Psychological Factors and Cascading Errors

Psychological Factors and Cascading Errors: A Fatal Accident Case Study

By: William K. Storage and John H. Ganter

It began like many Sunday trips do in late summer. Four young cavers—David (17), Jane (21), Paul (17), and Robert (17)—walked upstream along the Elk River in northern Pocahontas County, West Virginia. The Elk is one of the largest sinking streams in the east. The fact that it was flowing heavily meant that water levels in the caves in the valley would be very high. As the group, talking and laughing, crossed the Elk, Jane fell in and got wet up to her chest. She would warm up soon. The cavers walked up the hillside and entered My Cave. Their plan was to traverse a few hundred feet of large, dry passage, rappel the 79-ft Outhouse Drop, and then walk upstream before emerging at the Dry Branch entrance. That is not what happened. A few hours later Jane was dead and two of her companions were lightless and hypothermic. (...)

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