Thursday, March 12, 2020

Do Something, Eventing, Part 2, Investigation

"We're all going to die someday," that's another ignorant blanket statement to make.  But, if there was something that you could do to prevent an early death doing something you participate in regularly, wouldn't you want to know?

One thing I repeatedly see in forums and in the comments section on various social media posts is "well, riding is dangerous," or "everyone knows the risk when they get on a horse," or "riding carries an inherent risk."  Stop.  That's an insulting, ignorant statement to make when talking about this particular scenario, riders dying on cross country.  Riding is inherently dangerous?  No shit.



Everyone knows horses can easily kill us in about a million different ways, any day of the week.  But, does that make it ok to have that attitude?  Does that make it acceptable that people are losing their lives on cross country?  Absolutely not.  It's a dismissive comment/attitude to an actual PROBLEM.  Complacency kills.  Remember that.  Also, why would you not insist on some type of investigation in an attempt to figure out what happened?

There is another very tired saying people seem to use a lot on this subject as well, "you have a higher chance getting in a wreck and dying hauling to an event."  So?  And you know what?  Law enforcement would be out there investigating and documenting IMMEDIATELY, even though it was "just another fatal traffic accident, thousands happen everyday."  They try to learn from these things, they try to figure out what went wrong, who's at fault, and if it could have been prevented.

The same goes for the world of aviation.  Statistically, the same can be said about dying in an aircraft crash when it comes to the whole "you have a higher chance of getting killed doing xyz" statement.  In this case, just driving to the airport.  Does the FAA and the NTSB take the same cavalier stance and say "well, your chances are higher of dying while driving to the airport, this was a freak thing, it's not like planes fall out of the sky every day."  No, they don't.  A MASSIVE investigation is launched IMMEDIATELY.  The eventing community SHOULD want the same.

As far as investigations go, I am trained to be on the Accident Investigation Board for the Air Force, and I have been on one, just last July actually.  There are two investigations that take place. the first is a Safety Investigation Board, which happens immediately, the second is the Accident Investigation Board.  We reviewed flight data, we reviewed the weather conditions at the time of the mishap, we put instructor pilots in the simulator with it configured the same as the aircraft that went down and have them see if they could have recovered it.  We interviewed witnesses, we interviewed supervisors, co-workers, etc...  We reviewed training records of the crew, we reviewed the curriculum of the training courses the crew attended, we reviewed their logged flight hours, we reviewed the Heads Up Display video footage from the aircraft, we listened to the cockpit voice recordings, we reviewed the crew's medical records, we reviewed the "mechanical autopsy" that the manufacturer conducted once the wreckage was recovered and sent to them.  It was then shipped to the location where we were conducting the investigation and we personally inspected it.

We appointed subject matter experts to help interpret the information we received as well.  For example, we appointed a highly experienced crew chief for that particular type of aircraft and had him read through the mechanical autopsy and asked him if certain things were normal, common problems, etc...  We appointed instructor pilots for that particular aircraft as well to help us decipher the crew's actions and if that was standard procedure that was taught in training.

At the conclusion of our investigation, we compiled a large report that is publicly releasable and states what our findings were, as well as everything we did during our investigation.  Different tabs are attached to the report and they contain witness statements, training records, etc...  Certain information is redacted, and pseudonyms are used to protect privacy where appropriate.  An example, we used a pseudonym for our subject matter experts so that they were comfortable pointing out any issues with maintenance or crew procedures if they existed.  That way the subject matter experts would not be identified by their friends and looked at as if they tattled on their own people if they did identify crew or maintenance error.  They felt they could speak candidly knowing their names would never be revealed in the report.  We had to have brutal honesty, and that is one way to ensure it.  All interviews are recorded, transcribed and included in the final report with pseudonyms applied and sensitive information redacted (things like deployed locations and call signs are redacted).

There are also programs that will make a computer generated re-enactment.  Here is one as an example with a 747 going off a runway in Maui:


Here is a longer video that has a narrative of what is going on with the jet and what the pilots are saying:


These programs can re-create everything, to include a horse and rider fall.  I know people say "I don't want to see that."  Do you, or do you not want to learn from accidents?  Do you want to keep dismissing these incidents as freak accidents and refusing to WANT to learn what went wrong?  Why would you not want to know if something went wrong?

These videos are not a smear campaign on the pilots or any of the crew.  These videos are simply illustrations of factual events based on video or data pulled from the aircraft's computer systems.  Yes, in some of them the accident IS a result of a crew error.  Again, it's not a jab at the crew, it's facts.  People make mistakes.  Wouldn't you rather know if these accidents in eventing were a mistake in the design of a jump or the error of a person for sure?  With actual in-depth investigations we have a much better chance of deciphering that instead of just saying "well, shit happens. Riding is inherently risky" and shrug it off until the next one happens.

Why isn't there a push for something like this?  Why don't they want to be transparent?  Why don't you care more?  Why do you still support something that dismisses your safety, as well as your horse's safety?  I think I know, because it's fun and it's easy to just say "shit happens."  I'll tell you again, complacency kills.

Then next post will have some data in it from these fatal rides.

Friday, March 6, 2020

Do Something, Eventing, Part 1


For those of you that have wondered why I haven't been out eventing in quite a while, well it's because I'm not eventing anymore.  It took a while to let go, with the catalyst being a recognized event I was a jump judge at the summer before we left New Jersey.  I watched a blatant disregard for horse and rider safety at a RECOGNIZED event, at a very popular venue that resulted in serious rider injury.  I was absolutely at a loss for words and it affected me so much that still to this day, I remember it crystal clear and still, to this day, fail to comprehend it.  Accidents happen, of course they do.  This was not an accident.  This was a situation (apologies to those I have already told this story to) where after a significant amount of rain the week leading up to the even there were very soggy spots on the xc course.  The TD had told us all that if we saw any issues just get on the radio and let them know because there was a front end loader full of stone dust ready to respond.

