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The number of avalanche accidents, injuries and deaths last season went far beyond the averages for France, Switzerland and the USA. It was one of the worst seasons in fifty years for those countries. Other countries are likely to report similar statistics. From a technical point of view, the reasons for this are deceptively easy to explain: a very unstable snowpack throughout most of the season and a stormy season with several periods of intense snowfall that exacerbated the already unstable snowpack.
Addressing The Avalanche People Problem – title of the April 2021 edition of The Avalanche Review (TAR) which is the publication of the American Avalanche Association (A3) – is more difficult and more important for accident reduction than explaining the technical snowpack instability characteristics that also contributed directly to the rash of accidents. The ‘people problem’ is another term for the ‘human factors’ that have been identified as the primary reason for the vast majority of avalanche accidents over the last 3 to 4 decades. In sum, almost all victims of avalanches had enough training to recognize and appreciate the danger signs on the mountain and the warnings in the avalanche bulletins, e.g. a serious persistent weak layer(s) etc., before they headed up.
In this article my aim is to 1. clarify the problem and 2. suggest a solution. I also hope to validate the fact that there are almost always acceptably safe places to go, even when the snowpack is unstable and there are warnings of high avalanche danger. Is it safe? It depends on you: Where you go; How you go; and How well prepared you are to carry out a companion rescue (see Framework below).
Off-piste skiing and backcountry touring can be surprisingly safe – about the same risk as our everyday activities such as driving a car for an hour IF we regularly apply the basic decision making and risk reduction measures we learn in avalanche safety training courses. BUT, if we do not apply these measures, it can be surprisingly dangerous (more dangerous than most of us would accept in our everyday lives – like going base jumping) says renowned avalanche expert, Bruce Tremper in his article What is the Risk of Riding in Avalanche Terrain? The main reason for this stark difference between ‘safe’ (a risk level equal to things we do in our everyday life) and ‘surprisingly dangerous’, is that almost all victims of avalanches trigger the avalanche themselves. Indeed, after analysis, the vast majority of accidents are shown to have been avoidable. Avoidable if adequate accident reduction measures had been applied. Even if you don’t fully agree with Tremper’s statistical analysis (and my interpretation of it), all experts agree that the application of safety training is essential if you want to keep things reasonably safe – avoid a serious accident. Indeed, not applying basic accident reduction measures in avalanche terrain is very dangerous.
1. The Problem or: We Have a Problem as Pete Earle puts it in the title of his recent inspirational article in the April 2021 edition of The Avalanche Review (mentioned above). Why don’t we apply simple accident reduction measures in risk contexts such as off-piste skiing and touring in the Alps? It is because, to start with, nothing happens most of the time when we (and others around us) do dangerous stuff – by not applying these key accident reduction measures. So we keep doing it. If we don’t know, it doesn’t seem to matter; even if we do know, we get slack at applying the key safety points because nothing seems to happen if we don’t… That’s human nature.
Observation and research in the backcountry show that even if we ski (or climb) on hundreds, even thousands, of steep slopes without applying accident reduction measures, nothing happens most of the time. When nothing happens to us – and nothing bad seems to be happening to people doing the same thing around us – the chance of something bad happening to us seems remote. This leads us to treat bad outcomes as impossible even if we know there are facts showing the contrary says Daniel Kahneman: expert on ‘human factors’, the psychology of judgment and decision-making and Nobel Prize Laureate. Human factors’ impulses more easily take over n these contexts and our impulses don’t take signs of danger into account. So, rather than noticing signs of recent avalanche activity on slopes similar to the one where we’re aiming for (and the big terrain trap at the bottom), we’re easily distracted by other skiers’ tracks and thinking, “Let’s get there before the powder’s tracked out!”. Meanwhile, in the back of our minds, we’re reassuring ourselves: “Other people are around, there are tracks on a lot of slopes, so it must be OK”. We fail to account for the fact that tragic outcomes with long odds do sometimes happen.
This happened to me. I let myself get distracted. But unlike most people, I got caught on video setting a big avalanche off (see video below). It made it to National Geographic, much to the embarrassment of this so-called avalanche expert and educator… who, after this incident, became known simply as ‘The Avalanche Maker’! I was very lucky not to be killed by this avalanche. Most importantly, in terms of accident prevention, it shows that no matter who you are, if you don’t regularly apply safety measures you learn in basic avalanche training, even when nothing seems to be happening, things can and will become surprisingly dangerous.
Notice there are lots of tracks already on the slope. “Don’t take tracks seriously!” says renowned avalanche expert Bruce Jamieson in his video and paper on the Odds of Triggering.. a potentially deadly avalanche (see below in the works cited).
