CASM – A Human Factors Group Tool

CASM - A Human Factors Group Tool

Guides, Instructors and leaders operating in the UK in avalanche terrain frequently travel in groups, but yet there remains very little research into the ‘Non Technical Skills’ required to mitigate avalanche terrain.

CASM is a proposed Human Factors group tool which is based on Crew Resource Management (CRM) training from the aviation sector, an inevitably well-researched safety critical industry. In addition, established research into avalanche incidents and the applied psychology of Human Factors in safety critical industries has also formed the basis of CASM.

CASM stands for Communication, Alter Command Gradient, Situational Awareness and Minimise Disruption. Many guides, instructors and leaders will already carry out some of the practices that these headings aim to capture. There is no intention to negate those behaviours or propose CASM as a single option, it is a Human Factors group tool that can be used alongside others, or in conjunction with decision making frameworks such as Be Avalanche Aware (BAA).

It is hoped that CASM can be used alongside other established technical skills to reduce the risk of unintended “heuristic traps” or group affects. The ultimate aim being the safe conduct of a mountaineering or skiing day.

CASM v3.0 – Video

CASM v3.0 – A Human Factors Group Tool

Communication

Communication is arguably the non-technical skill from which all the other headings flow, in fact it is an essential element of all the others listed. Communication is regarded as critical for groups to perform effectively in winter snow sports (Trempler 2008, Zweifel 2014) and in aviation (CAA 2016). The ultimate aim here is to establish and maintain lines of communication between members of the group, and also between the leader and the group and vice versa. Discussion of the avalanche hazard is useful, along with the mantra of “saying what you see”. 

Communication should be CLEAR – Contextual, Logically structured, Essential, Ambiguity-free and Resonating (Zweifel 2014). In pressured situations structured communication may be useful such as SBAR and/or NITS brief (Hearns 2019 and Jackson 2021). SBAR – Situation, Background, Assessment, Recommendations. 

As a leader communicating using a logical structure demonstrates the legitimacy of authority due to competence. i.e. you have thought about your work and presented it in a rational and organised manner. The use of technical language of mountaineering/skiing is useful to establish credibility and trust (Ginnet 2019). 

Alter Command Gradient

The aim here is to flatten any hierarchy between the leader and the group. Although leaders will have established legitimate authority having been engaged to carry out their role, they need to balance the tasks as a group. In affect a leader is building a relationship by saying that although they have overall responsibility for the enterprise but members of the group can take on some of that responsibility as well. This is particularly important to create a situation where the leader is not relied on entirely without question, especially if they have made an error.

A frequent briefing for off piste skiing in avalanche terrain is a good example: 

“Any avalanche observations or snow conditions that you think might help out, I would really appreciate having my attention drawn to it. I will be keeping a good lookout as well, but there is always the potential for me to miss things”.

This simple statement is an example of disavowing perfection, by sharing a personal shortcoming e.g. everybody can be looking in the wrong direction, you demonstrate that you are not only human but can deal with you own vulnerabilities (Ginnet 2019, McKenna 2019).

Nobody feels comfortable in a group where the leader is always right. With a flatter hierarchy you empower people to speak up if they are uncomfortable or concerned.

Situational Awareness

Situational Awareness is a broad concept which simply means having an idea of what is going on, but also being able to project into the future and anticipate what may happen next. A common term in aviation, it is a broad catch all. For us in the mountains we can strive to achieve a shared mental model for the day, and anticipate what may lie over the horizon. Start by having a plan (and contingencies). 

Watch for the cues of loss of Situational Awareness (CAA 2016): Ambiguity, fixation, confusion, not prioritising the task, “being head down”, and being unable to resolve discrepancies.

Manage the factors which reduce awareness (Zacharias 2019) such as wellness, fatigue and distraction.

Minimise Distraction

Focus on tasks that enhance safety. The perception of danger requires focus and attention. Chatting, texting and checking social media at the wrong time can detract from the environment and decision making.

The term “sterile cockpit” is used to describe any period of time when crews or groups should not be disturbed except for matters critical to the safety. Additionally, leaders should focus on their essential operational activities (Pollitt 2021).

At key places during your day you may request not to be disturbed by anybody while decision making, and it is a two-way street, don’t disturb others. As such you might plan to call for a sterile cockpit at certain points in the day, or alternatively foster all group members to request it if they are stretched or distracted (Hearns 2019).

References

Be Avalanche Aware, Snow and Avalanche Foundation for Scotland / Scottish Avalanche Information Service.