The Training division was running and I could see this particular jump from the jump I was jump judging.  I heard the jump judge at the problem jump come on the radio and say that horses were slipping on the landing side of that Training level table.  I started watching, sure enough, horses were slipping on landing and struggling to catch themselves and keep all four feet under them.  The jump judge requested stone dust SEVERAL times on the radio due to horses CONTINUALLY slipping.  She was trying her hardest to ask for help to prevent an accident.  One of the managers of the event came on the radio and said "Well, there's only a couple more horses to go in this division anyway, we're just going to let them go."  The NEXT person left in an ambulance.

This, after a rash of rider deaths as well.  This, in a time where safety is such a hot topic.  It made me realize just how much we play Russian Roulette on course.  If organizers at a well known, recognized venue, that has several recognized events a year, along with year round schooling doesn't care, who does?  You won't know until you find out the hard way, or witness something horrible.

I'm not a timid rider, I never left the box scared.  To this day I have no qualms about jumping anything.  Triple bars, corners, jumps with tarps, and balloons on them, crazy looking gymnastic line, whatever, I'll jump it.  If Klein could jump five foot courses, we'd do it.  Will Super B get to that point?  I plan to find out.  I'm the rider that 100% believe that probably 80% of problems people have or think they have are all made up in their head.  For example, those that come in from a windy day of riding and say "well, I didn't die."  I'll ask, "does he/she usually do anything to make you question your safety on a windy day?"  More often than not, the reply is "no" which prompts me to ask "Then why would you expect it today?"  If you expect problems, you get problems most times.  I'm the rider that never lunges their horses before they get on, no matter how much time they've had off, or what the weather conditions are.

I loved eventing.  I loved the test of the whole thing overall, the different types of conditioning it requires, the fact that you an show up with a horse like Klein and people would be nice and never wonder what she was doing there, etc...  Cross country was always my favorite too.

My departure started with not wanting to support an organization that seems to not learn from its mistakes, then it traveled a bit further with the support of Bloody Mary aka Marilyn Little and the absolute inaction against her, then it went even further after personally witnessing the incident in New Jersey I spoke about above.  Sprinkle some rider and horse deaths in between all of that and, I'm done.

I'm tired of the excuse that social media is to blame because these rider/horse deaths are just more publicized now.  Eventing in north america just hit FIVE deaths in the past EIGHT months, there were at least two horse deaths in that group as well.  There is no excuse for that, you can't blame social media.  Is there really any acceptable excuse or reason?  Trick question, there isn't.

I'm tired of the "it was a freak accident" excuse too.  You know what's a freak accident?  Getting kicked in the head in a field by a horse, a horse spooking from an animal that came running out of the bushes and the rider falling and getting hurt or killed, a horse tripping at a canter and falling on its rider.  You know what a freak accident isn't?  A rider and/or horse dying every few months in a similar manner on a cross country course attempting to jump a solid fence.  This has become a predictable pattern, a trend.

Now we have the "frangible technology is too expensive to employ on every xc fence" statement.  While that may be true, where are all the big time supporters that are paying tens of thousands in sponsorship money, syndication money, prize money, etc...  What about the Essex HTs where the Prelim winner gets $10,000?  Can we not take that prize money for a year or two and say instead of giving this as prize money, it's going toward frangible fences?  There is a particular multi-billionaire ($29.4 Billion according to Forbes) that funds a lot of upper level horses and riders as well as sponsors events that could probably pay for every last fence in the country to be frangible.  Where's the support for safety at that level?  I'll wait...

I also expect the "people die in dressage and jumpers" crowd to come out too.  They're not wrong, people DO die in dressage and jumpers, every once in a long while.  Eventing still has everyone beat in that category.  Eight in five months?  I looked for a quite a while tonight to see what I could find about rider deaths in dressage and jumpers.  I am not talking about Hickstead, or an accident in the barn, or a horse suffering a cardiac event in general while in competition, or anything similar to Teddy O'Connor's demise, I'm talking about riders and/or horses dying as a result of meeting an obstacle incorrectly.  Here is what I found:

https://nypost.com/2016/09/02/equestrian-crushed-to-death-by-her-own-horse/

https://www.chronofhorse.com/article/rider-dies-fti-winter-equestrian-festival

But.......social media is everywhere now so we should have so much more as far as dressage and jumpers deaths, right?  Yeah, if they existed.

You can't even Google "dressage competition deaths" without Google suggesting eventing deaths.


Or dressage deaths...

Or showjumping deaths...

Or showjumping rider deaths...


The majority of eventing deaths are taking place at recognized events, aka places FILLED with professionals and medical staff on standby to assist.  These are not all people out alone where no one knew anything happened until it was too late.

This has been in the media for over 12 years now.  Here's an article from 2008:

https://www.nytimes.com/2008/04/09/sports/othersports/09equestrian.html

Read it.  Notice a familiar theme?  Why is this still happening 12 years later?

I have been taking some time to pull records, review videos, and run stats over the past week.  I'm going to post the information in the next post.  I think this problem is a multi-pronged issue with several hard truths that need to be addressed.  Just looking at scores and reviewing some video makes it pretty clear there are multiple issues going on.  Where do we start to address it?  I think some of it IS starting to be addressed and has been by committed USEA members like Doug Payne and John Holling.  But, we have a long way to go and some of it has to do with recognizing when something isn't right, and speaking up, or taking a real look at yourself and your horse and knowing your limits whether they are mental, or physical, before it's too late.