Accident Report: Joe Ivy, O-9 Well

Crocket County, TX -- 30 September 2000 

Edited by Rebecca Jones & Peter Sprouse

Contributions by: Rod Dennison, John Fogarty, John Ganter, Rebecca Jones, Dr. Jay Kennedy, Bill Mixon, Alan Montemayor, Bill "Carlos" Nasby, Matt Oliphant, Peter Sprouse, Tim Stich, Bill Storage, George Veni


O-9 Well is one of the deeper caves in Texas, around 100 meters deep. From the bottom of the 39-meter deep entrance drop, the downstream section continues down five more rope drops to a sump. In the dome above the sump, Joe had seen what looked like an infeeder in the ceiling that he felt might lead to more cave passage. In March 2000, Joe Ivy and Tim Stich made plans to do a bolt climb up the dome.


Aid Climb Project Background

To climb in O-9 Well, Joe and Tim used a cordless hammer drill and several types of protection in addition to expansion bolts. What was unique to this climb was the self-belay system. First, Joe drilled and set two bolts at the base of the climb, to which Joe attached a Kong Slyde. This shock absorbing mechanism is a small metal plate with holes drilled in it. Then the rope is threaded through the holes such a way that as to create friction. The purpose of the Slyde was to turn the 9mm static rope they were using into a dynamic system capable of absorbing the energy of a falling climber. Under normal static load this cord would not travel through the Slyde, but upon dynamic load it was set up to slip through the device and absorb energy.

As the bolt climber made upward progress, the rope connected to the Slyde went up through the protection carabiners and then down to the climber. The ascender (or in some cases two ascenders) of the lead climber was the attachment point to the lead rope. An ascender was used in order to conveniently adjust the length of the belay rope, something that in a normal belay system would be done by the belayer. On the first climbing trip Joe and Tim both took falls onto this rigging and it easily absorbed the energy of the fall. On average, the falls were around 4 meters including movement through the Slyde. Tim says that in the case of his fall there was around 7 meters of rope below the top piece, making his fall somewhat less than a factor 0.6. In both cases they were using a new piece of protection called a removable bolt (RB). These are reusable wired camming devices designed to be inserted into a drill hole, the use of which would reduce the number of bolts that they would have to place. These come in a variety of sizes. Joe and Tim used both 3/8 inch and 1/4 inch RBs on the first climb. Tim took a fall when a 1/4 inch RB pulled unexpectedly and Joe took a fall on a 3/8 inch piece, which he felt he had placed poorly. It was extremely difficult to avoid getting some water and mud on the RB before it was inserted. This may have adversely affected the performance of the protection. They decided to abandon using the 1/4 inch size RB and stay with the 3/8 inch ones.


The Day of the Accident

Joe and Tim made a total of five trips to continue working on the climb over three weekends. On the last weekend (30 September), they had cleared a muddy section that had made progress on the second weekend unusually difficult. Thick, clinging mud made manipulating gear almost impossible. The final section to the very top of the bolt climb, which was about 50 meters off the floor, was relatively mud-free and on what appeared to be good rock. Joe took the first shift on the climb, as he usually set up the Slyde rigging at the belay point.

After making at least six meters of progress, Joe descended to the fixed line below him and rappelled to the base of the wall. He remarked that he was going to eat and get something to drink. From time to time during that day's climbing other cavers on the trip visited the bottom room. Some were still there when Joe descended the standing line. Tim got a wrench and some carabiners from Joe and also the adjustable one stirrup etriers, which Joe had designed himself. Tim preferred these to the standard multi-step ones Joe also had on hand. Tim climbed up to the anchor for the fixed line and then attached himself to the lead rope. The rope had been passed through a vertical line of 3/8 inch bolts to Joe's last protection, a bolt. (During this part of the climb they used three-inch wedge- and sleeve-type bolts.) Tim switched his ascenders to the end of the rope that came down from the carabiner in Joe's last bolt and climbed to where the lead continued.

Along the way Tim cleaned carabiners and hangers from the protection Joe had placed, leaving the last two bolts. When he reached the top bolt, he transferred the hammer drill and bolt kit that were hanging on the bolt to his harness. From there, he continued the climb by the method they had established. This involved clipping his cow's tail into the bolt hanger of the topmost bolt. He then attached the etriers to the bolt carabiner which also contained the rope. This allowed him to then stand and attach a fifi hook to the bolt hanger. The fifi hook is a flat metal hook attached to his harness with a short piece of cord, allowing him to get as close to the bolt as possible.

