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Author Topic: Lessons Learned about near-miss avy incidents  (Read 6541 times)
Heli-Free North Cascades
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Lessons Learned about near-miss avy incidents
« on: 10/30/14, 02:39 PM »

I tried to post an article here about "lessons learned" and it will not make it past some roadblock. I obtained permission from the author to post this here. Since I can not delete this thread, I thought I would offer this explanation. The article concerned ski professionals and appeared in the print version of the "Avalanche Review" but did not make it to the on line version of that publication.
 
Try this link where I posted it over at NWhikers.

http://www.nwhikers.net/forums/viewtopic.php?p=970626#970626
« Last Edit: 04/05/17, 01:52 PM by freeski » Logged

two sets of principles. They are the principles of power and privilege and the principles of truth and justice. If you pursue truth and justice it will always mean a diminution of power and privilege. If you pursue power and privilege, it will always be at the expense of truth and justice
C Hedges
Heli-Free North Cascades
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Posts: 663


Re: lessons learned
« Reply #1 on: 04/05/17, 01:28 PM »

   
 Back when I posted this at NWhikers, I obtained permission from the author to post it. As you may recall, TAY was having problems with posting back then.

Since this will one of the issues that I will be addressing with the USFS-OIG, I thought that I'd update this thread.


Lessons Learned
GNFAC Professional Development Workshop


On March 6, 2013, members of the southwest Montana snow and avalanche community assembled in Bozeman to participate in the fourth annual Professional Development Workshop hosted by the Gallatin National Forest Avalanche Center.

The day-long workshop featured a medley of presenters with broad expertise in snow and avalanche research, avalanche forecasting, ski patrolling, ski guiding, avalanche education, mountain search and rescue operations, and institutional risk management within the scope of outdoor education and recreation.

Titled “Lessons Learned," the workshop was essentially a compilation of personal incident accounts in which significant injury or loss due to avalanche hazard occurred or was narrowly avoided.

Throughout the day, many themes emerged, the most consistent of which was the simple truth that, regardless of years of experience, even the most renowned and experienced practitioners in the field of snow and avalanches are not immune to making mistakes.  Efforts are made to maintain the highest standard of safety possible, and our professional community has made great strides in understanding the dynamic behaviors of snow and avalanches.  Nevertheless, we continue to chart unknown territory, and the eerie reality of trial and error remains.  By shining a spotlight on errors and miscalculations, and by being accountable for analyzing our mistakes, great contributions are made to this field.

The workshop began with Drew Leemon’s presentation entitled Risk Management: The NOLS Perspective. By sharing the ins and outs of the NOLS risk management system, long-time risk management director Leemon established a foundational framework for the workshop.  With 28 years of incident data that documents remote rescues, medical emergencies, evacuations, and “near misses," NOLS analyzes risk and safety practices constantly and has established risk management as a core component of its institutional culture.  With such an extensive incident database, NOLS has established a systematic incident review process.  Through documenting, categorizing, and analyzing incidents, NOLS can learn from experience, strive for self-improvement, and continuously revise institutional program standards when necessary. Leemon broke the ice and set a standard of transparency and critical self-analysis for the rest of the workshop speakers.

As Randy Elliot put it so bluntly, “If you can’t be good, be lucky." Listening to renowned avalanche practitioners recount heart-pounding stories of narrowly avoiding getting caught in avalanches is unnerving.  But, in recognizing how dynamic and complex the winter backcountry environment is, sometimes lessons are just learned the hard way and, as Karl Birkeland said, “as professionals, we need to recognize when we have close calls and change our behavior.”  Workshop speakers, fortunately for all in attendance, walked away from their near-miss incidents informed, grateful, and better prepared for the future. 

A recurring theme of the workshop was the importance of terrain selection.  As Doug Chabot and Eric Knoff learned on several occasions, appropriate terrain selection is crucial when digging snowpits.  Speaking about a slope outside of Cooke City, MT that he and his partner named “Almost Died," Chabot pointed out that it is never worth risking your life or your partners' lives (much less both at the same time) in order to collect data.  In support of Chabot's views, Karl Birkeland stressed the significance of route selection and stressed the importance of ascending slopes by the safest up-track possible.  Long-time Big Sky snow safety director Jon Ueland underscored the importance of always choosing islands of safety that will offer real protection. “You only know you are in a safe zone if all the snow around you disappears and you are still standing,” he said.

