# Grand Canyon River Fatality Review



## Tom Martin

The following is a write up of the trip in which well-known and well-liked Flagstaff river runner and Grand Canyon hiker Mary Simpson died on September 26, 2013. In the presentation of this write up, in consultation with a number of individuals including Mary’s husband Robert, it is hoped the river community can learn what not to do and what to be aware of on future river trips. Again, I am indebted to Robert Simpson for his most gracious assistance in the review of this tragic incident. Yours, tom

==================================================

The following is a rough recounting of a river trip in which Mary Simpson, a very well-known and well-liked Grand Canyon river runner and hiker, died. A large number of events all occurred on this trip, each adding to the other. This write up is intended to educate river runners about what can happen on river trips, and how to manage the rigors of a Grand Canyon river trip. 

Twelve people originally planned to go on the trip, and in the end, only seven people went. Two boatmen were in their 60's with a third boatman, Mary's son Kenny, in his 40's. Kenny rowed an 18 ft. raft with Mary and Robert, Mary's husband. Robert had been the expected boatman but a damaged shoulder prevented him from rowing. Rich rowed a large heavy twenty foot Cat by himself and Paul rowed a 14ft raft with his daughter and another passenger, the permit holder. Rich had offered to bring his motor for his Cat, but the permit holder had said they did not want to deal with the noise of the motor on the trip. The older boatman had run the river before. Kenny had little rowing experience.

It was Monsoon season with rain and the river was very muddy. Getting onto-off the beaches at camp was hard due to the mud. On the morning of the second day, the boats were beached in Marble Canyon and were hauled back to the water by a passing commercial trip. Mary had a long history of emphysema, worsening in the last year. She was often cold when on the water, and very tired on reaching camp at the end of the day.

Paul hit the pour-over at the top of Hance. He and the permit holder were ejected from the raft. He swam most all of the rapid finally getting to the right bank. The permit holder was retrieved mid rapid by Kenny. One of the 14 ft. boat's oars was lost. Paul flipped his boat on the right near the foot of Deubendorff Rapid. A commercial motor trip aided in the recovery and righting of the raft. Mary and the permit holder walked around Crystal and Lava.

The day before running 209 Mile Rapid, Kenny had an allergic reaction, resulting in a rapid and complete closure of his airway, possibly due to eating some mixed nuts. Quick thinking Robert retrieved an injectable epinephrine allergic reaction pack from the first aid kit and administered an injection. Kenny recovered. Meanwhile, Rich was having difficulty rowing his boat due to arthritis, with one hand swelling considerably from the rowing. A decision was made to cut the trip short and Satellite calls were made to arrange to have the vehicles at Diamond Creek in two days.

There was a strong up-canyon wind above 209 Mile Rapid, and the group was spread out, led by Paul, then Kenny and finally, Rich. A mile above 209, the wind stopped and Robert took over the oars so Kenny could rest. Robert rowed the boat into 209 Mile, and a gust of wind blew him off course and into the 209 Mile Rapid hole. The boat flipped.

Robert and Kenny were unable to get Mary out of the water onto the overturned boat. There were no flip lines or rescue ladders. Paul saw that the boat was overturned and tried to slow his boat. There were no eddies so he had to rub his boat on the shore to slow it down. The overturned raft passed him before he could get into the river flow, and he chased the boat against the wind for more minutes. Mary had been it the water for less than 10 minutes when she was pulled out and Paul's daughter began CPR, which continued for 30 minutes.

Lessons learned:

The rapids are not over below Lava. Stay close for safety. 

Have a capable rower at the oars in all rapids.

Boats should have a flip line or some sort of rescue ladder to help swimmers get back on an overturned raft in the event of a flip.

Immersion in cold water can be deadly to those with cardiac or respiratory issues. Dress to avoid cardiac or respiratory shock including either dry suits, wet suits or enough layers to limit heat loss. 

If you take a person who is very ill on the Colorado in Grand Canyon, even if they are willing to accept a high level of risk, if they die on the trip, the living will have to carry on as best as they can. This is not an easy task.


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## panicman

Sounds like people also need to assess their physical limits and abilities more carefully before taking on such a challenge in their older years and decide if it is worth the risk to themselves and others.


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## mrkyak

So sad...
Every trip leader should require every participant to practice, at least once early in the trip, a reentry on to a raft from the water. Even with ladder, flip line, hanging strap loop or what ever
Your system is, it's harder than you think in moving water that's 52* F.


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## [email protected]

If she was having trouble climbing on the raft, it is also a possiblity to try and help her to shore.


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## richp

Hi,

I was a participant in that trip. 

Tom and I have already duked this out on his listserv. As usual, he had a snappy answer to every reason I advanced, for him to have restrained himself for now on this topic. So I'll keep it succinct here.

Prudence would advise against prematurely assembling a version of events that relies on interpolation/extrapolation from a limited range of information. It would be far better to wait for the complete Park investigation, which will rely on official on-river interviews conducted immediately after the incident with all participants, as well as a review of the autopsy and all evidence gathered on the river.

FWIW.

Rich Phillips


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## Tom Martin

Hi Rich, thanks for your post. I certainly apologize for not attempting to interview all the trip participants. As I posted elsewhere, if you would be so kind, when you get that NPS report, please post it here. In the meantime, folks who launch before then will have a lot more data to go on to be safe out there, which was the original intent of the post. All the best, tom


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## richp

Hi Tom,

My responses to the posts about this incident have been (and will continue to be) restrained, out of respect for the others on the trip, particularly Robert and Kenny. And I've deflected numerous requests by phone and email for details, largely for the same reason.

