12/26 Fatality on Pucker Face, just beyond the JHMR ropes

[cdubski]

Thanks for writing, Alex and OM. I got a lot out of reading.

[SchralphMacchio]

People don't want a 14 point bullet list. There are safety cards out there, now. Like pilots use for preflight checks. They rarely sell and rarely get used. If it works for you, great, just pointing out the issues.

Like I said, the most important thing about checklists is whether we agree to use them in the first place, above and beyond the content embedded within them.

[icelanticskier]

waiting at least 72 hours for intermountain or continental zones is essential

rog

[SchralphMacchio]

http://m.blog.hu/fo/foka/file/3x3_assessment.pdf
http://www.monosar.org/safety_articl...Frameworks.pdf

Interesting article and risk reduction framework. What's your system?

Since the accident I've tried to use AIARE Blue Book communication checklist at trailhead, and then ALPTRUTH on slope, but not to 100% compliance, as it's varied by partner and general conditions. The one thing I've done 100% of time since the accident is to review the avalanche problem as a group at the trailhead and at key points along the approach.

[jono]

I thought SM's post on 1/6 addressed the ego/pride/group dynamic pretty well (at least from one perspective). On a face like that it's easy to think about dangers that are more obvious and get distracted from slides--and legitimately. After all, if someone skis a line and dies in a fall no one asks if he was distracted by the avalanche report.

How to address that in a checklist seems like a good question. FWIW I'm in the camp that thinks 14 points that are handled linearly so nothing is skipped is simpler than a 3×3 plus checking all the caveats and an equation at the end. Particularly given the limitations listed in Hugh's second link ('disadvantages of knowledge-based decision making' on page 3/4). Not to say the linear checklist can actually be kept to 14 points while being as thorough, so it's not an easy comparison. But I like the pre-flight checklist model and I'm still refining mine. Concise is a challenge, but using it at the trailhead and key points is my objective, too.

[neck beard]

Interesting article and risk reduction framework. What's your system?

Since the accident I've tried to use AIARE Blue Book communication checklist at trailhead, and then ALPTRUTH on slope, but not to 100% compliance, as it's varied by partner and general conditions. The one thing I've done 100% of time since the accident is to review the avalanche problem as a group at the trailhead and at key points along the approach.

Also consider buying the Avaluator from the CAC. The latest slope evaluation card (plastic, roughly the size of a credit card) has a terrain character checklist and an avalanche conditions checklist. The results from both checklists are then combined. It is designed for use in an area with a well developed avalanche bulletin.

[Hugh Conway]

I thought SM's post on 1/6 addressed the ego/pride/group dynamic pretty well (at least from one perspective). On a face like that it's easy to think about dangers that are more obvious and get distracted from slides--and legitimately. After all, if someone skis a line and dies in a fall no one asks if he was distracted by the avalanche report.

How to address that in a checklist seems like a good question. FWIW I'm in the camp that thinks 14 points that are handled linearly so nothing is skipped is simpler than a 3×3 plus checking all the caveats and an equation at the end. Particularly given the limitations listed in Hugh's second link ('disadvantages of knowledge-based decision making' on page 3/4). Not to say the linear checklist can actually be kept to 14 points while being as thorough, so it's not an easy comparison. But I like the pre-flight checklist model and I'm still refining mine. Concise is a challenge, but using it at the trailhead and key points is my objective, too.

OM developed a checklist of takeaways from this accident. Munter developed a method to reduce accidents (in a specific region). There are other methods out there; other research, I don't know whats the art now, the links are old. The point was not to get into camps of one vs. the other like every other thread . The point was to look at frameworks and research already in existence. Because people have spent time doing this already.

[SchralphMacchio]

baby bear - haven't had a chance to think through your comments until now. I'm trying to listen and process your statements.

I'd like to see you guys admit that egos were the driving factor that day bc, while you allude to it, you do not say that ...
It seems like you want this to be a learning experience for others so let’s recognize that the #1 factor that day- group dynamic is a fun buzzword but let’s call it what it is- ego.

I know that pucker face is a line to 'check off the list' so to say and I believe that came into play within the group dynamic. Maybe I'm totally off base on that but I doubt it. We all are similar animals us ski lovers.

Pucker is a line to brag about, sure. But not everyone wanted to ski Pucker, and not everyone needed to "check it off." Sure, everyone was interested in the idea of scoring that line in powder - but I can literally tell you that the majority of the group (4/6) did not have a driving thirst to score that specific line at that specific time.

I hear what you are trying to say, big-picture wise and mostly agree with the general direction of your points. But I am a lot more into nuance than you are, because I don't think that group dynamics is a fancy euphemism that boils down into ego.