From there, he adjusted the etriers to a position that allowed him the highest comfortable step from which to drill a new bolt hole higher up. After setting a new bolt, he then hung a carabiner from it. He put one etrier on this carabiner to use it to pull up on. This allowed him to thumb his chest ascender and get slack from the lead rope. Tim then stood up, clipped the rope into the higher carabiner and moved slack down through his two ascenders. Then he could remove his cow's tail and fifi and climb up to the new, higher bolt. This technique does create a loop of slack not normally seen in a standard belayed climb, where the belayer would be paying out slack as needed by the climber's ascent.

Joe performed these same actions while he climbed. However, earlier in the climbing project Tim had decided to use both of his ascenders on the belay rope, while Joe continued to use only the seat Croll to attach himself to the belay rope. Tim also had decided to use 3/8 inch expansion bolts exclusively. Although the 3/8 inch RBs appeared sound to him, he had enough expansion bolts with him to use for all of his placements. Joe continued to use the 3/8 inch RBs and had placed one on his first shift. At no time did they placed two RBs in a row, always placing a bolt above an RB.

When Tim finished his shift, he was within 4.5 meters of the top of the climb. A hole, two to three meters in diameter, could be seen at the summit of the climb. A low crawlway appeared to go off in one direction, although it was possible that it was merely a flat roof with a slightly hollowed out ceiling. He drilled two final bolts and tied a double figure 8 knot to make a standing line. At this point, it looked like the lead rope might not reach the top. In any case, Tim had run out of hangers and was exhausted. He decided to end his shift and let Joe finish the final pitch. At most, it would take four more placements. Tim left the two bolts at the top for Joe to climb up to. As he rappelled, he removed hangers and carabiners to give to Joe.


The Accident

Joe had gotten rest, food, and water, and was in good spirits. Tim told him he had two bolts at the top of the lead rope and might need another rope. Joe coiled one and attached it to his harness. Joe ascended the rope and disappeared from view into the darkness of the upper dome. The other cavers sounded like they were again visiting the bottom room, and Tim heard some voices and saw flashes of headlamps. He could occasionally see the dim glow of Joe's LED array high above him. Then, Tim heard what sounded like a brief exclamation from Joe and then a loud, resounding crash. Many times in the past, large chunks of mud and some rock had fallen on the climb, but this was much louder. Tim called up to Joe, but there was no response. More alarming still, Tim could no longer see any light above him. Tim decided that Joe must have had a mishap.

Tim shouted up to Joe several more times. One of the approaching cavers, Sarah Springer, heard the shouting and spoke out to Tim. He told her that he needed help. Sarah passed the word up and in seconds someone was making his way to the surface. At this point, Tim began to hear Joe moaning and trying to say something. Sarah continued descending into the room where Tim was. Tim quickly put on his ascending gear and climbed the standing line. Joe's moaning was coming from a point well below the lead, which frightened Tim. When he finally saw Joe, he could see that he was wedged within a slot above a muddy ramp they had discovered during their previous trips. Joe's legs were slightly raised, his helmet was missing (it was later found and put back on his head), and smears of blood were on the left wall. Joe continually complained of difficulty breathing. It appeared that Joe had fallen from 12 to 18 meters, hit a steep, sloping ledge on the left and then wedged into the slot above the muddy ramp. Tim climbed above the slot and then down climbed to Joe from behind.

Tim noticed that Joe was not attached to any rope. That was the first thing he decided to attend to, as it was very possible that Joe could slip down the ramp and off the wall. He made a quick overhand knot in the rope below him and attached Joe's harness to it. He then asked Joe about his injuries. Joe said, "Can't breathe. Left arm fucked." Tim tried to pull Joe through the slot, grasping his right arm. Joe yelled in pain, and Tim asked if that arm hurt as well. "Everything hurts. Do it anyway." With that, he pulled Joe and ordered him to kick if he could. He did, and he eventually came out of the slot and slid down onto the top of the muddy ramp. There is a very uneven ledge at the top of the ramp that is barely large enough to sit on. It is not possible to lie prone, but Tim reasoned that this was the best place to attend to Joe's injuries. The only other alternative was to pass him the three or so meters through the slot and immediately rappel to the bottom of the wall. Joe was loudly complaining that breathing was difficult, so Tim focused on that problem first.

The primary reason Joe seemed to be having trouble breathing was that his seat harness had ridden up onto his chest. This was a butt-strap type of harness without leg loops. Normally this type of harness (similar to the Petzl Rapide) utilizes an additional strap that goes between the legs, around the butt strap, and comes back through the legs to fasten to a buckle on the harness. Joe had deleted this strap from his own harness when he made it.