But my factual restraint also is keyed on the very principle I've been urging -- waiting for a full report. I was there, and I know what I saw -- both the tragic and the heroic. And I know the information we all exchanged during that very grim time on the river after it happened. But I don't have the full picture, and I continue to believe that drawing conclusions at this stage is premature. And as you well know, the highly generalized trip planning article I have on the GCPBA web site gives no reconstructed trip narrative, names no names, and doesn't even mention the fact there was a fatality on the trip.

But now to your most recent post.

No apology required. You know I wasn't going to get involved in any "interview", since I had already essentially conveyed that by my restrained emails shortly after the accident (when I cancelled our planned dinner stimulated by a prior exchange here on the Buzz).

You know I declined your request for me to endorse a theory you advanced barely a week after it happened -- a theory you already had formed on a key aspect of the incident. 

You know I told you it would be best to wait for the official report. 

Your "Lessons Learned" section points folks back to fundamentals -- that's good. And I have no problem with you or anyone else articulating things that are self-evident, for what that's worth. But from where I sit as someone who was actually there, a nuanced chain of many factors can't be readily reduced to a few bullet points. 

We all know that any incident with several participants/observers will result in multiple points of view. Assembling a complete picture is best done by trained investigators with all the facts -- not a third party. If the official report elaborates in useful detail on the broad stroke picture you painted in your story, then that's fine. And no doubt you will claim once again to have scooped the river community with your entrepid reporting.That's your style.

But no, I won't be the one to post the Park report. I have requested a copy for personal closure -- nothing more. I now understand why some people find these internet "inquests" on river deaths to be ghoulish.

FWIW.

Rich Phillips


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## okieboater

Don't know anything about the referenced accident and this post is not intended to do any thing but discuss the effects of cold water on the Grand Canyon this thread brings to the message board.

I do not think most people who have not done a extended swim in the canyon understand just how fast that water takes away your strength and you pass out.

This is especially true for folks in rafts in the warm months wearing nothing but shorts, tee shirt and PFD.

I was rowing my catboat down Hance. Had a good run and celebrated at the bottom by taking off my dry top, insulation down to tee shirt, shorts and PFD. Hot day and I was rowing. My fault, but I think I drifted in to the Son of Hance hole. Catboat pitch poled me into the water but stayed up right. I hit the water, felt good and after a while caught up to the catboat and grabbed the front crossbar planning to crawl up over the rocket boxes stored there. Some time later I woke up on a friend's catboat, several of my buds working on me and somehow I was clothed in fleece top to bottom. It took a while for my buds to catch up to my raft and get me off the cross bar and into the fleece. Had they not worked fast, things would have been much worse.

First point of this story is I never felt anything, just thought it was a normal swim but totally passed out. Second one is stuff happens and no matter how experienced you and your bud's are, that GC cold water takes you down in minutes.

I am not commenting on the accident. But do want to tell my story and hope it encourages others in the GC to dress for a swim till in totally flat water and stay close to other boats especially in the rapids.


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## Salidaboater

I have a grand trip this coming April and it is definitely and older group. The recent threads on this fatality have me thinking a bit different than other Grand trips I have done. We all are young at heart but even with very experienced boaters I think for some getting back in a raft might not be as easy as they remember. What sort of ladders, lines etc. do people suggest to help get someone on top of a flipped raft. My concern is from reading up on this, is that the cold zaps the energy of an older person much faster than a younger one. So if an older experienced boater finds himself in the water a bit to long and is losing energy, what is easiest to get back on top.


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## richp

Hi Salidaboater,

I own two Netties Bags, but have never bothered to rig them again after I got first one, then a second Rescue Rung. 

I've been out of the boat three times in combat situations (most recently Lava several years ago). As big as I am, as old as I am, and as bulky as my Extrasport PFD is, I was back in in less than a minute -- once to the top of an upside down cat. Rigged properly, they will allow you to equally easily get in an upright boat or on the bottom of an upside down boat.

Check this out:

Rescue Rung Self-stowing Raft Entry Ladder - YouTube

Best price will be found here, noting discount for GCPBA members:

http://gcpba.org/store-2/#!/~/product/category=2410298&id=10392790

Past Buzz discussion here:

http://www.mountainbuzz.com/forums/f15/rescue-rung-43201.html

Hope this helps.

Rich Phillips


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## Salidaboater

Thanks Rich,

They don't get in the way or get hung up on things?

Don


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## richp

Hi Don,

Not that I ever noticed. Just as the Youtube piece shows, I use the included straps to tie them to the frame, after running the straps through one of the hand holds on the side of the tube. That does a couple of things.

It keeps the ladder tight to the side of the raft. But it also means that if the raft is upside down, the ladder isn't dangling down under water -- it's still hanging at the midpoint on the side of the tube, where you can use it to get on the bottom of the raft.

There is a bit of technique to using it, as the Youtube clip demonstrates. So I suppose first time users would do well to give it a try in calm water, just to see how to best use it. 

The boat in the video has 30 inch tubes like mine, and the three rung unit I have works better on them than the two rung model. But the two rung model was perfectly OK on my NRS boats with smaller tubes.

An unadvertised benefit accrues to female passengers on those long stretches of river when they have to relieve themselves. The ladder lets people lower themselves into the water as well, if they don't want to jump. So the ladies can get in the water nice and easy, take care of business, and get back in just as easily. Doesn't mean much to us guys, but the women I've had on my boat sure seemed to like it.

FWIW.

Rich Phillips


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## Tom Martin

Hi Rich, the discussions and contemplations that are occurring here are excellent. We river runners need to know, as best as we can with as much basis in fact and with all due respect, what is happening on the river. We can then plan our future trips accordingly. 