This was the very first time that this group of 6 has ever set out to function as a team, whether skiing or fishing or whatever. When I say, "group dynamics," here is a more tangibly stated set of observations:
-I wanted to ski with Mike, and I am not really someone to disrupt a totally new group
-Mike wanted to ski with his friends and make sure everyone had fun, and he had also never skied Pucker
-Some of the group was deferring decision and discussion to others who had more snow evaluation experience
-Some of the group was deferring decision and discussion to others who regularly skied this area (not the same as above)
-The underlying idea that the risk is "Moderate" on Moderate days, superceded the idea that slabs up to 4' deep were possible in specific areas
-Ineffective communication failed to halt/address many mental shortcuts and failed to force a review of the situation / plan
-Ineffective communication led to dismissal or not exploring of alternative views, from both those who had them and those who ignored them
-Alternative views were let go of by those who had them, not because of fear of speaking up, but because everyone had an interest in supporting the group

I would call this a high level of dysfunction in communication and teamwork, and a desire to support the group even though no one is completely sure where it is headed, but not "ego." Ego may have allowed an innocently stated, yet subversively alluring, suggestion ("let's have a look at Pucker") to hijack the direction, but I really don't see that as the underlying weakness here.

In many studies I've read, groups are supposed to come to more accurate decision-making than the majority of individuals can. (A group exercise in our Utah Avalanche Center Freeride Clinic that Oceanman and I took after the accident also demonstrated this.) The crux of that is that the group must be capable of both independent reasoning and effective communication.

When those things aren't available within the group ...

Groupthink:

Groupthink is a psychological phenomenon that occurs within a group of people, in which the desire for harmony or conformity in the group results in an irrational or dysfunctional decision-making outcome. Group members try to minimize conflict and reach a consensus decision without critical evaluation of alternative viewpoints, by actively suppressing dissenting viewpoints, and by isolating themselves from outside influences ...

Irving Janis devised eight symptoms indicative of groupthink.

Type I: Overestimations of the group — its power and morality
1.Illusions of invulnerability creating excessive optimism and encouraging risk taking.
2.Unquestioned belief in the morality of the group, causing members to ignore the consequences of their actions.

Type II: Closed-mindedness
1.Rationalizing warnings that might challenge the group's assumptions.
2.Stereotyping those who are opposed to the group as weak, evil, biased, spiteful, impotent, or stupid.

Type III: Pressures toward uniformity
1.Self-censorship of ideas that deviate from the apparent group consensus.
2.Illusions of unanimity among group members, silence is viewed as agreement.
3.Direct pressure to conform placed on any member who questions the group, couched in terms of "disloyalty"
4.Mindguards— self-appointed members who shield the group from dissenting information.

One of the party members said it really well after the accident: "We all trusted each other, even though we have never really done anything to earn that trust."

If you want to truly make a difference with writing about your experience then help other guys to simply and straight forwardly recognize when the group is not thinking or communicating well and how to get out of that mode and back to focusing on those standard practices you have been taught.
Don’t rely on fancy biz euphuisms and let’s just KISS

If I modify your text to take out the word "ego" then I totally agree with this statement.

The challenge is that it's a lot easier to see when things are getting out of whack from the couch than when you're in it -
Which is the whole point of my campaign for practice and standardization of observable characteristics of mental shortcuts / group dysfunction.

I hear what you are saying about KISS, just consider that part of my audience for that article was addressed to the educational leadership. That's why I talk about exercises for facilitated & structured communication. I do believe that practice can make communication feel more easy, and development of standard communication exercises is a way to give people that practice.

So like I said, big picture, I'm with you. I just don't like the semantics and implications of ego, because I see that strong group communication and observing when shortcuts are being taken are more important to focus on.


(edit)
And, also requoting this for anyone coming back into this thread

I wrote an article for The Avalanche Review about the accident that just got published and posted. I sincerely hope that it is both informative, and also valuable to the rest of you folks out there, for your friends, etc.
http://www.americanavalancheassociat...32_4_Cover.pdf
(See Page 20 for the case study and article, the other one on Page 18 is an opinion piece by Blase Reardon)

[jhveteran]

And to answer your question. I will admit that my sense of comfort/confidence (ego, if you will) was too high, which led me to drop the ball when it came to concrete decisions. Tell me about your BC riding when you we're 26 years of age? I bet you might have made mistakes back then?

But see, that's the whole point.

Someone more or less in that age group is dead.

