Human Factors in Avi Accidents

[srsosbso]

blah, blah, FUCKING blah about the contributing factors. Everything boils down to the decisions that you make...or fail to make.

Uh... I think the point is identifying the factors that lead people to make bad decisions.

[VC]

From a Wildland Fire class about human factors on the Fireline, pretty similiar stuff:

At the heart of preventable wildfire tragedies are two key errors—two ways that situational awareness and decision-making break down. Contributing to these errors are seven key barriers to situational awareness and decision-making. These fundamentals—2 Errors, 7 Barriers—can be presented as a useable training tool

TWO ERRORS:

1-Underestimating hazards, and using inadequate safety measures
2-Failing to notice changing conditions and adjust tactics accordingly

SEVEN BARRIERS:

1-Inexperience
2-Getting Too Comfortable
(eg. Complacency, Inattention, False Sense of Security, Autopilot)
3-Distraction From Primary Duty
4-Priorities Out Of Order
5-Social Influences
(eg. Groupthink, Peer Pressure)
6-Stress Reaction
7-Physical Impairment
(From Fatigue, Carbon Monoxide, Heat Stress, Medication, etc.)

A little more in depth here: http://firelinefactors.com/MayhewThe2&7Tool3Jan08.pdf

[Tye 1on]

blah, blah, FUCKING blah about the contributing factors. Everything boils down to the decisions that you make...or fail to make.

Make good decisions.

No one ever seems to talk about being assertive in the group and speaking out.

For some reason, I never hear too much about 'painting yourself into a box' where all the options that you have are bad.

Fair point tarkdude.

I think skibee is digging down a bit into how to avoid making bad decisions.

My personal experience in being assertive in a group is that i'm sometimes looked at as an asshole who thinks he knows more than the others.

The best decisions are made by the group collectively sorting thru observations, prior experiences, training, etc. Not by one person bullying down or taking what they consider a 'leadership' role, when others don't buy his/her qualifications for that role. If you are indeed a leader, and the group agrees, you won't have to be assertive.

[srsosbso]

Haven't run into it in a ski avalanche assessment situation (seems to be a general consensus in my crowd most or all of the time) but in my climbing days, the rule was that the conservative voice always won, even if in the minority. Saved my ass more than once.

[Tye 1on]

Haven't run into it in a ski avalanche assessment situation (seems to be a general consensus in my crowd most or all of the time) but in my climbing days, the rule was that the conservative voice always won, even if in the minority. Saved my ass more than once.

smart.

imho group dynamics/rules/leadership/effective communications in a group:

could be another entire thread...not a bad one either...

but in a way different that the issues that skibee brought up, which could be mistakes made by groups, pairs, or even solo skiers.

[Sir Jongalot]

Since you didn't ask permission to steal, resize and post some else's picture how about you at least shrink it to a reasonable size so people who actually came to read the post can read much easier than scrolling back and forth. There are people who are more interested in the topic at hand than your preoccupation with tits and stalking.

x2 Thanks L7, give Lulu a belly rubz for me!!

Sorry for such dastardly ways. Jongy simply reposted a picture that Skibee posted on her own in another thread. I did not "steal" it, just posted a link to the picture she posted.

Seems she deleted it and since it was at her discretion to post it there in the 1st place all along, now that she deleted it there - it is gone.

Now I'm going to cry that I've offended someone.

[srsosbso]

she deleted it there - it is gone.

......................DOH!

[skibee]

The pic is still here in all it's enormous glory... and the only thing that offends me is that the size of the pic makes reading th thread difficult... the fact that you needed to post mah boobies distracts from the discussion by formatting the rest of the thread to be wde.

And the response seems to have been interested... I deleated the original in an effort to fix this thread. This thread is still not really readable (at least not for those us us peasants with small screened computers.)

Anyway... if boobies keep you safe... so be it!!

[homemadesalsa]

I'll chime in with a three-pronged set of attributes that we need to pay attention to while making decisions:

#1 is patience. Remember what Jim Morrison said, "we want the world and we want it now." Now might not be the right time for that splendid little couloir, not even at all this winter some years (like this one). I go re-read the excellent essay from Ed LaChapelle called "The Ascending Spiral" when I want a really well-written reminder of patience.

#2 is self-discipline- see above. And that's what makes us stop mid-run and throw in a leapfrog spotter, stop and traverse back to the ridgeline rather than following the line all the way down into the terrain trap.