Please let me know when you get the official report, and I'll ask for one then. In the past, the NPS has had a history of not closing their investigations for a few years or never, as the report needs to be reviewed by higher ups and is never signed off on. Hence there often times never is an "official report." (Please read Paul Berkowitz's 'The Case Of The Indian Trader' for an insiders review of what can happen to NPS investigative reporting.) 

No intention to scoop here, it's just that no one else appears to be researching these things and reporting back for the greater good. I personally do not think that ignorance of what is happening is a good idea. You know that with the release of information comes folks who take shots at the messenger. While that is not my style, it clearly is for others. 

All the best, tom


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## cataraftgirl

richp said:


> Hi Don,
> 
> Not that I ever noticed. Just as the Youtube piece shows, I use the included straps to tie them to the frame, after running the straps through one of the hand holds on the side of the tube. That does a couple of things.
> 
> It keeps the ladder tight to the side of the raft. But it also means that if the raft is upside down, the ladder isn't dangling down under water -- it's still hanging at the midpoint on the side of the tube, where you can use it to get on the bottom of the raft.
> 
> There is a bit of technique to using it, as the Youtube clip demonstrates. So I suppose first time users would do well to give it a try in calm water, just to see how to best use it.
> 
> The boat in the video has 30 inch tubes like mine, and the three rung unit I have works better on them than the two rung model. But the two rung model was perfectly OK on my NRS boats with smaller tubes.
> 
> An unadvertised benefit accrues to female passengers on those long stretches of river when they have to relieve themselves. The ladder lets people lower themselves into the water as well, if they don't want to jump. So the ladies can get in the water nice and easy, take care of business, and get back in just as easily. Doesn't mean much to us guys, but the women I've had on my boat sure seemed to like it.
> 
> FWIW.
> 
> Rich Phillips


I'll be getting a new raft sometime soon. A diminishing tube raft with 22/17 tubes. I have a bum leg, so this item looks like it would be a very nice safety item for me. Would you suggest a 2 rung or a 3 for my size boat & situation? If the 3 rung is easier to use, then I'd go with that, but I don't want overkill. Thanks for posting about this product.


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## richp

Hi Cataraftgirl,

I'd personally opt for the three rung, even with the size boat you describe. 

I had the two rung version on a 22" tube boat, and I could get in OK -- as I think would be true for others. But when I got the three rung version, I found it was even easier to get my foot firmly in place on the lowest rung. 

Having said that, even the two rung would be a signifiant improvement over other options.

Hope this helps.

Rich Phillips


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## cataraftgirl

richp said:


> Hi Cataraftgirl,
> 
> I'd personally opt for the three rung, even with the size boat you describe.
> 
> I had the two rung version on a 22" tube boat, and I could get in OK -- as I think would be true for others. But when I got the three rung version, I found it was even easier to get my foot firmly in place on the lowest rung.
> 
> Having said that, even the two rung would be a signifiant improvement over other options.
> 
> Hope this helps.
> 
> Rich Phillips


Super. Thanks. I've tried a Nettie ladder and didn't like it much. This looks a lot better. Not cheap, but worth the money when you need it.


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## richp

Hi Cataraftgirl,

The fact the Rescue Rung is so much wider than the Nettie's cross-pieces makes it much easier to get your foot into it for the first step. And of course when it self-retracts, the entrapment hazard is gone, which is a problem with the non-retractable versions until you can find calm water and the time to re-stuff in the sack.

FWIW.

Rich Phillips


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## kikii875

One correction to the original post. Paul flipped his boat going over the table rock in Dubendorf, not on the bottom right.
Signed,
A witness to the flip and the person who took charge of snagging the boat and righting it.

This is still a very tender wound. ADMIN, can you stop this and delete this thread?


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## coloclimber512

kikii875 said:


> One correction to the original post. Paul flipped his boat going over the table rock in Dubendorf, not on the bottom right.
> Signed,
> A witness to the flip and the person who took charge of snagging the boat and righting it.
> 
> This is still a very tender wound. ADMIN, can you stop this and delete this thread?


+1 for deleting this thread.


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## FrankC

Why delete the thread? I found it informational and not accusarial. I've been in this same situation (a couple times unfortunately) and just wanted to inform people what happened (asap) to hopefully help prevent future accidents. Just state what happened to the best of your knowledge and lessons learned. Post it to the AW site for future reference.


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## Salidaboater

I have learned from this thread and are doing some things differently, on an upcoming Grand trip as a result. I am a long time member of a pilots forum, where we do have accidents and fatalities and this very subject of threads etc. comes up.

As hard as it may be for some involved, people learn from these types of threads and lives may be saved IMHO.


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## carvedog

Concerning the suggestions to delete: I completely disagree with Tom for posting this, it does seem that some good has come from it. As long as the immediate family doesn't object or contact the admins for removal, this thread should stand. 

There are lots of people of marginal health who continue going down the river. Sometimes with tragic consequences. No need for finger pointing, no matter how oblique Tom, it is simply unnecessary.


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## CBrown

It is a sad reality that death and carnage are part of our sport. I have been around WW for the past 20 years kayaking and rafting and seen some scary stuff. I have always read accident reports and think information from those reports are helpful in many ways. I have taken that information forward with me and been able to avoid sketchy or fatal situations from that knowledge gained.
My heart goes out to those involved as well as the family and friends of the victim. I do not think reviewing the accident is at all goulish or disrespectful. It is what it is and if something can be taken away from this discussion that prevents a dangerous or life threatening situation in the future, then it is a discussion worth having.


