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

[QUOTE=snowrider;8665739]
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.

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?[/QUOTE]

Since I am just a mere youngster, I rode in the 70 and 80 advanced Long Format in Europe. Trust me our courses to day a very nice and save, compared what was than considered a save course. Nobody today would ride any of those course, they can not get drunk or stoned enough to do that. There were far more fatalities, horse/riders . The courses were meant to wheat out and that wheating out started at the lowest level, which were I come from was training for adults, 16 and older.There was a youth level and naturally the ponies.
Great times, for sure, but you honestly took your live in both hands and dumped into the trash can in the start box.

Oh I absolutely agree. I rode youth level.in Europe in the 80s too. I remember my pony running backwards on its hind legs mid course hula hooping a tire on one front leg that it pulled off a fence while the jump judge ran after us trying to pull it off! Those courses were insane and especially hard on the horses. One of my old employers who competed in the late 70s and early 80s told me how few top level events they expected a horse to complete back then in its career and it was eye opening to teenage me.

[QUOTE=YEG;8665672]
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.[/QUOTE]

I remember reading about the psychology of near misses. Airplane engineers take them very seriously. If there is any near miss, for instance even planes landing too close together, the whole safety study protocol comes into play. A near miss means you are already in the danger zone.

But IRL, car drivers tend see a near miss as evidence that they are in fact safer, not at more risk. They think “I got myself out of that, I’m a great driver” or they think “that was a fluke,” or “today’s my lucky day, I’m still alive.”

This made a big impression on me, and changed how I view my driving. If I have any kind of near miss, even if it is clearly the other person’s fault, even if it is just something minor like almost backing into a car in the parking lot, I dial it right back and make my driving super safety-conscious for the rest of the day. Realistically, my near-misses happen when I am emotionally distracted or excited about things, too. That is when other people almost hit me :slight_smile: and everyone else’s driving falls apart :).

I think that something like this could apply to riding at speed. You could be riding at the edge of control, or riding at the edge of the horse’s ability, or at the edge of where the horse is tipping onto the forehand, and save yourself again and again, and get the feeling you could pull yourself out of trouble. Then you are at a big competition, there is a little extra excitement, and the near miss becomes a catastrophe.

I haven’t watched a lot of eventers IRL, and its harder to really follow their whole round. But I’ve watched a lot of kiddie jumpers, and even some pro show jumping, live and on TV, stuff way beyond my pay grade :slight_smile: And I’ve found that it isn’t that hard to predict the balk, the run-out, the smashed fence, even the fall, a number of jumps in advance. As one of the posters here says, the horse goes on the forehand and starts getting bad distances. When I was a kid, I used to think this was the horse getting ready to balk or run out; now I see it as the horse losing balance over successive jumps so that by a certain point he can only balk, run out, or fall.

I haven’t watched hundreds of hours of video of rides leading up to rotational falls, like some of the other posters, because I don’t need to, and would find it upsetting. But I completely believe, from my rather limited experience watching show jumpers, that you could probably predict disaster. You could set up a series of videos, play the jumps, pause at a certain point, and ask: crash or champion? Are they going to clear the next jump? My guess is that, in most cases probably, it would be somewhat obvious.

That means that we do in fact have the knowledge to analyze what goes wrong.

And someone other than me can suggest how to train to fix the problems.

I agree with the first post absolutely completely.
OP has already proven that science can be compatible with eventing.

But they (as in USEA) DO want to apply real science to course concerns. At the convention they desperately sought funding for the Kentucky study to be continued and I think they did come up with part of it to fund the first year and more for the second year is needed.

The study is answering and studying the questions brought up here, from what I heard at the convention.

Deformable technology is very high on the list if not the top priority.