Jackson D, 2021, [Personal communication], Mountain CRM, Case Study: Take-Off with contamination on the wings prevented by cabin crew.

Jarvis (Ed), 2016, CAP737: Flight crew human factors handbook, Civil Aviation Authority

Ginnet 2019, Crews as Groups: Their Formation and Leadership. Crew Resource Management, Elsevier Inc.

Hearns S, 2019, Peak Performance Under Pressure: Lessons from a Helicopter Rescue Doctor. Class Professional Publishing.

McKenna L, 2019, [Personal communication] Mountain Manners, Not Mountain Madness. Proceedings of the Snow and Avalanche Foundation for Scotland conference, Inverness.

Pollit A, 2021, https://sleeveandspindle.wordpress.com/2021/02/28/small-talk-big-distraction-taking-a-look-at-the-sterile-cockpit-concept-through-the-lens-of-helicopter-operations/

Statham G, 2021, Thinking in Risk: Avalanche Education, Powder Cloud. https://thepowdercloud.com/learn/avalanche-education/thinking-in-risk/

Trempler B, 2008, Staying alive in avalanche terrain. 2 edition, Seattle, WA: The Mountaineers

Zacharias C, 2019, The Power of Noticing: Avalanche Education, Powder Cloud. https://thepowdercloud.com/learn/avalanche-education/the-power-of-noticing-avalanche-warning-signs/

Zweifel 2014, SOCIAL – A group check tool. Proceedings of the International Snow Science Workshop, Banff. 

Crew Resource Management and Human Factors in Avalanche Terrain

Crew Resource Management in Avalanche Terrain

A few days ago I shared the exciting news that Mountain Assurance is preparing to launch a short online course entitled ‘Mountain CRM’. This short course in Crew Resource Management and human factors in avalanche terrain will be a mix of written material, short lectures and audio interviews.

What is CRM?

But the obvious question is: what is CRM? Like any good three letter acronym it can mean different things to different people. In the context of human factors we are talking about ‘Crew Resource Management’, a term first used in aviation.

CRM training courses were introduced to mitigate the affects of heuristics and other human factors, but have since grown to encompass many ‘non technical skills’.

As mentioned in my previous blog post ‘The Human Factor in mountaineering and snow sports – Going beyond FACETS‘. I believe that non technical skills for skiers and mountaineers include: situational awareness, decision-making, teamwork and communication, leadership and task management and the application of these skills in the winter environment.

For leaders, instructors and mountain guides working in the winter mountains, CRM behaviours and non technical skills can be used alongside existing decision making frameworks such as ‘Be Avalanche Aware’ (BAA).

The winter mountains may not be your work place, but some of the behaviours and non technical skills will almost certainly be relevant to lots of recreational user groups in the mountains.

An introduction to ‘Crew Resource Management’ and ‘Human Factors’ in Avalanche Terrain

A generic definition of CRM might be the training of the cognitive and social skills needed to support technical training in order to optimise safe and efficient operations.

Work (or recreation) in avalanche terrain requires exactly that. The use of cognitive and social skills to better cope with uncertainty. We are not pre-hospital doctors or pilots but our observations and decisions are made in dynamic mountain environments with the potential for signifiant consequences.

Although we are arguably working in a low tech environment, in contrast to a modern flight deck, CRM has a place in any environment which relies on humans in the system.

Mountain CRM

Mountain CRM is an opportunity to “train your brain for avalanche terrain”.

What you will learn…

✔️ Enhance your awareness of human factors and human fallibility

✔️ Develop the knowledge, skills and attitudes to mitigate errors and manage risk

✔️ How to prevent and manage group errors

✔️ To use CRM knowledge as an outdoor professional, to balance making a living with safety

✔️ Integrate CRM knowledge, skills and attributes to shift the culture of the outdoor professional sector and help prevent incidents in avalanche terrain

Sign up via the link here for further news and information on the go live of Mountain CRM straight to your inbox: https://share.hsforms.com/1I35IP6_HROOhL4mfTMuh9A3pgcj

Mont Blanc: The Inconvenient Truth…

Mont Blanc du Tacul

To climb Mont Blanc remains one of the great accessible challenges in the Chamonix Mont Blanc Massif for climbers and alpinists. Standing on the highest summit (4810m) around and looking across the Italian plains, along the alpine arc and below to the smaller chains of Les Aravis and Chablais is a seminal experience.

But we are faced with a mountain under pressure from visitors and continually degrading conditions due to climate change. Year after year Mont Blanc is becoming a riskier proposition.