I made similar mistakes when I was in that age group, but others I knew well made worse mistakes and they're dead, too. My own take on this article is that the author admits mistakes were made, but assigns most of the blame to forces beyond anyone's control or some nebulous groupthink that couldn't be overcome.

My own opinion is that if ONE person in that group had had the balls to stand up and say "This doesn't feel right to me. I'm going somewhere else.", the rest of the story might have been very different.

The balance has definitely tipped over the years. Lines are being ridden in conditions today that I and my contemporaries would never have considered two or three decades ago. Bags and lungs and even beacons have changed the dynamic. For the most part, people are getting away with descents that I would have thought insane a while back, and most of the time there are no negative consequences.

To me, this Pucker incident was so obviously off-the-charts sketchy that I can't even believe someone could have stood at the top of Pucker on that day in those conditions and considered riding that line. That said, I've been wrong on so many other topics that y'all can just scoff and call me stupid or a wuss.

I just don't see very many "lessons" in this article that haven't been published time after time before. I don't see much here that really illustrates the tragedy of a life lost and many other lives impacted in terrible ways.

[jono]

OM developed a checklist of takeaways from this accident. Munter developed a method to reduce accidents (in a specific region). There are other methods out there; other research, I don't know whats the art now, the links are old. The point was not to get into camps of one vs. the other like every other thread . The point was to look at frameworks and research already in existence. Because people have spent time doing this already.

Agreed. Different strokes. Not saying one is useless, I'm just saying which one I use and will likely continue to use. I don't mind complex analysis tools in the least but the more of these I read about and the more experiences I have the more items I see myself remembering at the expense of forgetting some other critical point...so for me it's a list. And human factors get a point or three in it.

[bodywhomper]

Sure, everyone was interested in the idea of scoring that line in powder - but I can literally tell you that the majority of the group (4/6) did not have a driving thirst to score that specific line at that specific time.

this ^^^ stands out the most for me in that post.

[babybear]

Guys- Thanks for your responses and extra detail. You have been very vocal about this incident and to me there seemed to be missing pieces that the everyday skier could potentially take away, so appreciate your going deeper into your thoughts and choices that day.

OM- Thanks and I see you on the Teton thread trying to spread the info and stoke. I'm not hung up on the ego thing- as was discussed earlier, it wasn't the preferred nomenclature but I think it has lead to a good discussion on what it is. (And I'm only in my early 30's too- haha so we are not too different) I totally did stupid things in my early yrs, but not when I had the benefit of all the avy training/bc experience you guys had. I mean no disrespect when I say that- but where the everyday skier might benefit from your mistakes and think twice, or pinpoint the errors before they escalated might just save one more person. Which I think you guys would like.

Shralp- thanks for your responses too. Ok yes- the extra education steps/element def make sense for that publication.
And I guess I had hoped to hear you guys say what you said- that nobody in your group was trying to score that line and it was just a complex, but sorta simple thing that can get easily messed up in the name of fun and stoke.

How can we instill this danger upon our friends and visitors? Since, ahem OM , I still have many friends that are younger/new to here-(or live here but still just make poor BC decisions- egad I feel like the wilson moms can be the worst side country offenders @JH always going out Why Not etc with no packs) Anyway- how can we get them to not forget what they know because it's an amazing day w/ amazing friends? seems like this is still a newer factor in avy awareness that has not been totally addressed in avy courses despite a few incident PM's that I'm afraid only people that are already slightly more aware would read anyway.

Maybe this the curse of living in paradise that we get easily euphoric even if it leads to our demise- an almost rapture of the deep but in the mtns instead?
Ok I wish I could think of a better example than the DARE program when I was a kid (FD: the program didn't totally work on me ) but something in this sense could be added to avy curriculum or maybe an encouraged mantra that could taught about living to ski another day or something. Dorky but might've helped here since the guys were a bit blinded to the dangers, being new to the zone + and the lowering to moderate etc etc.
A bit of a digression but I've also wondered if it would be illegal to add a few frames of avy awareness messages to online ski videos. believe subliminal msgs are- but I bet it could be mildly effective haha

[creaky fossil]

this ^^^ stands out the most for me in that post.

it's a nice sentiment, but hardly accurate. I'd love to know how anyone believes he/she can read another's mind/motives. humans frequently say one thing about their motives/mindset, while harboring something different as a real motive/outlook. sometimes this is conscious (people feel shame, enjoy secrecy, etc) and sometimes it's unconscious (young, lacking self-awareness, etc)

baby bear's asking some good Qs.