Tim was wary of removing Joe's harness since Joe was in danger of falling of the ledge, but he needed to breathe. As it turned out, Tim could not have cut if off in any case as he couldn't find Joe's knife. Joe was still somewhat lodged in the lower recess of the slot, so the gear hanging from his harness, including the knife, was obscured. The angle of the ramp was too steep to allow him to pull Joe up onto the small ledge. Time was short, so Tim decided to get him off the wall altogether, but noticed that there was weight on the rope below him.

Even worse, from where he had down climbed the rope had rested on two rocks jammed into the top of the slot. These rocks were holding the weight of the climber on the rope. He repeatedly pleaded for the climber to get off of the rope, but she replied that she couldn't. Sarah was not familiar with the process of changing over to rappel while on rope. Tim then told her to just keep climbing up, as he reasoned that he couldn't describe how to do a changeover successfully. He then left Joe and climbed the three meters to get out of the slot. Once above, he could meet Sarah and let her change over to his part of the rope. This proved impossible, as the rope was deeply jammed within the chock stones and it kept Sarah from climbing to him. Instead, he pulled her through a wide part in the slot below the chock stones and Sarah eventually got onto the small ledge behind him.

Once there, he had Sarah attach herself to the rope above Joe with her cow's tail. By this time, Joe had lost consciousness but still seemed to be breathing sporadically. Sarah and Tim again tried to move Joe to the ledge so they could take his weight off of the harness and allow him to breathe, but Joe's body was covered with slick mud and the only place to grab him was his harness. Tim managed to stem the sides of the small ledge and pulled Joe up several times with his legs alone. This only worked for a time to relieve some weight from Joe's harness, but he would again slip down into a lower position in the slot.

Once again, Tim made preparations to get Joe off of the wall entirely instead of continuing the futile effort to get him onto the small ledge. The rope needed to be removed from the chockstones and passed through the back of the slot and down the ramp. He did that, and then rappelled below Joe and clipped him into his cow's tail with two carabiners. By now it seemed painfully obvious that Joe was not breathing. It would have been very difficult to administer CPR in Joe's awkward position, and so they didn't attempt it. Sarah is an EMT, and she confirmed that Joe had no pulse and was not breathing.

Regardless of Joe's condition, they were committed to getting him down at this point. Once on the ground, CPR could be given easily. Since the slot was very tight, it was difficult for Tim to see his micro rack, much less manipulate it effectively. He knew that he wanted it locked off when he took on Joe's full weight. He had to guide Joe down the muddy ramp, frequently pulling his legs out from under him and getting him unstuck.

Eventually, Joe slid out and onto Tim's cow's tail. Tim then rappelled with Joe to the base of the wall. The rack held both cavers' weight well, and the rappel felt safe. When Tim got to the bottom, he got Joe to a somewhat flat area and quickly looked for a knife to cut his harness off. Charley Savvas and Frank Delgado appeared at that moment and came to assist. Tim knew that Joe was probably dead, but said that he was trying to get his harness off and needed a knife. Charley produced one, and they moved Joe to a better spot and cut off his harness and cow's tail. Frank, also an EMT, examined Joe and concluded that he was dead. CPR was briefly given, but it was too late to matter.


The Recovery

Other cavers arrived from the surface with a SKED litter and other rescue gear, and the body was packaged for hauling. Patrick Lynott directed the rigging of haul systems that were used not only on drops but also in the canal areas. They moved the body up four rope drops to the bottom of the second drop, then left the cave to get some rest at around 0300 on the morning of 1 October.

Calls for assistance had gone out to cavers in central Texas at around 2300 on 30 September, and cavers began arriving at the site before dawn the next day. Law enforcement authorities had been notified during the night, they had visited the site and closed the entrance with police tape to keep anyone from re-entering the cave until the Justice of the Peace arrived in the morning.

After clearance was received from the authorities, trained cave rescue personnel led by John Green, South Central Regional Coordinator of the National Cave Rescue Commission went in to finish the recovery just after 1200. Besides John, these were Tim Comer, James Davis, Rod Dennison, Tommy Gillis, and Monty Strange. Rebecca Jones and Patrick Lynott rigged the entrance pit. Joe's body reached the surface at 1610.



At 1700 Andy Grubbs, Bill "Carlos" Nasby, Peter Sprouse, and Kevin Stafford entered the cave to photograph the scene, collect the equipment from the lead climb, and de-rig the cave. They found much of Joe's gear lying on the floor and in muddy pools.

While Kevin and Andy gathered gear, Peter took photos, and Carlos climbed up the bottom fixed line up the dome to have a look at the ledge area where Joe landed.