Professionalism and the importance of communication came up time and again throughout the workshop. Decisions made and opinions expressed by professionals carry great significance and can and should have a disproportionate influence on the safety and well being of others.  As Nick Meyers, Mike Buotte, and Lynne Wolfe all noted, good communication skills are essential for avalanche control work, when discussing and analyzing the stability of the snowpack, or when simply working with a partner or team in an intense situation.

The familiarity professionals develop with a season’s snowpack or specific terrain can often pose a dangerous sense of overconfidence.  As Karl Birkeland attested, it is so important to be thinking about the worst-case scenario and to be intentional with whom you travel in avalanche terrain.  "Ski with a partner who will be thinking about avalanches and skiing appropriately,” he advised.  And, as Nick Meyers suggested, “Ask yourself: are my thoughts, words, actions an asset or liability to the situation?”

An additional theme that surfaced was the fundamental importance of recognizing and assessing the type of avalanche problem you are dealing with.  According to Rod Newcomb, professionals need to be aware that they often analyze the snowpack only from their scope of experience.  Instead, he urged professionals to have heightened awareness of obscure and unfamiliar conditions, and to recognize that even the most experienced avalanche practitioners may still be novices to what can happen.  Obscure and unexpected conditions are often responsible for close calls and fatalities involving professionals.  However, depth hoar, he asserted, is the primary avalanche problem associated with patroller fatalities. According to Newcomb, a reliable rule of thumb with regard to depth hoar and depth hoar-like snowpacks is always "to expect the crown and the slide to exceed your expectation of how far it will propagate, and how large the slide will be.”

Experience with obscure stability conditions offered other workshop lessons.  Doug Chabot recounted a near miss during which he learned that even low density, powder snow can act as a slab and produce avalanches.  In reflecting on the 1996-97 winter avalanche that demolished the Shedhorn Lift at Big Sky, Scott Savage learned never to trust a rapid load on ice, a crust, or a hard surface, regardless of whether or not facets exist at the slab-weak layer interface.  And, regardless of what kind of avalanche problem is believed to be present, Lynne Wolfe urged professionals to ask: “How detectable is the problem?” and “How manageable is the problem?” with the intention of forming an honest, specific, and unbiased opinion of current snowpack stability.  Professionals often tend to overestimate manageability; even a small avalanche can pack quite a punch.

As risk management practices develop and become ever more ingrained in the work of outdoor professionals, “near miss” or close call incidents (in which significant injury or loss is narrowly avoided) have become focused opportunities for learning.  However, the negative repercussions for outdoor professionals of such incidents -- which range from embarrassment to the  loss of a job -- are not pleasant to contemplate.  Putting egos aside, the workshop speakers recognized the obvious truth that if you end up spending years in avalanche terrain, accidents will occur, and sooner or later you are bound to make a mistake. 

For more information, visit the GNFAC video archive on YouTube at www.youtube.com/user/AvalancheGuys where all the workshop presentations may be seen.



Bio:

Andrew Kiefer graduated from Prescott College this past spring and attended the professional development workshop during his internship with the GNFAC.

 
 
« Last Edit: 04/05/17, 01:32 PM by freeski » Logged

two sets of principles. They are the principles of power and privilege and the principles of truth and justice. If you pursue truth and justice it will always mean a diminution of power and privilege. If you pursue power and privilege, it will always be at the expense of truth and justice
C Hedges
Heli-Free North Cascades
Member
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Posts: 663


Re: lessons learned
« Reply #2 on: 04/05/17, 01:34 PM »

And here is a perspective on this issue and a quote from that blog post.

http://www.alanarnette.com/blog/2014/01/15/everest-2014-guides-disclose-deaths/

"Everest 2014: Should Guides Disclose Deaths?
Jan 152014
Twice while I was on an expedition a team member died. The guide company never mentioned it publicly. Were they correct? Let’s look at this in detail as it happens more than you know and there are two sides to this argument."