[Oceanman]

Babybear, all good things. To me, it all boils down to risk tolerance and teaching "absences" is tough. I spent 6 seasons touring all over colorado where I was taught Avy 1 and workshops by very conservative educators. This, along with the often sketchy colorado snowpack kept me on my toes, mostly avoiding avalanche paths until solid melt/freeze cycles in the spring. This was my third season in the Tetons, where a "intermountain" snowpack has led me to step into bigger lines (especially last season). This year was different and I dropped my guard that day on pucker with the persistent problem threat. On top of that was a terrible selection of a terrain choice.

I think one of the biggest lessons I learned from this tragedy other then my previously stated human factors is that persistent weaknesses are SERIOUS. 8 years ago I was taught this in Avy 1 and also when I retook the avy 1 from Exum last year. Unfortunately I did not truly learn how dangerous persistent weaknesses are until pucker. Craig Gordon at Utah Avy does a great job of stressing this point and I think it has a lot of value.

Going back to my first Avy 1 class with an instructor crew out of Aspen. Those guys included a lot of "ski to live another day" curriculum, often stressing how conservative they skied and it scared the shit out of me. It worked! Last season Nat and Ron at Exum touched on skiing smart and sustainability but not like my previous class years ago. A lot had changed in those 8 years between classes with the direction heading into higher consequence lines like jhveteran spoke of.

Happy Sunday

[bodywhomper]

it's a nice sentiment, but hardly accurate. I'd love to know how anyone believes he/she can read another's mind/motives. humans frequently say one thing about their motives/mindset, while harboring something different as a real motive/outlook. sometimes this is conscious (people feel shame, enjoy secrecy, etc) and sometimes it's unconscious (young, lacking self-awareness, etc)

baby bear's asking some good Qs.

it stood out for me because 2 of the group had a "driving thirst to score that specific line at that specific time." all it takes is one in that mindset for a whole group to end up following along, even if there is no assigned leader... my observation is that the "convincing" by the individual (or individuals) for the group to follow their desires can be unconscious by all in the group, including the ones with the specific desires.

[creaky fossil]

it stood out for me because 2 of the group had a "driving thirst to score that specific line at that specific time." all it takes is one in that mindset for a whole group to end up following along...

ah. definitely agree with that. to me the bigger issue is someone having a personal drive (ego, stoke, whatever) that propels him/her past what is smart and into what is, in relative terms, reckless. this can be from ignorance (don't know the risks, or the extent even if risks acknowledged), from cockiness (I'm a good skier etc), or from an alpha/top dog orientation socially.

[Foggy_Goggles]

First off, I'm sorry for the loss of your friend. That sucks. It's very admirable that you guys have been honest about your mistakes and discussing them in the open. It really does help others myself included.

Make no doubt about it, making good decisions is the hardest part about backcountry skiing. I get the analysis of the group dynamic, trying to create checklists...all of that. I'd encourage your to perhaps think about it in more simple terms however.

It seems to me that ya'll individually had the skills and knowledge to ID Pucker as a bad objective given the conditions. For whatever reason, the decision to walk away was not made.

Be a dick! Safety is not the time to be worried about other people's feelings. A lot of people thing I'm an asshole in the backcountry. I don't care. Say what you need to say loud. If it is not being listened too, say it again. Lead by example, " I am not skiing that". "Check you guys later, I'm going back to the resort". You'd be surprised at how many times your friends will follow the lead.

I'm not trying to be preachy. Point is, you know how to make good decisions, so do it. You knew on the tram deck that the dynamic was dangerous. Step to it and deal with it. If you think its a bad scene, let it be known.

The situation you found yourself in is happening everyday in Jackson, Europe, Utah, BC etc. Making good decisions will mean watching others shred the gnar. Collectively we have to accept that and live to ski another day. Those lines aren't going anywhere. It will snow again. RIP Mike.

[spook]

Be a dick! Safety is not the time to be worried about other people's feelings.

this is the part i don't get about groupthink. the larger number the greater the possibility of a dick in the group. but those aren't the stories you hear about. i've got zero problem being a dick. of course, sometimes i don't know enough to be a dick. then i just fall back on my default dickness.

[LightRanger]

You knew on the tram deck that the dynamic was dangerous.

Maybe intuitively, but they all failed to recognize the dynamic--despite training, reading incident reports about Tunnel Creek, etc. And that was one of first points made at the top of the thread and the purpose of this whole exercise: helping otherwise smart, avy-savvy people recognize when they're in a situation where they may not be making good judgment calls and not be realizing it, a la the massive lot of "industry" people, who otherwise should have known better, involved in the Tunnel Creek incident.

[Foggy_Goggles]

Agreed Light Ranger. All I'm saying is that is on us collectively. Checklists and flash cards can help that but ultimately we need to speak up, say what we feel and worry about people's feeling later.