Further to the low-frequency, Nothing happens…, aspect of the avalanche terrain risk environment that leads us astray, and perhaps more importantly, is the low-validity or low feedback nature of this risk context. The constant false negative feedback on the slopes in question, even when there’s serious instability, is dangerously misleading even for the most experienced amongst us. Trial and error fails us (even when we do trigger a slab, usually nothing bad happens) so our intuition also fails. We become blind to even the most dangerous of situations…. especially when we are in a beautiful setting and/or focused on the goal we’re heading to – which is a lot of the time.
In his book, Autonomy, Mastery and Purpose in The Avalanche Patch, Bruce Kay confirms that this low feedback, high consequence avalanche terrain environment is a context where we, as humans, have a very hard time staying risk-alert and making good decisions. A great example is this past season’s “persistent weak layer” fatigue, as Pete Earle describes it in his prophetic article for the Utah Avalanche Center blog, December 2020. Earle also uses the term pandemic fatigue to describe the very common attitude we all get when a real, dangerous risk has been present for a long time, and after a while it doesn’t seem to be posing much of a threat to us. So we stop regularly applying the risk reduction measures that we should. This is not fatigue from over-stimulation of mind or body. It’s more like a fatigue from being bored – tired of nothing happening in face of the authorities saying that the risk is actually still there. It’s a lot like the ‘under-stimulation’ mind-state referred to in the aviation sector, where pilots’ risk-alert levels shrink when they’re on ‘auto-pilot’ mode due to their lack of normal stimulation while flying without autopilot. Matthew Crawford points out in his book, Why We Drive: On Freedom, Risk and Taking Back Control: under-stimulation causes a pilot’s risk awareness capacity to reduce, leaving him/her more open to human factor traps – the impulses that lead us to overlook clues of lurking danger and to thus neglect danger signs. Furthermore, if something starts to go wrong when we’re in this under-stimulated mind state, we are also at a higher risk of panicking in a crisis situation like a rescue.
An illustration from everyday life is that were you to drive on the wrong side of the road, or look the wrong way while crossing the street (like me the Yank in the UK), you would receive instant feedback – hopefully not after you are hit by the vehicle. The clear feedback is, ‘WRONG PLACE TO BE‘ because you are in a high feedback, high consequence environment (the busy road). However, for a similarly high consequence scenario in avalanche terrain, we don’t get that feedback. So we let our minds coax us into dangerous places because, as nothing happens, we don’t get feedback most of the time. That’s how ’risky behaviour’ can become a habit, without us even knowing it. As a result, even very experienced people can begin to believe that they are getting better at risk management, when really they have just been lucky.
In his short article Is Anyone Listening? published in The Avalanche Review, April 2021, Halsted “Hacksaw” Morris, American Avalanche Association (A3) President, talks of his own shock and frustration at the avalanche accidents in the USA this past winter 2020-21, and the victims’ relatively high level of experience. Morris’s words and example provide an erudite insight to this sort of blind spot even with educated, experienced and intelligent individuals. He recalls an article in the Smithsonian Air & Space Magazine about the Apollo 1 launch-pad fire accident of January 27, 1967. The author’s major conclusion as to why this fatal accident happened was “Perceptual Blindness”. The article described perceptual blindness as a state in which even smart people (are) sure that they are paying attention and miss what is right in front of them. “NASA had gotten so used to designing spacecraft by using what they had gotten away with previously, that they did not realize that they were making bigger and bigger design mistakes, because they would not review their designs.” Of course if there had been regular feedback or ‘validity’ , like crashes in tests, they would have recognized that there were mistakes in their designs. Instead, with little or no feedback before the catastrophe, they believed that their commitment to their goal was on target. After all, commitment is what leads to success in most cases… but in low validity, high consequence contexts, it has been shown to be deadly on a lot more than one occasion.
So how do we fight these ‘human factors’ distractions that seem to be responsible for so many mistakes made by people, who ‘should have known better’, including myself?
2. A Solution: ‘Safety is Freedom’. The idea is that the more people know and apply their safety knowledge, the more fun, sense of adventure and satisfaction they will have on the mountain – they’ve made their own well-founded decisions, rather than having to rely on a guide or (heaven forbid) the ski patrol, to take care of them.
Risk management expert, Frank Debouck, in an interview with the French Avalanche Association (ANENA), compares his human and organizational factor expertise in the aviation, health and financial sectors with avalanche risk. The interview is entitled ‘The biggest error would be to believe that we don’t make errors’’. Apparently we all commit an average of 30 errors a day – no matter how smart or well educated we are. Indeed some experts even suggest that ‘smart and successful people’, the sort of people who are right most of the time (and are usually successful as a result), commit the biggest and baddest errors because they are more likely to trust their intuition even when it is wrong. In sum, we should not try to eliminate all the errors that arise out of simply being human. It’s the errors that lead to high consequence, tragic results that need most of the attention.