#3 is pay attention. We can happily yabber our way up the skin track when the danger is low, but in new terrain or dicey conditions, with new partners, know when you really have to pay attention (and that's what I like about backcountry, is being in that "pay attention" zone.)

that's all I have time for- have been thinking about this a lot, and esp a lot lately, "teaching" decision-making, which ends up showing people what are the most important things to pay attention to.

[pechelman]

last year i took an error prevention training class at work that rung so many bells with respect to backcountry skiing and decisions regarding avalanches. It should really be adopted in some way i think.
Also, before we do any move or major hardware transportation here at work, we do a quick group meeting to run through this checklist is done.
Its just a great idea i think.
Anyway, its called AESOP, and heres the brief checklist.

AESOP™ Model
Review before starting any task:

Assignment
Is it clear to all?
What are the risks/hazards?

Equipment
What’s needed? Available?
Is it working?

Situation – overall assessment
Go, Ragged edge, or Stop?

Obstacles
What are the potential problems? Look ahead?

Personnel
Who’s involved? Experience?
Any issues – illness, medication, stress, alcohol, fatigue?

[BaltiHimal]

Funny, prior to reading this post I was just reading Malcolm Gladwell's new book Outliers, in the second half of the book he discusses aircraft disasters, which included this little gem I thought useful when making decisions in avalanche terrain, a "typical accident involves seven consecutive human errors", none of the errors discussed was the sole cause, it was the compounding of the errors. Contributing factors that lead to pilot error were factors common in avalanche terrain, bad weather, fatigue, and lack of communication. I'm not saying this as if it is some huge revelation, only that it's important to be conscious of how these factors influence our decisions.

[MakersTeleMark]

Funny, prior to reading this post I was just reading Malcolm Gladwell's new book Outliers, in the second half of the book he discusses aircraft disasters, which included this little gem I thought useful when making decisions in avalanche terrain, a "typical accident involves seven consecutive human errors", none of the errors discussed was the sole cause, it was the compounding of the errors. Contributing factors that lead to pilot error were factors common in avalanche terrain, bad weather, fatigue, and lack of communication. I'm not saying this as if it is some huge revelation, only that it's important to be conscious of how these factors influence our decisions.

I agree completely, and think it's almost as tough (or tougher) to recognize them while they are happening (versus preventing them), and even more tough to have the balls to stop the chain once they become evident. For example, one person in a group deviates from the set line (maybe for many reasons: falling, equipment malfunction, powder enertia, missed a safezone, etc.) and the rest of the group is left to make a whole other set of decisions. How many times do the others just follow along, of course one-by-one, but how many times do you part ways or ski the intended line and do your best to have the loner get back into the group as safe as possible to the group, and that person? There are tons of other examples.

Here's another one: Recently, after making my own stability assessment, I decide to ski a line with a very clear knowledge of what could happen, and what would likely happen if things ripped. Others in the group who either had no participation in making a stability assessment, or who were not as confident in my stability assessment followed along anyway, despite their own judgment. Classic. I've actually gone the other way, and didn't loose a wink of sleep over it.

[RockBoy]

...
So many people think that a beacon,shovel,and probe make it OK to do stupid shit.
...

This is so true. These same people also seem to fail at realizing what a beacon shovel and probe are meant to do. They aren't meant to make you "core", they are meant for saving someone's life.

"Yeeeehaaaw!!! I have a beacon shovel and probe so now I can go out into the back country". No. You now have the tools to dig in the snow and locate a possibly dead best friend.

Beacon + Shovel + Probe != (does not equal) Safety

[Snow Dog]

Another human factor is (what I'd call) faulty experience. If you and your crew evaluate a slope and take a pass you'll never know if the slope was safe or not. There's no way to test your decision. Explosives are hard to come by these days and you can't always cut a slope. At some point these accumulated non-events will intrude as "are we being too cautious?" thoughts.

[pechelman]

Here's another one: Recently, after making my own stability assessment, I decide to ski a line with a very clear knowledge of what could happen, and what would likely happen if things ripped. Others in the group who either had no participation in making a stability assessment, or who were not as confident in my stability assessment followed along anyway, despite their own judgment. Classic.

if you're thinking of what i think you're thinking of, its interesting to note that the only person who verbalized their concern about skiing that slope was the one female in the group. And then, only half of the rest of the male group acknowledged her concern and talked it over.

and not sure who you're referring to (no offense taken, just promoting the discussion), but you could see a lot from the side wrt participating in stability assessment. While concerned about the bond, I just didnt feel there was enough of a slab or enough energy\cohesion for the slope to rip out, unless someone really ski cut just below that last and steepest rollover really hard. (similar to how the snow was moving if you were to remove the supporting concavity near the roads)

[pechelman]

Explosives are hard to come by these days .

nor are explosives the litmus test in avalanche assessment....