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## restrac2000

Posting a trip report and "lessons learned" synopsis in a third party fashion for a trip one is not a participant on is in poor taste and disrespectful. Sometimes the assumed "greater good", especially on the internet, does not trump the importance of the individual experience. This is especially true when multiple requests have been made by the participants of the party. Deaths and major injuries can take significant time to process mentally and emotionally. Putting the information into the public perview in a internet setting, especially with an incomplete picture of events, can make those wounds worse.

We can support individual participants if or when they choose to personally post their perspective. Until then what is best for the individual can be best for the community.....show restraint and patience. In moments like this in life it seems best to defer to those who actually experienced the event in regards to disclosure. Not everything that happens is ours to learn from.

Phillip Rhoades.....the participant of one SAR that I can't imagine someone else writing a TR about. And the witness to another rescue/emergency that I have yet to writeup years later.


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## cataraftgirl

I'm torn on how I feel about this thread. I did get info about the Rescue Rung as a result of the thread, but other than that there seems to be some incomplete information about this tragic event that has been posted. This is an obviously painful rehashing of events for some of those involved. When I step back and really look at what I might learn from this thread, it seems that there isn't anything new that we all don't already know. Bad stuff can happen on the river, some of that bad stuff can be avoided or minimized, some of it can't be. Getting a person out of the water quickly seems to be the main lesson I'll take away from reading the posts in this thread. To that end, I will investigate a rescue ladder for my raft. Other than that, the rest is just the way things go.......personal judgement calls. Do you cancel a trip because 7 out of 12 people cancel? Do you cancel because one boatman out of three is inexperienced? Do you exclude people who are over 60 or have health problems? These are questions that each person or group must answer for themselves. We can't presume to know the correct answer for this particular situation, with people we don't know. Flipping on the GC can happen to anyone, no one is immune to the fates and powers of the river.

I feel bad for those involved and pray that they can find peace and move past this tragedy.


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## johnryan

Tom's "River Fatality Review" is borderline irresponsible reporting. He didn't get a full accounting of what happened from all parties. Was there really such a rush to get it published by The Man Who Knows, at the end of a boating season, rather than be sure that it was an accurate account?

However, it doesn't hurt to periodically remind people to "Have a capable rower at the oars in all rapids".


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## Schutzie

I am an OLD OLD river rat who hasn't touched an oar for many years.
I'm on a Grand trip in August 2014; it will be my third.

I've thought long and hard about my age and fitness; the former is old and the latter is bad. I have no doubt this trip will be more demanding than my first two.

Never the less, I go because I love the river and want to experience the canyon one more time at least.

I will make sure that everyone on the trip and my family understand; I'm going knowing the risks, and accepting them. Do not grieve for me if we fail, I would rather die on the river because I over estimated my ability and underestimated the challenge, than to have sat home safe and dreamed what should have been.

To those who were on that trip and who now carry the wounds from it; 
Find peace knowing that Mary was in a special part of the world with friends. I can think of no better end.


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## richp

Hi Schultzie,

In the abstract, a person's willingness to die in a place they loved, doing something they loved, sounds great. But it's tremendously hard to communicate the burden such a death would place on others. Even knowing the way you felt, other powerful emotions come into play for the survivors. 

So you are right to talk to your trip companions candidly about your limitations. But there are no words you could share with them that would lay an adequate foundation for them dealing with your death on the river. The closest I can come is to tell them that it likely would be a dark shadow over their Canyon experience, and a longstanding source of pain and profound sadness. 

FWIW.

Rich Phillips


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## deepsouthpaddler

An event synopsis and accident report are appropriate in my opinion. Carlie walbridge does 3rd party reporting of this kind, and he provides an incredibly valuable resource. Sometimes folks too close to the event don't have the heart to write and someone else does it for them. Accident reports and community info and learning save lives and should be shared.


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## Jensjustduckie

My dad died a few months ago, I hadn't seen him in 10+ years and we weren't friends. I thought his death would be easy, it isn't. I still cry when I think of him, I couldn't go through the things I got from him for quite a while because of the sadness it brought. This was a man who I didn't share common views, friends or much time with as he left when I was a baby and I saw him only once a year until I was an adult and then very rarely. 

Here's my point: I cannot fathom losing an actual friend who I cared about on such a wonderful trip and then trying to carry on with the daily chores on the river. Sometimes you roll the dice and things go terribly wrong, unfortunately the people left after you've gone have to still manage to get on with life. Dying doing what you love sounds great but when you're gone your crew has to somehow manage to go on. The only thing I've learned from this story is that sometimes people take chances and then things can go terribly wrong.


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## drhughjorgen

I know Mary and I (see that I stated I) don't for a moment think she would want this thread deleted. First because she was always willing to learn and second because she was always ready to teach. Keep this thread alive. This is a teaching moment. This is a learning moment.


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## coloclimber512

I would not be for deleting this thread if the investigation was more complete. I just feel that Tom was a little anxious to post this without getting more facts. ie. Interviewing more than one of the involved parties, putting all the pieces together and coming up with a summary. I think that one can learn from these reports, but, they need to be as accurate as possible. I just don't think Tom did his due diligence before writing up and posting a unofficial report. It is unfortunate what this trip had to endure and my condolences to those involved.


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## lmyers

I agree the original post to this thread was in bad taste, but I feel everyone has been very respectful and there have been some good lessons and quality information shared. We don't "delete" threads hardly ever. If it boils down to personal attacks or if it is requested to be removed by family or members of the trip in question the thread will be locked. We don't delete them that way a record is preserved in the Mountain Buzz database.