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two sets of principles. They are the principles of power and privilege and the principles of truth and justice. If you pursue truth and justice it will always mean a diminution of power and privilege. If you pursue power and privilege, it will always be at the expense of truth and justice
C Hedges
Heli-Free North Cascades
Member
Offline

Posts: 663


Re: lessons learned
« Reply #3 on: 04/05/17, 01:37 PM »

And here is what every client should know, from a guide companies perspective and a quote dfrom that article;

http://www.sierramtnguides.com/a-case-for-guide-certification-from-the-sierra/


"A case for guide certification from the Sierra
In From the Range of Light & Fast by Howie SchwartzMay 16, 2014111 Comments
Today I ran into a local climber and mountain enthusiast in the Black Sheep Coffeehouse in Bishop. She worked for us as a porter and as a camp cook last summer, and I asked if she might be interested and available for some of that work again. She said “yes” but she explained that she just took a Wilderness First Responder course and has been hired by another local mountain guide service as a guide, specifically for trips on Mt. Whitney and in the Palisades. She has had no mountain guide training, and limited alpine climbing experience."
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two sets of principles. They are the principles of power and privilege and the principles of truth and justice. If you pursue truth and justice it will always mean a diminution of power and privilege. If you pursue power and privilege, it will always be at the expense of truth and justice
C Hedges
Heli-Free North Cascades
Member
Offline

Posts: 663


Re: Lessons Learned about near-miss avy incidents
« Reply #4 on: 02/07/18, 08:13 PM »

The following link gives a good synopsis on the human psychology of accountability.

There's lots of research on this subject if you prefer to read the research papers, however they can be kind of dry if you don't like to read psychological research papers.

The paper in the link may give an understanding of why I always say being held accountable for near-misses Avalanche incidents ultimately leads to better decision-making.

The reason why that occurs are deeply rooted in human social psychology.

An example would be traffic laws as a means of accountability. Let's say you get a ticket for texting and driving. That   law is in effect because tests on stopping distances  have shown that texting while driving is even more distracting then driving under the influence of alcohol.

 When you receive a ticket for texting while you're driving you are being held accountable for your actions that place others at  increased risk of harm.

That measure of accountability is in place in the hopes that you will not text and drive and make better decisions in that regard in the future.

 Some people don't learn that lesson until they've actually killed another person.

Same goes for near-miss Avalanche accidents. Being held accountable for actions such as triggering an avalanche down on the another person, would likely  lead to better decision-making practices in the future.


http://psychology.iresearchnet.com/social-psychology/social-cognition/accountability/


"Increased accountability will alter decision-making strategies. When expecting evaluation from an audience, people will think more carefully about their decisions than they normally would. They will consider the outcomes of their judgments and process the relevant information more deliberatively. Under low-accountability situations, people can process the relevant information superficially, knowing that any decision made will not be scrutinized. Nevertheless, when under increased accountability, a greater consideration of possible counterarguments is necessary as the person must be able to fend off criticism during the evaluation process."
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two sets of principles. They are the principles of power and privilege and the principles of truth and justice. If you pursue truth and justice it will always mean a diminution of power and privilege. If you pursue power and privilege, it will always be at the expense of truth and justice
C Hedges
Heli-Free North Cascades
Member
Offline

Posts: 663


Re: Lessons Learned about near-miss avy incidents
« Reply #5 on: 02/14/18, 09:25 AM »

It's always interesting to find research that supports the case for the reporting of commercial near Miss Avalanche accidents as well as recreational Avalanche near-miss accidents.

In this thread  I'm trying to show the need.

And in this thread link I'm trying to show how  roadblocks within the industry itself continue the culture of what I call the "cone of silence" ie the non reporting and Analysis of  commercial near miss Avalanche incidents,which is counter to the interests of Public Safety.

http://www.turns-all-year.com/skiing_snowboarding/trip_reports/index.php?topic=39662.0

"Compiling and studying professional avalanche worker incident
data to improve worker safety
Ron Simenhois1
 and Scotty Savage2
1Coeur Alaska, Juneau, AK 99803, United States of America.
2
 Friends of the Gallatin National Forest Avalanche Center, Bozeman, MT 59771, United States of
America..
ABSTRACT:
Avalanche professionals work in a hazardous alpine environment, often under physical and emotional
stress. Working in an uncertain, stressful, and risky environment takes its toll on the avalanche
community. A growing number of studies suggest that decision-making errors are significant contributors
to avalanche accidents. Although decision-making processes leading to avalanche incidents in
professional settings are seldomly studied, we believe they play a significant role in avalanche incidents
involving professionals. Therefore, attempts to reduce professional avalanche accidents should include
improving decision-making. In this paper, we present a road map to improve workplace safety in the
avalanche field. Our intention is to create a confidential online database where avalanche professionals
can report avalanche related incidents and near misses. The data will be used to better understand the
decision-making processes and snowpack, weather, and avalanche conditions associated with
professional workplace incidents or near misses. In addition, this database will allow us to develop a
decision-making focused training program, gain field experience without hazardous exposure, and
improve awareness by sharing case studies across the industry.



