak. While I’m sure not all of the 25% is rotational, part is. Rotational Falls on Tables have definitely been replicated by more then a few riders, and needs to be addressed. I am an H/J rider, and would never actually consider Cross Country until the fences fall instead of you. I really felt so much emotion with all the news this weekend, and I am actually happy to see such a strong community in the eventing world. So many of you seem to be voicing such strong opinions, and in a constructive way for the most part. I hope that the funds are mustered up to do the science behind all this!

[Grasshopper]

I have two questions so far, have not followed too closely as, frankly, it hits a bit too close to home for me with 2 small children.

1. I am far from an expert on course design…but I took a look at the fence where PH had her rotational and it gave me a flash-back to the fence where Darren had his rotational that very nearly killed him (I happened to be a fence judge at that one and have it fairly permanently imprinted in my brain). Not the fence itself–the one that ate Darren was basically a hanging log–but the funky “groundline” and the visual impression of the front edge. Did anyone else get the same impression?

2. Has there been additional research/ development of safety gear such as the Exo vest? I bought one last year after I had my son, since I have a horse I’d like to get back into eventing with, and I’d had a front-row seat at Darren’s accident. Sure, it’s a little more unwieldy and won’t protect against all kinds of crashes, but I am grateful to have the option.

Decided to add that, as mistakes and accidents will inevitably happen, perhaps the focus should be (and to be fair, some already is) on ways to minimize the resulting damage. Derek seems to have been very successful in designing courses that are tough but non-damaging. I rode some of his (lower level!) courses while in CA 10 years ago and my impression even then was that they were hard, but if you were unsuccessful, you (ahem, I) would end up with a refusal or a run out. Likewise, I don’t think anyone would say Hugh’s courses at Red Hills are easy, but there certainly seem to be far less devastating consequences for mistakes than on some of his predecessor’s… Of course, I know there are more options now in terms of frangible pins, etc. What can we, as a sport, perhaps learn from what has improved and has “gone right” over the past few years?

I’ve been out of the sport for a few years, so forgive me if this kind of thing is well known, but is any data collected regarding hits to frangible fences; fences where rotational falls occur; review of video, etc etc?

[msmom]

[QUOTE=Xctrygirl;8665329]
Yes but which of the “powers that be” are leading the reins on the so called next steps?

~Emily[/QUOTE]

I think this is the crux of the problem. Who is accountable and/or has the authority and resources to properly investigate and make recommendations on how to improve safety in our sport?

Sadly, based on my personal experience (and based on what I’ve read on these forums RAyers and several others went down this road long before I did), it’s not the USEA Safety Committee. I emailed Jo Whitehouse last spring and volunteered to help with data collection/analysis (I have 20+ years experience with Systems Engineering and Test & Evaluation). While Jo was appreciative and receptive, I got zero response from the Safety Committee. I emailed the co-chairs twice asking what I could do to help and got absolutely no response. Last fall Jo emailed the Safety Committee the rider fall data that had been collected for 2015. I did not see a single reply to Jo’s email.

And just to complicate things further, the falls this weekend were at FEI events, so I’m guessing that just muddies the water further. Even if the USEA did want to investigate the falls, how does that work with the FEI?

I wish I knew of a way to incentivize the USEA and/or FEI to put resources into the kind of investigation RAyers is advocating–and then have the cojones to follow through on the recommendations.

[hb]

@JP60;8665463

The sport of Eventing should not be allowing Course designs or Fences that are such that a yard one way or another results in the potential for inury or death. Looking at Rolex, DeGracia designed a course with positive lateral stability. Glance offs, refusals, run outs the still impacted the team, but did not put them in immediate peril. Badminton was more the opposite with the worst being the V Vee.

This is key. No matter what question the fence is asking, in this example it is “can you ride an accurate line”, the result of a wrong answer should not be injury or death.

Refusals, run-outs and activating the frangible pin are enough to keep an event from being a dressage test.

Falls are not the right way to separate the top horse/rider combinations from the rest of the field.