In order to achieve concrete results (in aviation), it’s important not to overcomplicate things by introducing too many procedures. We only check the essential things. For example, during take-off we only check 3 items: position of the flaps, position of the air-conditioning packs system and the (aircraft) trim. We used to have a long checklist, which included things such as the correct closing of the doors. But, if we were to take off with the aircraft doors open, while not very smart, this wouldn’t actually kill anyone. We’d just need to go back, land and shut them. On the other hand, a mistake with the positioning of the flaps during take-off can kill everyone onboard.Debouck, 2019
So making errors is not irresponsible. What would be irresponsible would be to deny the fact that we all make errors and not to take steps to reduce the high consequence impact of certain errors that we are also bound to make, not because of incompetency, but simply because we are human.
In the same spirit of accepting that we all make lots of errors and not overcomplicating things: I’ve developed a Framework with the HAT team to help us to regularly apply the basic, key accident reduction points. Below is a very basic version of the Framework of the key prevention and rescue points that has been reduced down from the work that a few dozen of us have done over the last 30 years or so (work that has been shown to save over a hundred lives during this time span according to recent accident analysis and estimates).
We’ve tried to keep this Framework in line with what experts suggest for people engaging in high consequence, low feedback environments, such as avalanche terrain. Simple, easily-applied decision & risk reduction tools that can compete with distractions from those ‘human factor traps’ that often lure people into accident scenarios where there was ‘ample evidence of danger’ previous to the event. “Luckily, such tools don’t need to be perfect to save lives” according to avalanche expert and behavioural psychologist, Ian McCammon, in his papers cited below, …They just need to be more accurate than the social cues that most avalanche victims apparently rely on (McCammon, 2004).
In his interview with the French Avalanche Association (ANENA), Frank Debouck talks about the benefits of the co-pilot, in his example of aviation solutions, for ensuring application of accident reduction measures – it’s the concept of ‘teamwork’:
…in a plane cockpit, to the left sits the captain – the older grey-haired man, to the right is the young co-pilot. During any ‘critical’ part of flying the plane, each individual does a control check on the other. The co-pilot thus ‘checks’ the captain. This took a long time to implement, but today it no longer shocks anyone and has been accepted. While not compromising the authority of the captain, we have made the system much more reliable. Having someone else watch you is very important for avoiding errors and accidents.Debouck, 2019
A co-pilot type of relationship is a big part of helping an individual and/or team cover the blind spots (or Perceptual Blindness as NASA put it) and ensure that risk / error reduction is being applied.
In summary, if the goal is to reduce the chance of an accident by regularly applying accident reduction measures, then the Checklist / Framework is the weapon to keep Human Factors ‘in check’. The Team is there to act as a co-pilot(s) to help ensure that the accident reduction measures are applied – key errors are prevented. The National Health Service (NHS) England’s campaign to reduce the occurrence of ‘never events’ – simple, rare but consistently reoccurring and devastating surgical errors (like operating on the wrong limb or the wrong patient), bring it all together in the following statement:
Safety is Freedom!
Further info on the subject:
For an overview of the key points in the HAT Framework, see the ‘Essentials Talk’ modules on this link_____ (new on-line talks not available yet – coming soon) . And for an interesting adaptation of NOTHING HAPPENS… most of the time , see The Financial Planning Conference 2019 hosted by the Chartered Institute of Securities & Investment (CISI), for a keynote address that I did. Here’s a video of that talk.
References and acknowledgement. The references and authors below have contributed to this post and to our mission of helping people to have a successful and enjoyable experience off-piste and touring in the backcountry. I paraphrased (hopefully not plagiarized) most of the authors – it’s well worth taking a look at their work!
- Atkins, R. 2014. YIN, YANG, AND YOU. International Snow Science Workshop, 2014 Banff, Canada. https://arc.lib.montana.edu/snow-science/objects/ISSW14_paper_O9.02.pdf
- Bourke, A. 2017. The Chain of Events Leads to the Scene of the Accident, FIGHTER PILOT KEYNOTE SPEAKER, San Fransisco, USA.
- Crawford, M. 2020. Why We Drive: On Freedom, Risk and Taking Back Control, The Bodley Head, London UK, pp.103-104, citing Nicholas Carr, The Glass Cage: Automation and Us (New York: Norton, 2014), pp. 90-91, citing Mark S. Young and Neville A Stanton, “Attention and Automation: New Perspectives on Mental Overload and Performance,” Theoretical Issues in Ergonomics Science 3, no 2 (2002) and other works in psychology by Robert M. Yerkes and John D Dodson (1908).
