cindy canyoneering
Above: Fourth from left, Cindy Spangler and compadres canyoneering 2017.
Canyoneering Close Call: Always Have a Safety Plan
Engineer Cindy Spangler compares canyoneering and surgery and identifies a common thread: the need for high-reliability processes. She describes how surgical time-out, a quick huddle to debrief before surgery, can serve as a useful model for reducing the risk of harm in canyoneering.

went canyoneering a couple of weekends ago. Canyoneering involves 3 to 12 crazy people deciding to wear 40-pound packs, enter a canyon, and do dangerous things in remote locations. General information about the canyon is known–length of rappels, distance, and time required in normal conditions.

canyoneering sheer

But the canyon changes every day. So we work as a team to problem solve and “arrive alive” back at camp. There are redundancy plans to prevent injury, and we have a safety plan:

  1. If anyone in your party is injured, get help.
  2. Stay together.
  3. If you need help, whistle once. Or is it twice? Not sure, depends on the group.

I’m guessing you are starting to see the problem. This plan is not a high-reliability plan! There are three well-understood steps between us and harm. There are a lot of “what ifs” once you enter the canyon.

What happened on my most recent trip has me thinking about our safety plan. It was near the last hour of a 10-hour day. We were tired. One of our members became separated from the group. We violated rule #2: stay together. He went up when we went down. Sometimes this works in a canyon. That day, it didn’t.

As the three of us are waiting at the exit of the canyon, twilight set in. Temperatures started to drop. We yelled, whistled, and travelled back into the canyon. No sign of him. Then, we started to consider the possibilities: He’s lost, He’s injured, he had a medical issue. Would he be able to return safely?

During our 15-minute walk back to camp, we discussed what to do next. I realized we were past the planning stage and in the middle of a safety event. We called search and rescue. Four hours later our lost companion wandered back to camp. It was human error–overconfidence in his ability to find his own way back–that led him astray. Search and rescue were called off. A happy ending to a stressful day.

"I wondered how could we have prevented this near-miss in the future? How do you plan for the what-ifs?"

I started to think about the operating room and surgical “time outs.” Surgical “time out” is part of the Universal Protocol to verify the right patient, right procedure, and right surgical site prior to starting a procedure. If we, as a team, would have taken 10 minutes to talk about what we were going to do for the next 10 hours–taken a safety time-out to verify the plan–maybe we could have prevented the indecision that followed.

We needed to discuss today’s conditions, but we also needed to consider the what-ifs. What kind of decisions may confront us? What are the ways in which things could go wrong? How could our equipment fail? What about our communication methods? Engineering processes are usually built with these questions in mind. Are critical processes in your area three steps from harm?



Cindy Spangler

Quality Manager, Global Surgery, University of Utah Health

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