From Tim's description they knew this rope was tied to two bolts that had not been affected by the fall. The rope passed up a narrow crack to the steep, muddy slope. The rope went up over a rounded hump to the side, and was fixed to two bolts about eight meters above the mud ledge. From that point, a smaller diameter rope went straight up out of sight. The bottom end of it was tied to one of the two anchors, the top end was presumably attached to the two bolts that formed the belay point that Joe was using. The Slyde was not present at the bottom. Carlos tugged on it, and it felt solid, but at that time there wasn't any assurance that this rope would be safe to climb.

On 2 October, John Fogarty, John Green, Rebecca Jones, Missy Lynott, Patrick Lynott, Carlos Nasby, Charley Savvas, Jessica Snider, Peter Sprouse, Kevin Stafford, and Tim Stich met to analyze the gear that had been retrieved from the base of the climb.


Items Damaged in the Fall

1. The frog chest loop was cut at the point where it went through the Croll.

2. The belay rope was cut in two, half of which was recovered, the other half is presumably at the top of the climb.

Unfortunately the Croll was not found. This seems to have been lost in the mud as his body was being prepared for removal. No one specifically remembers removing it when the gear was removed from the body, but the body was covered with heavy mud at the time. It would be useful to inspect the Croll for fall damage or rope fibers.

The cut lead rope was immediately seen as the cause of the fatality. The damaged area on the rope had 80 cm of core exposed, though due to stress on the core the actual length of this section of core prior to the damage may have been less. The core was puffy, bundles separated, and there were lumps where it had melted. The sheath was shoved down the core and had noticeable compression for 90 cm. It is assumed that the Croll cut the rope under a catastrophic load.


Gear Selection and the Belay System

Joe always looked for ways to improve caving techniques, and for this climb had developed a direct aid self-belay technique. In Joe's experience, more than one of his belayers on dome leads had fallen asleep or dropped him a long way during the many hours a climb typically takes. The climb in O-9 Well would have been especially dangerous to belay. The route corkscrews, making communication from top to bottom nearly impossible, and large chunks of mud were continuously knocked down to clean the wall for the drill. Self-belayed aid climbs are more common in outdoor rock climbing than caving.

One of components that Joe decided to use was the shock absorbing Kong Slyde. This device had worked in previous falls in the dome, however the performance of friction devices of this type is unpredictable due to variables such as water or mud on the rope, orientation of the device at the time of loading, and friction added by pieces of protection and rock rub above the belay.

Joe also used a seat harness that did not employ individual leg loops, but rather was made up of two sewn webbing bands: a waist belt and a butt strap. Joe had used this harness, without the crotch strap to hold the butt strap in place, without incident in many minor falls. With the severe shock load, the butt strap came out of position and the entire harness rode up around his chest. This could also have had serious consequences had the rope not broken and left him hanging.


Possible Scenarios

Joe climbed the second standing line and moved the self-belay setup to the highest two-bolt anchor. In the 30-45 minutes between the beginning of his ascent and his fall, he would have been able to drill and set a maximum of two pieces of pro. At the time of the accident, Joe's hammer was on his seat harness in the carabiner that held it, and his hammer drill was in its pack, which Joe used like a holster to keep mud off of it.

Joe was alone when he fell, and no one knows exactly what he was doing at that moment. This scenario is speculative, based on the evidence currently available. If and when it is possible to inspect the actual fall site, a more accurate account may be possible.

It is believed that Joe set one piece, probably a 3/8 inch RB. Joe had set the RBs in between bolts on the previous pitch, so it is likely that he continued the practice. Following the steps, he would have put a carabiner with etriers on the RB, and stood up to pass a loop of slack from the lead rope into the carabiner. He would have ascended to the RB, put his fifi hook into it, and then readjusted and stood in the etriers. He may have drilled a second hole, put a bolt in with a hanger and carabiner, and again thumbed his Croll to get slack in the rope.

At some point during this process, the RB that Joe was hanging on pulled out, and he fell with very little rope out. This would result in a short fall that approached fall factor of 2.

As Joe reached the end of his rope and began to decelerate, the first thing to fail was the chest harness, which cut at its attachment point to the Croll. (The chest harness in the Frog system is not a life support component by design.) Joe's hips then slipped through his seat harness, which rode all the way up to his chest. There is no way of knowing how much cord, if any, traveled through the Slyde, since the rigging at the top has not been inspected. The few meters of damp 9mm static rope may have stretched as much as 10%. However, not enough energy was dissipated in these events, so the remaining force caused the cam on the Croll to cut the lead rope. Joe then fell free for 12 to 18 meters.