In recent years, I have climbed (and guided) Mont Blanc on a handful of occasions choosing to make attempts early and late in the season to avoid the heat waves, and crowds of the high season. More recently, at the high of the season I have decided to avoid it altogether.

We all have to decide the level of risk we are prepared to tolerate, and this approach has always seemed logical for some guides in an attempt to reduce the cumulative risk of making multiple ascents.

The reality is that limits in hut space and availability due to crowding puts significant pressure on guides and independent climbers to attempt the mountain on schedules that wouldn’t be their first choice. The result is an incremental mission creep towards narrower margins of safety, and judgements on the ground taken on smaller and smaller criteria.

The Inconvenient Truth

A new project initiated and led by the Petzl Foundation, arguably places my own previous strategy in doubt. These independently led projects have centred around the Goûter Couloir some times simply referred to as “The Death Couloir”. No sensationalism is required here though, with this intimidating location and its immediate surroundings being responsible for an average of 3.7 fatalities per year and countless injuries.

Regardless of your experience to climb Mont Blanc by the normal route (voie normal), you will need to pass the couloir, either in ascent, descent or both.

The Petzl Foundation asked the simple but logic question: How can we reduce accidents in the Goûter Couloir?

Presenting such a significant objective danger due to rock fall, the Petzl Foundation postulate that the Goûter Couloir tarnishes the image of mountaineering. That assertion is certainly an inconvenient truth, but one that would be worthwhile stepping back and scrutinising away from the commercial pressures of the tourism industry and individuals livelihoods.

The full links to the reports, are available below and worth reading in full.

Petzl Foundation Reports – Mont Blanc

Petzl Foundation – Mont Blanc: how can we reduce accidents in the Goûter couloir?

https://www.petzl.com/fondation/Couloir-Gouter_Rapport_EN_web.pdf?v=1

Petzl Foundation – Goûter Couloir on the normal route, Mont Blanc

The latest reports make some stark observations:

“Despite its limitations (see Conclusion), this study provides valuable information for those planning to ascend Mont Blanc:

– The number of rock destabilisation events recorded over the course of the study is an indicator of extreme gravitational activity.

– In 2019, a rock destabilisation event was recorded every 37 minutes on average and every 24 minutes on average during a peak of activity between 7 pm and 8 pm.

The highest frequency of rock destabilisation events was recorded between 6pm and 8 pm. It increased an average of three hours after temperatures became positive at the top of the couloir.

– Rock destabilisation events grew more frequent and larger in size when the couloir became exposed to the sun.

– The time of day when rock destabilisation was least frequent was between 9 am and 10 am.

– The couloir was as dangerous at 3 pm as it was at 10 pm.

– Rock destabilisation was more frequent at the beginning of the season, partly as a result of snowmelt. However, these events were relatively small in size, but still hazardous for mountaineers.

– The frequency of rock destabilisation events was lower in the second half of the summer season, but the longest events (“boulder showers”) and those involving the highest volumes of material also occurred during this period.

– The liquid water present in rock fractures seems to be the primary factor governing the risk of rock destabilisation. The more liquid water is present in the cracks in the rock (melt water/precipitation), the greater the frequency of rock destabilisation events. Mountaineers need to be particularly cautious during periods of snowmelt or after rain/storms.

– The presence of snow in the couloir is not necessarily a guarantee of safety, since snowmelt promotes rock destabilisation.

– A cold period marked by frequent freeze-thaw cycles is conducive to the occurrence of rock destabilisation. Only a cold period without thawing (which is rare in the summer) can reduce the frequency of destabilisation events.”

Climbing Mont Blanc

The conclusions from this report adds evidence to the widely held view that crossing early in the day before the couloir is fully in the sun, is in relative terms “safer”.

This includes ascent and descent, so hut reservations that facilitate these timings are essential. Starting early from the Tete Rousse Hut, and staying at the Goûter Hut in descent is one option. There are inevitably financial barriers to this, and the issues of securing bookings of huts that are in significant demand.

Finally if starting from the Tete Rousse Hut, some guides choose to start at first light. So at least they can see the conditions in the couloir and will get visual confirmation of any rock fall activity. Choosing to cross in the dark, although common, degrades you ability to make observations.

There are alternatives, and with fifty major 4000 metre peaks in the alps there is a whole collection of challenging objectives on these classic peaks alone. Although any alpine route will be subject to objective dangers and can never be risk free, there are plenty of summits that can be climbed without the same exposure to rock fall on Mont Blanc.

Statutory Regulation of “Mountain Guides” in Scotland…?