[MakersTeleMark]

if you're thinking of what i think you're thinking of, its interesting to note that the only person who verbalized their concern about skiing that slope was the one female in the group. And then, only half of the rest of the male group acknowledged her concern and talked it over.

Even more interesting was that that concern was solicited by me initially upon asking, "So how do you feel about it?" and then, offering a very non-threatening, "You do not have to ski it if you are uncomfortable, you can go back down the skin track and we'll meet up in a bit." What about the douche (joking) who initiated the RB2 and partook in the ice crust potato chip fest? I don't mean to single out folks either, but you have to admit, it was one of the most interesting human factors plays in my recent memory.

[skibee]

Another human factor is (what I'd call) faulty experience. If you and your crew evaluate a slope and take a pass you'll never know if the slope was safe or not. There's no way to test your decision. Explosives are hard to come by these days and you can't always cut a slope. At some point these accumulated non-events will intrude as "are we being too cautious?" thoughts.

Hey Snow Dog, very nicely put. The question of "Did we make the right decision?" will always play out if the slope does not slide... only when it does is there a definitive answer. If if you ski it and it does not slide the question remains "did we miss the sweet spot?"

I completely agree with your question "are we being too cautious?" thought... that depends on who you are making decisions for: your self and friends with similar risk tolerances or the general public driving a highway with no clue they are even in the mountains? The decisions must take into account the risk acceptance level of the group.

I love the contributions from the well thought out business models out there, decision making in groups is similar in so many risky situations and the business models proposed are much more articulate and easy to understand than my original ramblings!!! Thanks for consolidating my thoughts!

[MakersTeleMark]

Explosives are hard to come by these days ...

Apparently not everyone is aware of that, as evidenced by the woman on the chair lift the other day who asked if my probe was explosives (slow pitch, but true).

[Danno]

Even more interesting was that that concern was solicited by me initially upon asking, "So how do you feel about it?" and then, offering a very non-threatening, "You do not have to ski it if you are uncomfortable, you can go back down the skin track and we'll meet up in a bit." What about the douche (joking) who initiated the RB2 and partook in the ice crust potato chip fest? I don't mean to single out folks either, but you have to admit, it was one of the most interesting human factors plays in my recent memory.

I wondered about what went on with you guys out there.

This post and your earlier one bring up some interesting points. Makes me wonder about the issue of making a solo decision amidst a group dynamic. I.e., "I'm going to ski this, you don't have to if you don't want". How does the rest of the group handle that? How acceptable is it to make individual decisions in the group dynamic? And then there's the issue of people being "shamed" into maybe skiing something they aren't comfortable, when their only option is to turn around and descend the skin track while others ski the pow (when what they really wanted was for everyone to turn around).

Not intending to criticize any decisions, just noting some more group dynamic issues highlighted by what you just described.

[MakersTeleMark]

Makes me wonder about the issue of making a solo decision amidst a group dynamic. I.e., "I'm going to ski this, you don't have to if you don't want". How does the rest of the group handle that? How acceptable is it to make individual decisions in the group dynamic? And then there's the issue of people being "shamed" into maybe skiing something they aren't comfortable, when their only option is to turn around and descend the skin track while others ski the pow (when what they really wanted was for everyone to turn around).

That was one of my original points. It takes balls to fight getting sucked into bad human factor decisions, especially when they can compound the danger. I've backed away from lines when the group en toto was not in consensus, and I've made a decision to not personally go when the group did not agree with my assessment.

Not to single you out, this is just evidence that folks on this board actually do ski together, remember a couple of years ago when you set a skin track I didn't agree with? Pretty much everyone else followed you, but I didn't, and followed a different, and more strenuous skin track because I personally didn't feel comfortable with your decision. Did your route slide, no. Was I going to take it, no. I had to follow my own assessment on that one, and sometimes that doesn't make everyone feel good, but it matters.

This is a great thread.

[madturtle]

"You do not have to ski it if you are uncomfortable, you can go back down the skin track and we'll meet up in a bit."