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## onefatdog

My two cents on reporting of river fatalities is this; Rivers, like roads, skies and rails, are open to the public to be traveled. If there is a car accident, plane or train wreck all the information available is recorded publicly. Rivers and river accidents are and should always be open to public scrutiny just as any other means of public transportation. 
Posting the events on this or other public forums gives the everybody who'd like to know vital information that may saves future lives and should, and usually is, done respectfully. Because others were witnesses, friends or family does not mean that the information is somehow sacred and held in private until the time is right.
With all due respect for the deceased.

Nathan


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## johnryan

Exactly! Well said. Patience to be certain of what happened should be more important than quickly wanting to be the guy who tells.




coloclimber512 said:


> I would not be for deleting this thread if the investigation was more complete. I just feel that Tom was a little anxious to post this without getting more facts. ie. Interviewing more than one of the involved parties, putting all the pieces together and coming up with a summary. I think that one can learn from these reports, but, they need to be as accurate as possible. I just don't think Tom did his due diligence before writing up and posting a unofficial report. It is unfortunate what this trip had to endure and my condolences to those involved.


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## buckmanriver

*Grand and BASE fatalities more perspective*

1. Tom was acting in good faith and without malice in his write up. Furthermore, I would argue that the rive community could do a better job of reporting accidents in a respectful way in the hopes that interested river runners could read and learn from them. 

2. I hope the sensationalizing a single accident reports validity does not detour readers from making a trip of their own. Of the 28,000 people a year that run the Grand Canyon. The average number of river caused fatalities is less than five people per year. Assuming, it was as high as five. That is a 0.000178 chance of death (5/28,000). You could run the Grand Canyon once per year (the maximum allowed to private river runners) and you are still more likely to die of heart disease in you 80s than in a rapid in the grand. 

3. The BASE jumping communities web form provides good contrast for those apposed to reporting of fatalities. This list linked below allows the web used to see patterns in the cause of death in jumpers over time. For example, there has been clear increase in wing suite fatalities in the last 10 years as compared to the first ten year in base. 

BASE Fatality List - BASE jumping :: Wingsuit :: Speed Flying :: BASEJumping.tv @ BLiNC Magazine

4. I think a similar list would be appropriate for Grand Canyon river users. Extracting patterns from the data from multiple fatalities over time could give users a better understanding of the inherent risk in a trip and how to prevent them. A list of this sort could go way beyond my division problem above, the purchasing of a ladder to climb back into your boat after a flip, or reading a single report.

Happy paddling.


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## Tom Martin

Buck, Thank you for your post. It's possible you might be a little high in the numbers, as it may be more like one to two river related fatalities per year. That includes what the Search and Rescue rangers at Grand Canyon call clutch-and-drop heart attacks that occur on the concessions trips while hiking in the heat. 

One has to wonder if driving to and from the put-in/take-out is the most dangerous part of the Grand journey. 

That said, I have been trying to report on river related fatalities and injuries at Grand Canyon for well over a decade. It is not an easy thing for me to do, and I do my best to be as civil and as tactful as I can. Yours and others points about needing to learn from what is happening is why I do this. 

To the mudslingers, it's been 10 weeks since Mary's passing. drhughjorgen said it very well. I too was lucky enough to call Mary "Friend" for over a decade. We worked together on a number of backcountry issues in Grand Canyon. I am typing this e-mail from the house Mary grew up in. Some of you may be interested to know that within two weeks of Mary's passing I had a very good understanding of the events on the trip, but it wasn't till another 6 weeks had past and i had spend another 20 hours or so researching this that I posted the report, after it was reviewed, re-written and approved for release by one of the trip participants. 

We as a species don't look at death well. It draws out the best and the worst in some of us. We as river runners hardly look at our own injury and fatalities at all. I don't know why that is, but I do know that we do a disservice to the deceased and our fellow river travelers if we keep quiet and tell others to do the same. 

Please note that as of this time, no one is saying the report I released is incorrect. Am I God's gift to investigative journalism? Heavens no! Is this report incomplete? Certainly. It always will be. Is it complete enough to learn from? Absolutely. 

Finally, I have posted this report on another river list where johnryan and rich are not members (yet), but over 600 other river people are. There were over 37 comments made by 12 folks. While the comments were robust and reviewed aspects of trip safety, not one post had anything bad to say about the written report or the person who posted it. Just sayin...


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## restrac2000

buckmanriver said:


> 1. Furthermore, I would argue that the rive community could do a better job of reporting accidents in a respectful way in the hopes that interested river runners could read and learn from them.
> 
> 4. I think a similar list would be appropriate for Grand Canyon river users. Extracting patterns from the data from multiple fatalities over time could give users a better understanding of the inherent risk in a trip and how to prevent them. A list of this sort could go way beyond my division problem above, the purchasing of a ladder to climb back into your boat after a flip, or reading a single report.
> 
> Happy paddling.


I personally never assumed malice on anyone's part but tend to believe the experience of those on such trips trumps the immediate demand of the public to know information. In this particular case we are still talking mostly about weeks. The internet has created a lust for information faster and faster which often comes at the expense of individuals privacy and grieving. As someone who has been carried out on a liter by SAR and also done a body search for friends I can say in all honesty that a "detailed" report done avocationally by a forum member this soon would have been hurtful and unproductive for me as an individual. I know the internet creates some anonymity but if we really care about fostering community than sometimes we need to respect the individual request.

