By Kim Smiley
On February 12, 2010, Nodar Kumaritashvili, an Olympic luger from the country of Georgia, was killed during a practice run. He lost control of his sled, flew off the track and hit a steel pole.
The investigation into the accident is still ongoing, but a root cause analysis can be started with the information that is available. This accident obviously impacts the safety goal because an athletic was killed and it also had potential to impact the schedule goal because the track was closed during the initial investigation.
There are a number of causes that can be added to the Cause Map. One of the more obvious causes for the accident is that the athletic was traveling at high speeds. This occurred because the crash happened near the bottom of the track so the sled was near its top speed. Additionally, the Vancouver Olympic track is also a particularly fast track. Top speeds on the track were predicted to be 96 mph, nearly 6 miles faster than the standing 2000 world speed record.
How did the track get designed to be so much faster than typical tracks? There are a number of causes that contributed to fast design. The designers choose Whistler as the site of the track because Whistler has a colder climate than the alternatives, resulting in firm, fast ice and because there is high tourist traffic there that would help make the track a commercial success after the Olympics. Whistler was also the site of the Olympic alpine events.
The land that was available at Whistler was long and narrow. The site was a valley approximately 100 yards by 800 yards. By comparison, the Calgary track was about 300 yards wide and Salt Lake City’s track was 500 yards. Designing a track to fit in the available region meant the track couldn’t include any long curves that slow down speed as is typical.
The result was the fastest track in the history of the sport.
As the investigation continues, more details become available and they can be added to the Cause Map.
In order to ensure safety during the Olympic Games, several solutions were implemented following the accident. A wooden wall was added to the curve where the accident occurred to keep athletics on the track, the steel poles were padded and events were started lower on the track to limit the maximum speed. The lower start was predicted to slow top speeds in the men’s events by about 5 mph.
There have been several crashes on the course since the accident, but thankfully no farther significant injuries have occurred.
I am a failure analysis, forensic management expert and I thank you for your efforts in this analysis; it is haunting me that someone focus on these elements.
I wish to convey to the family what a horrible and seemingly avertable tragedy this has been for me and I’m sure the rest of the world. If there is anything we can do we are happy to help in any way.
My first thought, like everyone was disbelief and I never wish to view the incident again.
Since the incident burned a horrible image in my mind; I did give it a step by step thought as to how this young man; so full of life could have been killed by what first appeared as just an accident.
It appears, as with all failures of this type that the Sun, Moon and Stars needed to line up for the end result to occur. In this case it was more than three things.
When I had heard of the event a statement about him being an amateur seemed to brush off other factors. If there is substance to this, let the authority claim this as contributory but I thought all Olympians were required to be amatures. I would take issue with anyone claiming amateur to an Olympic Athelet; qualified by his country and countrymen and likely top of class.
When I heard that the track was faster by 6 to 9 miles an hour, at 90 miles per hour [40 m/s] he would be about 4′ beyond a point of his “muscle/reactionary memory capability.” Any neurologist could easily explain better than I. I do not believe this is contributory to a death as errors are to be expected and tracks, safety barriers, and management is expected to meet standards.
When I heard he was not given a chance to train as needed, I would bring this to a major contributory factor; not for his death as one should not die if making an error. If this was out of standards then I would hold this more contributory to “setting an increased risk factor” because of failure to aid in the prevention or errors [a basic expected Olympian standard is to keep athletes safe].
When I saw that AFTER his error in missing the turn [due to the speed difference] he then ended up hitting the “Inside Wall” before he was catapulted outwardly beyond the plane of the track and into the pillar. I felt that this wall could have been designed wider (inward away from his ricocheting body) by making it wider on the inside by perhaps a meter. This would have prevented ricochet and simply would have resulted in sending down the track. Because of the tight inside wall he was sent out toward the outside wall. I see no reason for creating such a tight, narrow inside wall and using roller coaster technology may have shared that given a good ISO 9000 Design Process. The Design Process may have missed this danger.
The final missing barrier was clearly the cause of death and therefore, to omit such a barrier in the face of all other elements, one would have to conclude culpability to the safety engineers responsible for checking design flaws.
If there was practice limitations then the root of those limitations should be investigated as a major contributory factor to the original error of going into the turn wrong.