I think this goes back to exactly what tarkman was referring to

For some reason, I never hear too much about 'painting yourself into a box' where all the options that you have are bad.

If you head up a slope and at the top your only options are
(a) ski a rad line with stability that is not necessarily obvious red light conditions but more "yellow" than you'd prefer
(b) go back down the skin track

What are too many people going to do and eventually get bit doing? Hint it's not (b) . I'm not passing any judgement on whether the line you guys skied was or was not safe but given those options it sounds like you might be pushed to ski a line you and or your group had 2nd thoughts about.

I think one of the most important pre-trip planning exercises you can have is leave yourself with other fun less risky options (that's my contripution to the OP). Fun being a key word there. And realize ahead of time that you could run into "yellow " conditions and what your going to do about them.

Please don't take any offense I used your situation as an example, I fully acknowledge I am unaware of the full situation but I think my point is the same. I speak from experience when I say that "painting yourself in a box" frequently leads to bad decisions and we've all gotten away with plenty in life and the mountains, but that streak will only last so long.

[MakersTeleMark]

I think this goes back to exactly what tarkman was referring to



If you head up a slope and at the top your only options are
(a) ski a rad line with stability that is not necessarily obvious red light conditions but more "yellow" than you'd prefer
(b) go back down the skin track

What are too many people going to do and eventually get bit doing? Hint it's not (b) . I'm not passing any judgement on whether the line you guys skied was or was not safe but given those options it sounds like you might be pushed to ski a line you and or your group had 2nd thoughts about.

I think one of the most important pre-trip planning exercises you can have is leave yourself with other fun less risky options (that's my contripution to the OP). Fun being a key word there. And realize ahead of time that you could run into "yellow " conditions and what your going to do about them.

Please don't take any offense I used your situation as an example, I fully acknowledge I am unaware of the full situation but I think my point is the same. I speak from experience when I say that "painting yourself in a box" frequently leads to bad decisions and we've all gotten away with plenty in life and the mountains, but that streak will only last so long.

Just to clarify, I was comfortable skiing the slope and it was my impression that others in the group were less comfortable, or did not possess enough information to make as informed of a decision as I made.

This brings out another small point as well: these types of situations usually only come up in as you describe yellow, to high yellow scenarios, which exacerbate the effects of human factors. When it's all green/go, there may be human factors involved, but they don't necessarily manifest themselves in a dangerous situation.

I strongly concur with your "painting yourself into a box" observation, and like I have always said, you must always have a backup plan and be prepared to take it, no matter how much it hurts that other human factor - ego.

And just as an FYI, I stood in that very same pit almost a year ago to that day, and backed down from that very line.

Another small point: Isn't it interesting to note how many, if not most, human factors are eliminated when skiing solo? Sure, expert halo, previous experience on slope, powder fever still exist, but it is really the combination of multiple people that kicks all the factors effects up exponentially.

[Danno]

That was one of my original points. It takes balls to fight getting sucked into bad human factor decisions, especially when they can compound the danger. I've backed away from lines when the group en toto was not in consensus, and I've made a decision to not personally go when the group did not agree with my assessment.

Not to single you out, this is just evidence that folks on this board actually do ski together, remember a couple of years ago when you set a skin track I didn't agree with? Pretty much everyone else followed you, but I didn't, and followed a different, and more strenuous skin track because I personally didn't feel comfortable with your decision. Did your route slide, no. Was I going to take it, no. I had to follow my own assessment on that one, and sometimes that doesn't make everyone feel good, but it matters.

This is a great thread.

I do remember that skin track, and you're right, sometimes you have to follow what your own internal compass tells you. Figuring out how that will play out in a group dynamic is the tricky part.

It's also useful to think about these situations from all perspectives. There's the perspective of the person who thinks it is safe and says "I am going to do this" outside of any consensus (or thinks it is unsafe and says "I am not going to do this" outside of any consensus). Then there is the perspective of the person trying to process their own actions within a group dynamic, and having to act within that dynamic when someone else has made a more individual decision.

[srsosbso]

How acceptable is it to make individual decisions in the group dynamic?

I think that once you choose to engage in a group activity, you really stop making "individual decisions." It's worth remembering that if you choose to ski a marginal line and it goes, well, your pals are now out there trying to dig you out, and potentially exposing themselves to immediate risk (from further avalanche activity) and (at risk of sounding like a flake) the possible emotional trauma of a failed rescue attempt.