In December 2014 there was much discussion within the UK instructional and guiding community following the Fatal Accident Inquiry Determination into the tragic death of Graham Paterson on the Isle of Skye.

Sheriff Principal Derek CW Pyle made the following recommendations under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976:

1. Consideration should be given by Scottish Government and relevant stakeholders to discovering a means, whether statutory or otherwise, to ensure that mountain guides in Scotland are properly qualified and equipped to provide a commercial guiding service for adults.


2. The relevant authorities should inform the public of the importance for amateur climbers and hill walkers of at least two members of any party being fully equipped to deal with the possibility of an accident occurring to the leading member of the party.

The full determination can be viewed here at: https://www.scotcourts.gov.uk/search-judgments/judgment?id=ba0fbba6-8980-69d2-b500-ff0000d74aa7 (note the terms “mountain guide” is used generically in the document, rather than representing the qualification).

Personally I have no desire to dwell on the events of this tragic case particularly within a small mountaineering community. As ever it is important that we apply the lessons learnt from these incident’s to ensure our own safety as well as that of our clients.

Secondary Communication?

Immediately after the determination (which in itself is less that specific), there was much discussion about the second recommendation and whether parties should be equipped with a multitude of technical devices to summon help. As usual views were polarised, mine included, as the recommendations for satellite phones, EPIRB’s, Spot Locator devices etc were championed on social media networks and in personal communication.

As usual ‘technology’ and tangible advances in equipment were pushed to the front of the discussion rather than considering the ethos of what Mountaineering Instructors and Mountain Guides are trying to achieve.

Firstly, we should and in many cases do, foster self reliance within groups regardless of whether we operate at 1:1 or on a much larger ratio. This simply means ensuring that members of the party are adequately equipped for the venture, have some situational awareness as to their location and the plan for the day, combined with a brief to summon help if required. All of these issues are well engrained in the Mountain Training UK Awards at all levels, for those who have chosen to undertake them.

Secondly, the choice of communication to summon help should be carefully considered on a needs based assessment. To do so those working in the mountains and amateur mountaineers should understand how to summon help and the timescales with which that resource can be sought. Finally, it’s worth considering whether one way communication e.g. Flares, EPIRB, Spot Locator or two way communication is more useful e.g. VHF Radio, mobile phone or satellite phone.

In discussing the panacea of “tech” many have failed to acknowledge the the first recommendation of statutory regulation.

Statutory Regulation

The recommendation of statutory (or other) regulation of mountain guiding activities in Scotland is a radical departure from the current status quo in the UK as a whole. Currently, activity leadership in the hills and mountains of the UK is unregulated with the exception of those under 18.

Within the European Union the UK is one of the few countries which chooses not to regulate these activities. However, arguably we are in a way very good at self regulation within the industry, with a proven pathway to demonstrating competence as defined by the Health and Safety Executive (HSE).

The HSE acknowledge four ways to demonstrate competence: to hold a qualification, to hold an equivalent qualification (e.g from within the EU), to have received training by a suitable advisor (i.e. in house/organisation) or have significant experience. As such many people do the obvious thing and use the Mountain Training UK Awards as an obvious way to demonstrate competence by proxy.

The challenges with this complicated system is that it sadly isn’t very transparent for a client hiring somebody to take them into the mountains. While it should be encouraged that people ask questions when entering into a service agreement, the whole point of the instructional and guiding community is that individuals shouldn’t necessarily need to take the full responsibility of the enterprise?

Sadly, Mr Paterson didn’t hold a substantive Mountain Training UK qualification but had started the process registering for the Summer Mountain Leader Award. It should be noted however, that there was no legal requirement for him to do so.

As for statutory regulation, Sheriff Principal Derek Pyle made the stark observation that mountain guides should be properly qualified and equipped to provide services to adults. Critically, Mountain Training UK also issued a Briefing Note for its Providers and Association members regarding this Fatal Accident Inquiry – Skye.

This makes interesting reading and makes particular reference to the terms ‘Guide’, ‘Instructor’ and ‘Leader’ all of which relate to very specific qualifications. These titles are not legally protected and are frequently abused or simply ignored due to lack or understanding or apathy.

As instructors and guides perhaps we can be more transparent about how we use those terms, and those associated with them. e.g. Aspirant MIA, Aspirant MIC. Particularly, when they do not represent a position within the MTUK framework. Note: The names MIA and MIC have now been replaced by the MCI and WMCI respectively.

That’s one small thing that we can do as individuals to make our industry more transparent. If we can’t regulate ourselves effectively then somebody will probably do it for us.