And one more thought. One of the reasons that course designers use tables or table like obstacles is they are a fence that typically represents the max dimensions for the level, and it’s an obstacle that incorporates those dimensions while asking a horse to go forward to the distance yet clear it and land in balance and go on to the next question. They aren’t put first on a course or last for those reasons - about the middle when you know the horse’s blood is up and they are warmed up and rolling, perhaps after a section that required some compacting or tricky footwork. You can’t build a course with all max obstacles for the level, but you can’t do the opposite either, because then there’s no standard. And it becomes an even worse free for all. Courses have to be build to the standard as best as possible. If we don’t we aren’t really eventing. We’re just doing dressage and stadium with a little grass and dirt thrown in.

Einstein said (to paraphrase), God did not roll dice with the Universe. The only things that are random, are things we don’t yet understand.

I don’t know enough to calculate whether RAyers 1 in 10 Billion odds of an explosion are correct or not. However, we live in the physical world so nothing can be 100% or 0%.

[QUOTE=vineyridge;8665425]

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]

I know there was an option at Vicarage Vee… more riders need to take options. What a statement that would have made if the majority of riders refused to jump a fence. Think it might be changed next year??? As for riding it wrong… that’s going to happen, but a spill like Boyds and the horse that chested it and fell in the ditch, and the one that fell down the ditch on the other side shouldn’t be the outcome of riding a fence wrong! Again there was ZERO room for error on that fence. I just don’t think anyone is a good enough rider on a good enough horse to risk jumping a fence with zero room for error. Even JUNG!!!

[QUOTE=Scribbler;8665812]
I remember reading about the psychology of near misses. Airplane engineers take them very seriously. If there is any near miss, for instance even planes landing too close together, the whole safety study protocol comes into play. A near miss means you are already in the danger zone.

But IRL, car drivers tend see a near miss as evidence that they are in fact safer, not at more risk. They think “I got myself out of that, I’m a great driver” or they think “that was a fluke,” or “today’s my lucky day, I’m still alive.” [/QUOTE]

In sports car racing, unlike NASCAR, we (drivers) have a notion called “the 2 corner rule”. For this discussion a corner is equivalent to an cross country obstacle. The 2 corner rule is a mental check the driver continuously runs to evaluate him/herself. Did I do that corner perfectly? Did I do the next one perfectly? 2 corners not perfect means I am over my head. Reassess. Slow down. Get it together. Stop if need be. It is very difficult to have the mental discipline to race at a top level and continuously self evaluate. The “red mist” often takes over. This happens in XC riding as well.

[QUOTE=snowrider;8665605]
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.[/QUOTE]

The Safety Committee members are listed here: http://useventing.com/sites/default/files/Commitees_5.4.pdf

I agree with you that if the USEA reached out to it’s general membership, there are a wealth of experts in engineering, animal science, data mining, risk management, etc. they could lean on who would be willing to be part of a task force or advisory committee. I think that’s what happened with the previously mentioned study RAyers and others were involved with that got round filed. Unfortunately, you only need to do that once to a subject matter expert who would normally get paid for their time, and they are far less likely to volunteer to help pro bono again. Everyone’s time is valuable, so if you are going to make use of a volunteer’s time and expertise, you sure as heck better use it wisely.

[QUOTE=Stall Rest;8665878]
In sports car racing, unlike NASCAR, we (drivers) have a notion called “the 2 corner rule”. For this discussion a corner is equivalent to an cross country obstacle. The 2 corner rule is a mental check the driver continuously runs to evaluate him/herself. Did I do that corner perfectly? Did I do the next one perfectly? 2 corners not perfect means I am over my head. Reassess. Slow down. Get it together. Stop if need be. It is very difficult to have the mental discipline to race at a top level and continuously self evaluate. The “red mist” often takes over. This happens in XC riding as well.[/QUOTE]

Good to know! I will keep this in mind as I drive around the 'burbs.