Per the ideas expressed about reporting....annual reports are different than detailed reports about individual accidents. I have studied several approached in the outdoor fields and do believe there is a place for the first. I learned a lot from the anonymous studies about avalanche deaths and "heuristics" as I think that style provides a healthy balance between community learning and individual privacy. This specific post and report has obviously struck a cord and exposes for many of us what is an unfair and unproductive balance.

To Tom....I am sorry you lost a friend as well. Each of us deals with that process differently. But I wouldn't dare publish information regarding accidents with such immediacy and against the wishes of survivors of the event still dealing with the trauma. And I would hope an organization would be even more cautious with the time trauma demands.

Its not about mudslinging but about trying to protect what is one of the most challenging experiences we have in life from the carelessness of the internet and the interactions it creates. If a "lessons learned" report is desired than I would recommend you learn to be more patient and maybe consider doing so in a group setting with oversight as it tends to produce outcomes that are less harmful to individuals. Waiting more than a few months isn't much to ask for especially considering the low rate of fatalities on the river anyways. And handing the reporting off to someone who does not have the complex social ties to the event you do may have led to different outcomes.

We can find a healthier approach. I sincerely ask people reconsider instead of justifying their actions. And I think we need to respond to those who need the extra time and not those who are ready to share. Keep it to private settings until the group is ready as a whole. Because if we don't then we alienate and disenfranchise community members (and we do that enough with less serious issues as it is) during a painful experience. 

Phillip


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## Phil U.

Nicely said, Phillip.


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## BoscoBoater

"not one post had anything bad to say about the written report or the person who posted it. Just sayin..."


Be that as it may Tom, you still come across to me as a serious dick.... Just sayin....


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## Tom Martin

Hi Phillip, thanks for your post. While i will respectfully disagree with your note, I greatly appreciate your thoughts. If we were to wait till all members of "the group is ready as a whole" would fatality reports ever be released? Not in my research. You may do better and I hope you get my point. 

Meanwhile, the rest of the boating community would paddle on in ignorance. That does not seem like a smart thing to do. Yes, it is a balance. In the normal world events like this, had they happened in downtown (name your city), they would be reviewed in the next day's paper, or in the weekly review. Your mention of a healthy approach is exactly what I strive for. To that end we attempt to get the information out there to learn from others joys and misfortunes, and carry on with as much knowledge as we can bring to the journey. All the best, tom


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## cataraftgirl

Tom Martin said:


> Meanwhile, the rest of the boating community would paddle on in ignorance. That does not seem like a smart thing to do.


I'm not sure what the boating community learned from this particular report that they were ignorant of before reading it? Flips happen, hypothermia happens, bad things happen.....even to people who are experienced and did not appear to be making any major or egregious errors. 

For me, reading reports about river fatalities or mishaps are all about asking the question.....what would I do different than the folks in the report? What decisions would I make to obtain a different or better outcome? I'm not sure after reading this report that I can find something that I would have done differently than this group did at the time. Will I invest in a decent rescue ladder for the future? Probably? Did I learn that sometimes bad things happen, even to people who are experienced and prepared? Yep. Do I feel heartsick for those involved in this tragedy? Most definitely.


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## richp

Hi,

I re-engage with great reluctance, and hopefully in a narrow and constructive manner. 

I am unable to see the case that:

a) It is better to compile and publish a report based on a limited range of interviews;

b) that is missing other relevant data that we know will be available in due time; and,

c) is compiled by a person who had significant personal ties to the victim (as well-meaning a motivation as that might provide).

I think the case is much stronger that it's preferable -- and ultimately more useful to the river community -- to wait for a comprehensive report compiled with:

a) full interview data obtained in the immediate aftermath from all participants;

b) incorporating all available physical evidence; and,

c) is produced by an impartial, independent, experienced investigative resource.

How much of Tom's broadly-painted version eventually coincides with the offical report is not the point. It's the detail that matters when usefully sorting out something like this. I actually was there. And my account -- as sure as I am about it -- would be neither complete nor dispositive, as to at least some of the important details. 

That's why we should be waiting for the official report, which is all I've ever said. 

FWIW.

Rich Phillips


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## D-Sieve

richp said:


> Hi,
> 
> I re-engage with great reluctance, and hopefully in a narrow and constructive manner.
> 
> I am unable to see the case that:
> 
> a) It is better to compile and publish a report based on a limited range of interviews;
> 
> b) that is missing other relevant data that we know will be available in due time; and,
> 
> c) is compiled by a person who had significant personal ties to the victim (as well-meaning a motivation as that might provide).
> 
> I think the case is much stronger that it's preferable -- and ultimately more useful to the river community -- to wait for a comprehensive report compiled with:
> 
> a) full interview data obtained in the immediate aftermath from all participants;
> 
> b) incorporating all available physical evidence; and,
> 
> c) is produced by an impartial, independent, experienced investigative resource.
> 
> How much of Tom's broadly-painted version eventually coincides with the offical report is not the point. It's the detail that matters when usefully sorting out something like this. I actually was there. And my account -- as sure as I am about it -- would be neither complete nor dispositive, as to at least some of the important details.
> 
> That's why we should be waiting for the official report, which is all I've ever said.
> 
> FWIW.
> 
> Rich Phillips


I've been waiting for either trip participant to say something nice and thoughtful about Mary - who she was, what she stood for, or a short recounting of an event from the last 2+ weeks of her life! WTH?

+1 Tom Martin - thank you for all the GC advice given throughout the years.

To the family of Mary, I hope that somehow you can find comfort in sharing the last few weeks of her life, in a beautiful place, doing the things that she loved doing. I'm so sorry it happened, but many of us don't get the same "privilege". Peace to you.