[Fred]

[QUOTE=frugalannie;8665296]
Thank you, Reed. Your examples make all too clear what is not happening but should.[/QUOTE]

Yes, thank you, Reed.

[snowrider]

Msmom is the Safety Comittee riders? Is it all volunteers? To me this really calls for accepting offers such as yours, setting up a technical advisory committee of volunteers with significant experience nd knowledge in the key fields (modeling, engineering, data mining), having that group take the general concerns of “dangerous courses”, defining a few areas of study and data collection and then raising money to contract out the actual work. Come together later to review, develop a strategy to test in the field or under controlled conditions and define new tasks. Maybe have one part time employee to coordinate and do contracting. Pretty simple, do it all the time.

But expecting professional riders to do it is not gonna happen. They haven’t the skills in organizing a research endeavour or doing any applied testing. They wouldn’t know where to start and are at the mercy of and so called expert who appears to advise them. I also see that happening a lot.

[JER]

Eventing might do well to devise a ‘Vision Zero’ initiative for the sport. Vision Zero is a Swedish road safety platform that doesn’t accept ‘acceptable’ risk. Since the adoption of this plan, Swedish road fatalities have dropped from 7 traffic deaths per 100,000 people to 3. (More here.) Of course, the goal is zero, but you can see what progress has been made.

[YEG]

Let’s draw on the incredibly effective and time-tested risk identification and management strategies that can be found at any industrial/engineering company. I’m an engineer, so that’s what I’ll draw on. At any company I’ve worked at, safety really has been the number one concern, as it should be. No accident is called a “freak accident” in the workplace, because the root cause can always be identified and measures can always be taken to improve safety as a result. “Accidents” aren’t even called accidents anymore, to prove that point: they are incidents, and there is always something to learn from them.

Some of the ways incidents can be reduced:

1. Risk identification and mitigation, as OP mentioned. Even if the risk is infinitesimal, let’s make a plan to mitigate it. The probability may be small, but the consequence (death) would be unacceptable.

2. If an incident does occur: a thorough investigation has to happen, and a plan made to prevent it from happening in the future. Again, others have mentioned this, and it isn’t happening enough yet.

3. Near-misses: this is where we need even more action. We can learn as much from the near-misses as we can from the horrible events that cause injury or death, and the benefit is that we can apply mitigation measures before something catastrophic happens. I think this is an area that needs to be greatly improved. Sometimes jumps are removed from the course, yes, but are they really analyzed to find out what the danger was? Is that learning shared throughout industry so that practices can evolve and others can benefit from the knowledge? I agree we need to collect more data about the jumps involved in injuries and death, but lets go further and collect data on the near-misses as well.

Of course, this all costs money and time and expertise, which isn’t necessarily available in our sporting bodies. I argue that the money and time would be well spent, and that a third party that is an expert at risk management and prevention (not necessarily with an equestrian background!) should be hired to really look at this, for the sake of our horses and our riders.

[vineyridge]

Maybe USEA needs to have a capital fundraising campaign. Get itself on a strong enough financial foundation that it can afford to do safety research from the income of its endowment.

[IFG]

[QUOTE=msmom;8665591]
I think this is the crux of the problem. Who is accountable and/or has the authority and resources to properly investigate and make recommendations on how to improve safety in our sport?

Sadly, based on my personal experience (and based on what I’ve read on these forums RAyers and several others went down this road long before I did), it’s not the USEA Safety Committee. I emailed Jo Whitehouse last spring and volunteered to help with data collection/analysis (I have 20+ years experience with Systems Engineering and Test & Evaluation). While Jo was appreciative and receptive, I got zero response from the Safety Committee. I emailed the co-chairs twice asking what I could do to help and got absolutely no response. Last fall Jo emailed the Safety Committee the rider fall data that had been collected for 2015. I did not see a single reply to Jo’s email.

And just to complicate things further, the falls this weekend were at FEI events, so I’m guessing that just muddies the water further. Even if the USEA did want to investigate the falls, how does that work with the FEI?