[QUOTE=msmom;8665879]
The Safety Committee members are listed here: http://useventing.com/sites/default/files/Commitees_5.4.pdf

I agree with you that if the USEA reached out to it’s general membership, there are a wealth of experts in engineering, animal science, data mining, risk management, etc. they could lean on who would be willing to be part of a task force or advisory committee. I think that’s what happened with the previously mentioned study RAyers and others were involved with that got round filed. Unfortunately, you only need to do that once to a subject matter expert who would normally get paid for their time, and they are far less likely to volunteer to help pro bono again. Everyone’s time is valuable, so if you are going to make use of a volunteer’s time and expertise, you sure as heck better use it wisely.[/QUOTE]

Yes, even if I’m getting paid to be an SME if they round file everything I’m not coming back. I have too many requests as it is.

I also see a big organizational issue with the course designers committee being entirely separate from safety. I think that speaks quite clearly to those who might volunteer as to how seriously they’ll be taken.

In sports car racing, unlike NASCAR, we (drivers) have a notion called “the 2 corner rule”.

In fairness, NASCAR doesn’t have corners :wink:

[QUOTE=Gnep;8665747]
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.[/QUOTE]

This a thousand times!

I was nearly a statistic years ago and I was having trouble on the early part of the course. I wasn’t riding well. I was trying to be brave and tough it out but I made a very bad mistake at a wide oxer. I saw a long one but my horse couldn’t do it so he added. The thing that saved us was all him! I don’t know if it was because he had started out hunting in England and had been brought up to intermediate by someone good but he had a sense of self preservation! He hit the fence with one knee and above the knee on the other and then rotated. His butt was straight up in the air, his head was down and he managed to pull his one leg out and put it down on the ground. I got slammed to the ground on my back and Harry, my wonderful Harry, put the rest of his hooves down and stopped dead with me in front of him.

People were astonished. Jim showed up so I know it looked bad. Nothing was broken, I was lucky. Stupid but lucky. Harry was a bit sore but really fine.

So it is obvious how these falls happen. Horses fail to clear them with their front end. Mostly ( I think) because they add a stride and are too close and can’t get their legs up.

The question is why do they get too close? So the question there, is who has made the mistake? The horse or the rider? If the rider is dictating the stride then most likely it is the rider. If the two are arguing about the stride, it is still the rider who is also the trainer. If the horse makes the mistake all by itself, that is something quite different. In fact, does this happen much? How often do loose horses fall when jumping? While they may reek all kinds of havoc during a steeplechase, do loose horses often fall? Or do they do well on their own? Without a human messing them up!

My guess it is the human element. But maybe not quite what you might think. Yes riders miss distances. The problem, I think, lies with the horse who listens to the rider who has missed the distance.

If the horse is constantly listening and believing what the rider is saying about the jump, the horse has no initiative of his own. My horse tried to make the best out of a wrong distance that I asked him to jump. We are still here because he is/was a great horse (he is 32 now!) it was his athleticism that saved us. I was most insistent about that distance and we were going fast and he was not a stopper so he did the only thing he could–add a stride and then deal with the consequences.

But some horses don’t really listen and, instead, take the initiative. You see combinations like this. The rider just keeps the direction, speed, balance and impulsion going (those things Le Goff used to talk about) and let the horse figure out most of the striding. It was easier to do this when the courses were simpler.

Nowadays things are so very technical I think we have taken away the horse’s initiative. The thing that kept us safe.

Or safer.

My first 3 day event was in 1983. Where Mary Bebee was killed.

[QUOTE=Stall Rest;8665850]
Einstein said (to paraphrase), God did not roll dice with the Universe. The only things that are random, are things we don’t yet understand.

I don’t know enough to calculate whether RAyers 1 in 10 Billion odds of an explosion are correct or not. However, we live in the physical world so nothing can be 100% or 0%.[/QUOTE]

Well, the 10 billion is based on the mass, molecular mass and total moles with the aspect of Brownian motion due to random collisions in a suspended particulate.

When I was a working student for a GP dressage rider/trainer she told me that a properly trained dressage horse doesn’t do anything that the rider doesn’t tell them to do. The horse is entirely focused on the rider and basically isn’t allowed to have thoughts of its own while being ridden. Is it possible that the increased focus on dressage is making the horse depend on the rider’s brain too much? Are they possibly losing their ability to think for themselves on course?