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## cataraftgirl

D-Sieve said:


> I've been waiting for either trip participant to say something nice and thoughtful about Mary - who she was, what she stood for, or a short recounting of an event from the last 2+ weeks of her life! WTH?


You must have missed the original thread about this event, posted on 9/27/13. All of the information, comments, and remembrances of Mary were contained in that thread.
http://www.mountainbuzz.com/forums/f42/river-fatality-in-grand-canyon-50501.html


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## The Kooz

+1 Thanks to Tom.

Any one following Tom's write up on this incident, or any incident for that matter, knows they are done thoughtfully and tastefully. He clearly has done due diligence on this matter, and 10 weeks is more than enough time for an objective analysis of events. I'm doubtful any formal investigation will provide a better synopsis, particularly one geared directly towards the boating community. Any arguments to the contrary are shortsighted and ignorant.

The fact of the matter here is there was a failure on the part of this group, and a seemingly wonderful person paid the ultimate price for that failure. That's is worth examining, and a thoughtful, objective analysis like this has value for rookie and experienced boaters alike. 

I was a commercial guide/manager for 8 years, and still spend the majority of my free time on the water. I've been on the scene of injuries and one fatality. I can point to at least 3 contributing factors I see frighteningly often on the water. I understand this is a emotional issue, but I wish half of the energy of this thread was spent actually learning from this incident. 

Tom, thank you for all you do. We've never met, but I greatly appreciate your contributions to the Canyon boating community.


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## restrac2000

The Kooz said:


> The fact of the matter here is there was a failure on the part of this group, and a seemingly wonderful person paid the ultimate price for that failure. That's is worth examining, and a thoughtful, objective analysis like this has value for rookie and experienced boaters alike.
> .


And this is the reason the internet is a horrible place to process accidents in this fashion. The blasé judgement above totally ignores the complexities of group dynamics and risk management we all face on a daily basis on the river. Calling this approach remotely "objective" ignores far too many foundations of that concept to be acceptable. 

Tom, I hope you take note, as when you choose to personally post informal and incomplete assessments like you have you prioritize the hypothetical benefits of the "learning of the community" over the very real experience of the participants. You have participated on this forum long enough to realize that even the best intentions lead to finger pointing and very real social tension. I would have expected someone with your professed interest in the community to have the wisdom to recuse yourself from this report and respect the boundaries of others. Your spirited history and relationship with one of the participants should have been enough of a red flag for anybody with professional ethics to completely stop work on this announcement. Just because you have the desire to report to the community does not mean its broadly beneficial, healthy or even remotely professional.

As of right now, "we" haven't learned anything that hasn't been known by the community for years about the dangers of cold water and instead we have provided an unsafe environment for the participants of the incident (and when it really comes down to it they are the ones that matter) and fostered an environment that places blame on a situation we sincerely know very little about. If there had been some shockingly new discovery in river safety then maybe we might be having a different discussion right now. But there wasn't and we aren't. The current reality is that the lessons learned already are prevalent on the web and could have waited to be reinforced at a different time.

The internet seems to allow us to so easily ignore the complexity of life and make snap judgements. I have made some poor judgements on this forum in the past but wouldn't dare assume I have the authority or wisdom to pass such judgement and analysis of someone else's trip without the full group participation and consent.

Lest we forget, a community is made up of real people, several who participate here and experienced this incident and trauma first hand. I don't think we would totally ignore their repeated and sincere pleas to respect their boundaries if we were interacting in person. So why have folks ignored them here? I sincerely hope those so comfortable with this forced public approach never experience such involuntary probing in their lives.....

The idea that this is the best and only way to learn from accidents ignores the reality that most of the critiques thus far are supportive of community reporting but think there can be changes that reflect all the complexities inherent to our pursuits, including respecting the participants.

I can only continue to plead that people reconsider and at a minimum take their judgements about the incident sideband for the time being. Its really not much to ask.

Phillip Rhoades


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## cataraftgirl

restrac2000 said:


> And this is the reason the internet is a horrible place to process accidents in this fashion. The blasé judgement above totally ignores the complexities of group dynamics and risk management we all face on a daily basis on the river. Calling this approach remotely "objective" ignores far too many foundations of that concept to be acceptable.
> 
> Tom, I hope you take note, as when you choose to personally post informal and incomplete assessments like you have you prioritize the hypothetical benefits of the "learning of the community" over the very real experience of the participants. You have participated on this forum long enough to realize that even the best intentions lead to finger pointing and very real social tension. I would have expected someone with your professed interest in the community to have the wisdom to recuse yourself from this report and respect the boundaries of others. Your spirited history and relationship with one of the participants should have been enough of a red flag for anybody with professional ethics to completely stop work on this announcement. Just because you have the desire to report to the community does not mean its broadly beneficial, healthy or even remotely professional.
> 
> As of right now, "we" haven't learned anything that hasn't been known by the community for years about the dangers of cold water and instead we have provided an unsafe environment for the participants of the incident (and when it really comes down to it they are the ones that matter) and fostered an environment that places blame on a situation we sincerely know very little about. If there had been some shockingly new discovery in river safety then maybe we might be having a different discussion right now. But there wasn't and we aren't. The current reality is that the lessons learned already are prevalent on the web and could have waited to be reinforced at a different time.
> 
> The internet seems to allow us to so easily ignore the complexity of life and make snap judgements. I have made some poor judgements on this forum in the past but wouldn't dare assume I have the authority or wisdom to pass such judgement and analysis of someone else's trip without the full group participation and consent.
> 
> Lest we forget, a community is made up of real people, several who participate here and experienced this incident and trauma first hand. I don't think we would totally ignore their repeated and sincere pleas to respect their boundaries if we were interacting in person. So why have folks ignored them here? I sincerely hope those so comfortable with this forced public approach never experience such involuntary probing in their lives.....
> 
> The idea that this is the best and only way to learn from accidents ignores the reality that most of the critiques thus far are supportive of community reporting but think there can be changes that reflect all the complexities inherent to our pursuits, including respecting the participants.
> 
> I can only continue to plead that people reconsider and at a minimum take their judgements about the incident sideband for the time being. Its really not much to ask.
> 
> Phillip Rhoades


Amen.