I wish I knew of a way to incentivize the USEA and/or FEI to put resources into the kind of investigation RAyers is advocating–and then have the cojones to follow through on the recommendations.[/QUOTE]

So sorry to hear that little has changed.

[Gnep]

[QUOTE=RAyers;8665194]
I am presenting this as a separate thread simply because I feel that this should be separated from the threads commenting to the direct tragedies.

Some context as to my position. In my professional work, I develop and use explosive reactions to synthesize materials (and in some cases try to remove materials). I’ve conducted failure investigations of explosives. I’ve been involved with, well enough, failed reactions that EH&S and I spoke almost weekly.

What is the important thing? In all my work, I’ve had to “sit down” and REALLY think about risks and ways to reduce the threats to my and my colleague’s lives so that if something went wrong, we all walked away. And trust me, some of what I do and what has happened has/had the potential to be insanely lethal. There is nothing that wakes your ass up to what you are really doing and what the risks are when you need to send everyone out of the BUILDING so you can prepare a “simple” sample for processing.

I don’t say this to be cavalier but to point out that eventing is on a serious CRASH (pun intended) course to oblivion by “ignoring” the tragedies both with horses and riders by hiding behind the concept that “riding horses is risky.” So is playing with unstable fireworks and trying an explosive chemistry nobody ever has tried, ever.

To whit: I tried a highly unstable reaction that is fairly common and well defined. I knew that risk so I built into the protocol several checks. However, one instance (we figured it was about a 1 in 10,000,000,000 shot) I literally blew up a preparation chamber. IT was NOT a freak accident! It was two grinding balls crushing the unstable oxidizer in the presence of fuel at 40gs. Something that appeared totally random but because I considered the POSSIBILITY, I was in another room when it went.

WE KNOW THE RISKS in XC. WE KNOW THE RISKS AT MANY TYPES OF FENCES. Where the hell is a HACCP plan? Where is the real, transparent investigation? Why aren’t these data incorporated into a full on analysis of mitigation?

Why do we accept the idea “ah, that’s horses?” Or, how about looking at this, what if we said, no riders would ever die again, but YOUR HORSE will die. Would we get a bit more proactive? We protect the horse, we will protect the rider and vice versa.

I’m not saying I’m the only person with the answers, but I know eventing could greatly benefit from applying the experiences and knowledge form other sports and industries where participant death was/is a regular thing.

Reed[/QUOTE]

When I played around with that collapsible, I wanted first to understand what really happens. I dug up every dam video I could find and even had people send me their private videos. Some came from friends or families of riders that had nasty crashes. I went through those videos, single pic, by single pic and wrote a protocoll for each crash. Than I searched for reports of the whole ride, than anecdotal material horse/rider. I did about 800 crashes in a few month, included Frodo, Amy in HK and some other realy nasty ones.
90% showed one pattern, in the last 3 strides the rider disturbed the balance of the horse and that the horse was on take of hard on the forehand, Frodo so hard that his head was below the top line of the jump, same for Amy’s crash in HK, just to name some prominent crashes. Amy’s horse corcksrewed over the jump and she did the lawn darting thingy
But the first impact at 90% of the crashes I looked at was at the front and that’s were the rotation starts and those are the rather nasty ones. If the jump is just to short, than the result is lawn darting of the horse, disloging of the rider and than the horse rotates. In those cases I found that over 90%, the horse bends its neck to the right,rotates over its left should and very seldom has a full hit on the rider, less deadly for the rider more deadly for the horse broken neck or so.
My point, the material is out there, it takes a little effort. I do not understand, well yes we dealt with the Org und I should understand, why nothing happens. If a bozzo like me on a home PC, can do that in his pare time, than…
Well you and I know, why nothing will change.
Just picture a killed rider at the Olympics, that would be Hasta La Vista Time for the sport.