[QUOTE=Desert Topaz;8666026]
When I was a working student for a GP dressage rider/trainer she told me that a properly trained dressage horse doesn’t do anything that the rider doesn’t tell them to do. The horse is entirely focused on the rider and basically isn’t allowed to have thoughts of its own while being ridden. Is it possible that the increased focus on dressage is making the horse depend on the rider’s brain too much? Are they possibly losing their ability to think for themselves on course?[/QUOTE]

Wofford has argued that. Here is a good counter to that argument:

http://www.horsemagazine.com/thm/2015/06/event-horses-accidents-and-collection-is-there-a-connection/

[QUOTE=YEG;8665672]

  1. 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.[/QUOTE]

THIS! Data collection does go on for major falls. There are all kinds of forms and queries. But I don’t think that the same happens for the near misses and they are going to be just as revealing if not more so.

Gnep, you are absolutely right that the problem starts before the specific jump where the incident occurs. And I’m willing to bet (agreeing with you) that loss of balance is the key element. My question is how does that get identified in real time?

[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]

And this is why I’m reluctant to donate to the USEA collapsible fence study or other like it. It’s not enough to know what fences or conditions or characteristics are problems, we have to do something about it. Say we have a study that finds that red obstacles are 50% more likely to cause catastrophic falls than jumps of any other color. Can we count on course designers to stop using red jumps, or at least not have red be the primary color of the jump? I honestly don’t know. As long as teams can rack up penalties for tripping frangible pins, will course designers be less likely to use them, even though a study may find that they reduce the risk of rotational falls by a large margin? Say the researchers/safety experts recommend reducing the optimum speed of x-c, will it actually happen?

We need the powers that be to actually have the courage to act. Even if it makes things less “exciting” for spectators. Even if it means rethinking what we’re designing x-c courses for. Even if it means that the Pros™ could lose a lot of money. All those things are not worth as much as having as death-free weekend be a welcome surprise.

If you Google MIM rotational fall study you can read a study on frangible pins and rotational falls done in Sweden. Or look at the pdf with diagrams.

They’ve been installed obviously as I think only 2 kinds are FEI approved but I don’t know of anyone is tracking the results? They’ve been around 5 or 6 years now. Would be interesting to see how they work in practice.

I believe the USEA has a page to donate to fund safety studies but how many actually do?

https://services.useventing.com/Services/Donate.aspx

[QUOTE=snowrider;8665895]

I also see a big organizational issue with the course designers committee being entirely separate from safety. I think that speaks quite clearly to those who might volunteer as to how seriously they’ll be taken. [/QUOTE]

But there’s also an argument that the safety committee should be independent from the course committee, to maintain independence.

I’m a HJ person who works in infosec, and I’ve seen a version of this issue come up repeatedly - should your information security group be within IT, where they can better ensure that security is a part of every build and deployment? Or outside of IT, to serve an independent review function. Arguments for both ways.

[QUOTE=Badger;8666045]
Wofford has argued that. Here is a good counter to that argument:

http://www.horsemagazine.com/thm/2015/06/event-horses-accidents-and-collection-is-there-a-connection/[/QUOTE]

But you see it is the horse’s initiative that is needed!! I think the complexity of these intricate combinations, does take the horse’s initiative away. If the rider is not doing exercises that work on the horse’s ability to figure things out for himself then I think they do lose that initiative. But that will vary from rider to rider. It might not be the actual dressage arena dressage that does it but the dressage between the fences that does.

The problem is, if it comes down to just the rider’s ability to get the horse to the correct take-off spot, then human error will intervene. I remember many years ago when Bruce Davidson had a terrible rotational fall and his horse died and Bruce was badly smashed up. I thought to myself, if the best rider in the world can make that mistake, what chance do the rest of us have for always getting the right (or, let’s face it, nearly right) take off spot?