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## richp

Hi Kooz,

The only fact of the matter is that nobody -- including you or Tom -- has all the facts at this time. 

And any conclusion you so confidently pronounce, regarding some supposed "failure" in the way this trip operated, is premature and ill-advised. 

Rich Phillips


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## The Kooz

This incident is proof we still have more educating to do. I truly feel for all those involved. But there was a failure of the group that day. I don't know to what degree each of the factors Tom brought up actually contributed, but - unless Tom is COMPLETELY offbase - I am certain that those factors cascaded into tragedy. And all of those factors were entirely preventable. Yes there is risk in this sport, but they weren't running a VI+ drop. There is no excusable reason for someone perishing from a swim at that location. I'm not saying that to be cruel - i'm saying that as a very experienced boater. If someone enters the water, and dies as a result, that is a failure of the group. It's that simple. 

And no, the Buzz shouldn't be used to process this tragedy. But that's not what Tom was doing. Certainly Tom doesn't have the entire story, but that doesn't mean his write up has no merit. If second hand incident reports had no merit, AW's incident library would look pretty meager. What he was presenting a learning opportunity. Maybe Tom has some ulterior motive here i'm not aware of. but as someone who knows no one involved in this thread, I find the dispute here clearly runs deeper than just this writeup. The write up has basic points, and shows how incidents escalate and risk factors compound quickly. These are basic concepts i find 50% of boaters don't understand. The whole "bad things happen" attitude is just pure ignorance, and i see this as a great example of how quickly things turn deadly.

All that i care about is preventing this sort of incident in the future. So unless the "unknown information" that is being eluded to somehow completely contradicts Tom's write up, there is merit there. Of course there is some error here, but the fundamental points are valuable.


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## coloclimber512

The Kooz said:


> This incident is proof we still have more educating to do. I truly feel for all those involved. But there was a failure of the group that day. I don't know to what degree each of the factors Tom brought up actually contributed, but - unless Tom is COMPLETELY offbase - I am certain that those factors cascaded into tragedy. And all of those factors were entirely preventable. Yes there is risk in this sport, but they weren't running a VI+ drop. There is no excusable reason for someone perishing from a swim at that location. I'm not saying that to be cruel - i'm saying that as a very experienced boater. If someone enters the water, and dies as a result, that is a failure of the group. It's that simple.
> 
> And no, the Buzz shouldn't be used to process this tragedy. But that's not what Tom was doing. Certainly Tom doesn't have the entire story, but that doesn't mean his write up has no merit. If second hand incident reports had no merit, AW's incident library would look pretty meager. What he was presenting a learning opportunity. Maybe Tom has some ulterior motive here i'm not aware of. but as someone who knows no one involved in this thread, I find the dispute here clearly runs deeper than just this writeup. The write up has basic points, and shows how incidents escalate and risk factors compound quickly. These are basic concepts i find 50% of boaters don't understand. The whole "bad things happen" attitude is just pure ignorance, and i see this as a great example of how quickly things turn deadly.
> 
> All that i care about is preventing this sort of incident in the future. So unless the "unknown information" that is being eluded to somehow completely contradicts Tom's write up, there is merit there. Of course there is some error here, but the fundamental points are valuable.


Wow, I think your mislead here a bit. Blaming the entire group for this accident? Cumulative events caused it? That's BS. From what little info is in the report it sounds like a normal GC trip up until the tragedy. People bailing, mud, flips, yeah normal. If you want to learn something from this incident, just remember that when you have a severe illness, you are taking a risk doing anything outside in the elements. For some this risk vs reward is worth it. For others it is not. You have to make that decision for yourself and make sure your team is okay with your choice as well. 

I have lost respect for Tom as others have respectfully asked for his patience on this matter but he continues to slam how he's doing the right thing down everyone's throats. Sure others have said they learned something and Tom put in his plug for the rescue rung. It is likely in this scenario the rescue rung would be worthless. You still need to be able to use the rescue ladder to get yourself back in the boat. The best way to get someone back into a raft is to grab them by their PFD and pull them into the raft. 

I would rather wait a year for Charlie Walbridge to put up an official AW report that may or may not be the same. But, we will know that he did his homework and relayed the actual happenings the best he can. Otherwise you get fingerpointing from idiots like The Kooz.


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## cataraftgirl

The Kooz said:


> If someone enters the water, and dies as a result, that is a failure of the group. It's that simple.
> 
> All that i care about is preventing this sort of incident in the future.


It's not that simple. Bad stuff does happen on rivers, and thinking that you have total control over the outcome is pure arrogance. That doesn't mean you shouldn't be prepared, it just means that you shouldn't assume that your preparation will save your life or someone else's 100% of the time. Not everything in life can be prevented or fixed. It's not ignorance, it's reality. A reality that some folks must unfortunately deal with after a tragedy happens.

As for preventing this sort of incident in the future.....how about posting some sage advice instead of stating that a person died because her group failed her. That would be more helpful and less mean spirited.


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## carvedog

Locking this thread pending review from the moderation team.


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