Loss aversion
"In human decision-making, losses loom larger
than gains." (Tversky and Kahneman 1991). In
other words, people will take significant risks to
avoid losing possessions, money, or status.
People will also take significant risks to avoid
uncomfortable situations (e.g. disappointing
others). Recent research (Gal 2006) suggests
that sometimes, the phenomena attributed to
loss aversion are outcomes of inertia rather than
loss/gain asymmetry.


Motivated reasoning
Unfortunately, our mind often surrenders to the
temptations of motivated reasoning, drawing
conclusions that we want to draw instead of
objectively examining the situation at hand.
Drew Westen (2007) showed that during the
2004 presidential election, both Democrats and
Republicans tended to disregard facts that
showed inconsistencies in their candidate while
being concerned with inconsistencies of the
opposite candidate. Further, he showed that
when presented with facts contradicting their
beliefs, they “shut down” the frontal cortex, the
region of the brain responsible for rational
thoughts and processing new information. Goal-
oriented, type A personalities and those with
large egos are especially susceptible to
motivated reasoning.

Cognitive dissonance
Tavris and Aronson, (2007) describe cognitive
dissonance as the internal conflict that ensues
when someone holds two inconsistent or
polarizing cognitions (ideas, attitudes, beliefs, or
opinions). We tend to view ourselves in a
positive light as intelligent, rational and moral
human beings. When we do something that
goes against our self image that we like to
project, we self-justify our actions to maintain
our positive view of ourselves. Over time, we
tend to convince ourselves that our actions were
rational, appropriate and well justified, luring us
to repeat the same action again and again. For
example: many avalanche professionals have
experienced an avalanche related near miss during the course of their career. Many of them
tend to regard these isolated near misses as “no
big deal” events. Other folks tend to remember
how they managed to get away and regard the
event as a testimony to their skiing ability rather
than a near miss. Some folks even change their
technique to fit their newly formed (and
incorrect!) opinions (e.g.thinking that ski cutting
hard slabs, ski cutting under small pillows, or
using fewer explosives in order to save the
company’s money are safe, accepted practices).
In general, if you have been working in the
avalanche field for years thinking you have
never had a near miss then you are probably
self-justifying."

* ISSW_P-044_1.pdf (227.26 KB - downloaded 3 times.)
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two sets of principles. They are the principles of power and privilege and the principles of truth and justice. If you pursue truth and justice it will always mean a diminution of power and privilege. If you pursue power and privilege, it will always be at the expense of truth and justice
C Hedges
Heli-Free North Cascades
Member
Offline

Posts: 663


Re: Lessons Learned about near-miss avy incidents
« Reply #6 on: 02/15/18, 03:08 PM »

I worked in the construction industry for over 30 years, and I can tell you safety is something that reputable companies take very seriously in my industry. Everything I learned about safety in the construction industry crosses over with everything I've learned about safety in the mountains.


http://www.safetybok.org/near-miss_reporting_the_missing_link_of_safety_culture_revolution/

"Near-Miss Reporting: The Missing Link of Safety Culture Revolution

Summary: Culture is often described simply as “the way it is around here.” When few near-misses are reported and acted upon in an organization, it indicates something about the relative health of the safety culture. Can it be considered safe and healthy or does this indicate something else, something much less positive? Too many organizations fall into the comfortable trap that comes by believing the former and do so at their own peril. Robust near-miss reporting processes that engage employees to identify and permanently solve hundreds of potential injury-causing situations that they are tired of living, with is crucial to healthy safety cultures."



« Last Edit: 02/15/18, 03:20 PM by Heli-Free North Cascades » Logged

two sets of principles. They are the principles of power and privilege and the principles of truth and justice. If you pursue truth and justice it will always mean a diminution of power and privilege. If you pursue power and privilege, it will always be at the expense of truth and justice
C Hedges
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