It's hard. I probably deal with it about once a week. I had to tell one of my wife's friends she wasn't welcome on a tour. She came over the next night for dinner. That shit is tough.

We need to all be hyper aware of our and other's decision making. This is why, IMO, it is best to tour with people you know real well (skiing and other wise). Be able to read their body language and voice, look in there eyes, know where they are at emotionally. Do the same for yourself.

[Oceanman]

Great points light ranger and foggy goggles!

[LightRanger]

Agreed Light Ranger. All I'm saying is that is on us collectively. Checklists and flash cards can help that but ultimately we need to speak up, say what we feel and worry about people's feeling later.

It's hard. I probably deal with it about once a week. I had to tell one of my wife's friends she wasn't welcome on a tour. She came over the next night for dinner. That shit is tough.

We need to all be hyper aware of our and other's decision making. This is why, IMO, it is best to tour with people you know real well (skiing and other wise). Be able to read their body language and voice, look in there eyes, know where they are at emotionally. Do the same for yourself.

For sure. Good comments.

[SchralphMacchio]

This thread has been really awesome. Getting to sticky status.

Thanks all for the good and respectful discussion.

[icelanticskier]

We need to all be hyper aware of our and other's decision making. This is why, IMO, it is best to tour with people you know real well (skiing and other wise). Be able to read their body language and voice, look in there eyes, know where they are at emotionally. Do the same for yourself.

bingo!

rog

[CookieMonster]

Hey schralp- Thanks for your debriefing, and since you keep putting things out there I guess it is still up for discussion. I think the main lesson to be learned here is being slightly missed.

I'm sure both you and OM are suffering in your own way and I wish you peace, but I'd like to see you guys admit that egos were the driving factor that day bc, while you allude to it, you do not say that and I think that is THE BEST lesson to come out of this tragic event and to help Mike's legacy and others from similar losses.

You reference adding more 'standard practices', but you all knew the basic standard practices learned in your avi 1 and 2 and yet chose to ignore them or simply allowed yourselves to blinded by the exact thing that are drilled into our brains in the classes to not get blinded by
What do you think the benefit of adding more standard practices are if experienced backcountry people, as you describe yourself, already did not take into account the very first and most basic principles learned in avi classes in the face the red flags? Let’s focus on putting into practice what you already know until it’s like second nature rather than trying to put into practice some more standards for after an event. The focus should be not letting it happen in the first place.

It seems like you want this to be a learning experience for others so let’s recognize that the #1 factor that day- group dynamic is a fun buzzword but let’s call it what it is- ego. If you want to truly make a difference with writing about your experience then help other guys to simply and straight forwardly recognize when the ego starts to drive you and the group and how to get out of that mode and back to focusing on those standard practices you have been taught.
Don’t rely on fancy biz euphuisms and let’s just KISS…..bc you guys all honestly seem like smart, great, conscientious guys and yet you were completely blinded by the pow fever in the face of several obvious red flags.

This guy has got it exactly right.

Ego lead this group to confuse their experience ( they had a lot of experience ) with their skills ( low skill despite being experienced ). This is a very classic problem in many domains; it is in fact so common that there is in standard English an aphorism for it: "a little knowledge can be very dangerous". After a significant failure, it is just common sense to acknowledge that knowing how to do something is not the same as knowing how to do something the right way.

This group clearly knew how to tour, but lacked the skills to tour safely, both collectively and as individuals. Unfortunately, they managed to convince themselves otherwise with tragic results. The winter snowpack is stable at most times, and most places relative to normal triggering forces... and I think this party was used to getting away with it. Here's why: the fact that those involved in this accident are now suggesting/re-iterating basic safety protocols ( the importance of which is already known; I could spend days citing the prior art ) tells me that they had been ignoring basic safety protocols for a long time.

If anyone is interested in learning from true masters, Martin Volken, Margaret Wheeler, and Scott Schell have written an absolutely wonderful book on backcountry ski touring. Following the practises outlined in the book helped me replace a lot of bad habits ( that I was taught and that I fell into ) with solid best practises - and my bad habits were at least as bad as this party's. It might not seem like a lot to plan ALL your trips properly, but it totally changed my outlook on nearly every aspect of the sport.

Personally, I think the state of avalanche education is perfectly fine. People devote incredible resources to finding the time and money to buy gear and stay fit, but they have incredibly unrealistic expectations about the cerebral aspects of the sport. The fact of the matter is that developing real skills takes focused effort. Not just reading idiot blogs ( like the one I write ) and articles. That's just reading without learning.