- Debouck, F. 2019. The biggest error would be to believe that we don’t make errors. Interview by Martin Mazza, French Avalanche Association (ANENA), La revue Neige & Avalanches N° 165. L’ANENA, Grenoble, France. For a translation of the article in English see the middle of my article here.
- Duclos, A. 2016. Que veut dire être attentif sur la neige? & other articles. Hors-série Neige et Avalanche. Montagnes Magazine, Seyssinet-Pariset, France.
- Earle, P. 2021. We Have a Problem. The Avalanche Review 39.4, American Avalanche Association. Bozeman, MT, USA: pp. 26-27.
- European Avalanche Warning Services (EAWS). 2017. Typical Avalanche Problems (also EAWS Matrix). EAWS General Assembly. Munich, Germany.
- Gawande, A. 2010. The Checklist Manifesto, how to get things right. Metropolitan Books of Henry Holt and Company LLC, New York, NY, USA. http://atulgawande.com/book/the-checklist-manifesto/
- Jamieson, B. 2009. Regional danger ratings and the odds of triggering a potentially fatal avalanche. Dept. of Civil Engineering, Dept. of Geoscience, University of Calgary, Canada. http://schulich.ucalgary.ca/asarc/files/asarc/TriggeringOdds_Tar_Jamieson.pdf
- Jamieson, B. J. Schweizer , C. Shea,. 2009. Simple Calculations of Avalanche Risk for Backcountry Recreation. International Snow Science Workshop 2009, Davos, Switzerland. http://schulich.ucalgary.ca/asarc/files/asarc/RiskCalc_Issw09_Jamieson.pdf and video presentation https://vimeo.com/50900661)
- Jarry, F. ; M. Gletty. 2015. Avalanches hors-piste et prevention :…. La revue Neige & Avalanches N° 149. L’ANENA, Grenoble, France.
- Kahneman, D. 2011. Thinking, Fast and Slow. Farrar, Straus and Giroux, New York, NY, USA.
- Kay, B. 2015. Autonomy, Mastery and Purpose in The Avalanche Patch. Library and Archive Cataloguing in Publication. Canada.
- McCammon, I. 2002 & 2004. Heuristic Traps in Recreational Avalanche Accidents: Evidence and Implications. Avalanche News, No. 68, Spring 2004. USA. http://www.sunrockice.com/docs/Heuristic%20traps%20IM%202004.pdf
- Moody, Dr. M. and H. Schniewind. 2017. (video) Patient Safety is Freedom 2017.
- National Safety Standards for Invasive Procedures (NatSSIPs) Group – NHS England Patient Safety Domain. 2015. National Safety Standards for Invasive Procedures (NatSSIPs). London, UK.
- O’Bannon, A. 2016. Book Review: Autonomy, Mastery and Purpose in The Avalanche Patch. The Avalanche Review, American Avalanche Association. Victor, Idaho, USA.
- Schniewind, H. 2017. ITV, Sky News & Other Broadcast Media Interviews . UK/Europe
- Statham, G., Haegeli, P., Greene, E., Birkeland, K., Clair Israelson, C., Tremper, B., Stethem, C., McMahon, B., White, B., Kelly, K. 2018. A Conceptual Model of Avalanche Hazard. Nat Hazards90: pp 663-691.
- Tremper, B. 2013. Blog: What is the Risk of Riding in Avalanche Terrain? Utah Avalanche Forecast Center, Salt Lake City, Utah, USA.
- The Avalanche Review 38.3, February 2020. PROBABILITY & LIKELIHOOD. American Avalanche Association. Bozeman, MT, USA: pp 26-33
- The Avalanche Review 39.4, April 2021. THE AVALANCHE PEOPLE PROBLEM (Various. Contributions and comments by authors cited and named in above article). American Avalanche Association. Bozeman, MT, USA.
- Henry’s Triggering video caught by Nikalas Alsteg of Downfilms. Thank you Nikalas.
Final credit goes to Dr. Graham ‘Ski Doc’ Plant for alerting me to the video in the first place (which shocked me out of my denial about the incident and thus provided a much needed look in the mirror). Graham provided me with many other short videos at a time when they were not easy to make PowerPoint friendly, and he provided encouragement that has helped me and the HAT Team communicate our message in those early years. Graham had no idea that it was me in the video. His initial comments about the ignorance/foolishness of the ‘culprit’ have been the source of much humour and mocking over the years. You are sorely missed by all of us Graham.