[snowrider]

Gnep, that is exactly what we saw last night. We also watched racing and show jumping falls for my non horse-y friends benefit. He has an engineering degree and was a test pilot and so had some interesting input. But yes, the rotational falls follow a very predictable pattern as you describe. The rider arc was less predictable.

A lot of the falls we watched were over the last element of a combination that the horse struggled through. Once the horse was straight legged in front with his shoulder ahead of his feet it was inevitable he would go over if the jump didn’t collapse.

We also looked at older courses, I have a couple of the old thrills and spills from the 80s and more online. Lots of falls still: more horses swimming through open fences. Although the nasty falls don’t make those videos it was still interesting.

There is certainly work that can be done, sophisticated work, in this problem. I wonder if the fear is that any study so prove eventing to be “unsafe” under any circumstances?

[LogansLuv]

There is a stretch of road in my town that has taken the lives of 126 people over a 12 yr period. (averages 10.5 deaths/yr) While there was chatter in the town from time to time on what to do, it wasn’t until a local resident, one of our own, was killed did outcry from the community force the authorities to do something. The roads were re-paved with reflectors and ridges, so you can tell if you are going over the centerline. Every 3 miles, a speed limit sign would record your speed and flash if you were going over the limit. POs were out in force running radar, darkened sections of the road, where there was no light, are now lined with new street lamps. Speed studies were conducted, action was taken. While there is no guarantee in life that you won’t die on this stretch of road, there have been measures taken to counter these risks. There hasn’t been a fatal reported in 8 months. I guess what make by head explode, is this mantra that riding horses, being around horses, is dangerous and that as riders we accept that risk. I accept that risk to a point. I love to ride and compete and will do whatever I can to ensure that I’m riding well into my golden years. The young girl who was kicked by a/her horse in Aiken, that was a freak accident. But UL eventing has become a game of Russian Roulette. It has nothing to do with skill (e.g KOC, AN, WFP, DC, WF), but has turned into a lethal game of chance.

I live 10 minutes from the NJHP. I haven’t attend this event in the past 3 yrs. I didn’t attend because of the remote chance of seeing carnage. I was there when the curtains went up with LA St James Place and a few others over the years. Didn’t want to see it again. Didn’t want to be entertained by the sadness and loss of others. To echo RAyers, this sport at the UL is in serious trouble. This cannot continue.

On another note related to this story for which I may catch a lot of sh$t, but to hell be damned…I am simply heart broken for that little girl who will never know her mother and all for the love of a sport. In the end, we all have choices, but when you choose to become a parent, it is time to hang up your adrenal activities for awhile. At least give your children a little bit of time to get to know who you are as their parent. RIP to all those past, present and future lives lost prematurely. I pray their senseless deaths will not be in vain, but I fear that this will continue. God Bless!

[Gnep]

YEG, When I looked into the crash of Amy in HK, I found an interesting side pattern, which made me to take a second look at the crashes I had already looked at. It was the whole ride. Amy’s lawn dart developed several jumps earlier when started to have a massive fight with her horse. That guy was a brute. She was rather stout and strong Lady and kept things under control. But one could see that she got tired and the Brute could feel it. The Jump before the spread, as much as I recall, was a brush landing on adown hill slope, at the bottom was a dirt road or so and than it went up hill to the spread.On landing on the down hill the Brute took over, hauling ass, she faught him hard, but every time she seamed to gain control, he just threw her forward, one could see her being very tired. The up hill gave her a chance, which she used but than that Brute took over again. 6 strides out, she made a rather strong stand but it got both of them so out of balance, that only the superb athletic abilities of the horse, corck screwing over the jump, saved them from a rotational. I am still in awe how that horse saved his live. Any other horse would have rotated.

I found that the accidents are a built up of mistakes, previous to the accident, or that history of horses and riders lead to those accidents, Frodo, supposedly he had a problem with jump that had something overhead, jump throu some thing, key holes and so on. It showed, by what the than young Lady did during the last 3 strides and explains why she did it.

As Reed says their is no freak accident, they all have a pattern a reason.