Fatal Flaws in this Belay System

- The main problem with the belay system was connecting the climber to the rope with an ascender. Ascenders are designed for ascending, not belaying. Petzl's loading figures indicate that the Croll will cut a 9mm static rope at 4kN (a moderate fall).

Although Joe was aware of this data, he did not believe the failure mode of the Croll with the rope diameter he selected would be the complete cutting of the rope. Joe had expressed to Tim that he believed that the rope sheath would be ripped and bunched while the Croll slid down core. Joe had several experiences where a Petzl ascender had cut a sheath in this manner, most dramatically when shock-loading an 8:1 haul system. The core was puffy and separated, but held. In this case, the load was removed after the sheath failed. The force in a fall will continue until expended in other ways.

- Using a static rope for a leader belay, where high fall factors are by definition expected, is dangerous, even with the addition of energy absorbing devices. The lead rope Joe and Tim used was 9mm static line. In standard lead climbing practice, the stretch in dynamic rope absorbs most of the force of a fall. The Slyde, whether because of its inherent functional limits or because of the method of application, was not able to absorb sufficient energy. The choice of static rope comprises one of the miscalculations made in the design of this belay system.

Factor 2 falls put tremendous strain on equipment and climber, and should be avoided if possible. In lead climbing, the beginning of the pitch can be the most dangerous because the potential of a factor 2 fall is greatest. When beginning a dynamic climb, it is essential to put in the first pieces soon, and make them bombproof. Although counterintuitive at first glance, short falls can in fact be the most dangerous. [In rigging fixed ropes for caving, where there is no energy-absorbing mechanism, it is essential to design and rig anchors to minimize potential fall factors.]

Testing conducted by Petzl shows that a factor 2 fall on dynamic rope will generate a force of 9 kilonewtons (kN), assuming a typical climber weight of 80 kilograms. [A kN is the force which gives to a mass of 1000 kilograms an acceleration of 1 meter per second squared.] Joe weighed more than 110 kg with his gear, which would increase that load to 13 kN. A paper by Bill Storage and John Ganter suggests that these forces may be MORE than doubled by the use of static rope, bringing the impact force to greater than 26kN.


Performance of RBs in Caving Conditions

The problem with placing RBs during this dome climb was that they performed erratically in the cave. It was nearly impossible to keep them clean before inserting them in the drill holes. Muddy hands, random patches on clothing, and the mud and water covering the cave wall made contamination almost assured. The hardness of the limestone varied, as is common in caves, and the integrity of the rock effects how well an RB will hold. Wallowing out the hole with the drill also negatively effects RB performance. RBs were, however, quick to place and did hold in many cases without trouble. One 3/8 inch RB placed in an overhang caught Tim's fall, which attests to the device's potential performance. Overall, the small time and weight savings in using RBs is questionable, given their unreliability in cave rock. It takes only a few more minutes to install a bolt.

Joe and Tim used Climb Tech Removable Bolts and they each fell when these pulled out. In every fall, they had the benefit of several pieces of protection prior to the RB placement, thereby reducing the fall factor. Tim found the fall he took to be fairly soft, he was able to immediately continue bolting and was not unduly shaken by the experience. Joe was similarly unconcerned about the force of his own two falls and did not see a need to redesign his belay system to handle more energy. Both Joe and Tim stopped using the 1/4 inch variety after the first trip, and by the last trip, Tim had quit using RBs altogether, though he blamed their failure on mud and water contamination of the holes. - Through their experiences of falling, they became wary of the performance of the RBs, but developed more trust in the belay system.



Lessons Learned

A mechanical ascender should never be used as a primary part of a belaying system, no matter how many subsequent devices are added to absorb the energy of falls.

Static rope is unacceptable in a belay system. Dynamic rope of 10mm or larger diameter should always be used for belaying leader climbs.

Removable bolts, if used at all in caves, should be used with extreme caution, as they perform poorly under wet and muddy conditions.



The fact that some falls of lesser force had occurred before the accident led the climbers to feel that the belay system was adequate, however these falls were too few to actually validate the technique. Planning an ascender belay that was believed would "only" result in the stripping of the rope sheath was poor judgment from the start. Joe's death was due to his own actions and the judgments he made in designing and applying his belaying system. No piece of gear failed in a way that was not known to happen. The belay system design was perilously flawed in that it did not allow for the force of a factor 2 fall. A belay system should be designed to handle the maximum fall possible. The good performance of the belaying system on gentler falls helped foster a sense of complacency in the climbers. Overconfidence kept them from continually questioning their system and methods.


All illustrations by Tim Stich

For the complete accident report, details of the recovery, and all related links, see


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