The Normalisation of Deviance and how I nearly killed myself at an avalanche “safe” venue…

MOVE, MOVE, MOVE, we pushed forwards in towards the cliff as we were hit by the air blast. Pelted by chunks of snow I wrapped my arms around my head and waited either for the avalanche, or my life, to end…

Moments before I was gearing up at the bottom of the classic ice climb ‘Vermicelli’. I was looking up at pretty much fifty metres of vertical ice. Named after a thin strip of pasta, I could see the resemblance, the narrow smear of ice was aesthetic as well as compelling.

It Sounded Like an Avalanche…

There was a loud crack of trees snapping on the hillside above. Andy and I looked briefly at each other before turning our gaze upwards. It sounded like an avalanche. The sky was still visible fifty metres above, and we shared a split second of calm before the roaring torrent of snow appeared over the cliff.

Our situation was grave, with hundreds of tonnes of snow accelerating towards terminal velocity above us. MOVE, MOVE, MOVE, we pushed forwards in towards the cliff as we were hit by the air blast. We probably only managed a step before being knocked to the ground.

Pelted by chunks of snow I wrapped my arms around my head and waited either for the avalanche, or my life, to end…

The day had started like any other during another two week trip to the Briançon and the Hautes-Alpes department in the Provence-Alpes- Côte d’Azur region in southeastern France.

(Above) ‘Les Formes du Chaos’ at the popular cascade ice climbing venue of Ceillac

The conditions were ideal for ice climbing, with just enough snow to feed ice development and continued cold (but not too cold) temperatures for chewy ice. The avalanche hazard scale had been at Category 2 Limité (Moderate in English) for the last two weeks, partly due to the lack of snowfall. Generally it was well bonded and we had been able to climb in many places unconcerned by avalanche risk.

Cascade Ice Climbing

Ice climbing is a little bit different as the lines often follow water courses unsurprisingly, with snow in collecting zones lying on ice rather than snow or bare ground. So while the posted avalanche bulletin is relevant, often ice climbing relies on careful judgement on a route to route basis. As an ice climber you need to think about the overhead hazard all the time.

In France routes have an engagement rating of I-IV which in part give an indication of their seriousness. The home of the ice route ‘Vermicelli’ is a popular area above the village of Ceillac. Immediately next to a ski area, the ice climbing here is really accessible and a correspondingly popular location in the parc régional du Queyras. Most of the routes have low engagement ratings due to their short approaches, bolt belays and easy descents. These are in sharp contrast to the more committing venues in the Ecrins National Park such as La Grave, Fournel, Freissinieres and the Vallon Du Diable.

Given the stable weather conditions we had been climbing well, and decided to visit Ceillac again having climbed pretty much all of the other more accessible routes such as ‘Les Formes du Chaos’, and ‘Sombre Heros’. An ascent of ‘Vermicelli’ would have allowed us to tick the crag.

The Normalisation of Deviance

The normalisation of deviance was proposed by an American academic Diane Vaughan who investigated the causes of the Challenger space shuttle disaster. The normalisation of deviance is often linked to organisational management but can be used to describe any situation where deviations (or even drift) from rules and practicers become the new norm.

These sometimes have devastating consequences, but often further down the line. Especially in the mountains where the absence of a negative outcome frequently reinforces sub optimal behaviour. We operate in a wicked learning environment where the consequences often manifest themselves as a surprise years later.

Habit Forming

Your phone beeps when you are driving. You know the score, the temptation to check is immense. Perhaps you do, because after all it could be something important. It looks like a straight and quiet bit of road so you do a quick check. It was something minor, you put the phone down and continue without incident. And here in lies the problem – the lack of any negative consequence reinforces the use of your phone as being ok.

Maybe over time we don’t even consider the risk. It’s ok “i’ve got this”, “this isn’t dangerous” become the thought process. The deviation from the norm with no feedback probably means you do it more frequently. You are caught in a spiral of habit forming behaviour, and then bang!

The Normalisation of Deviance in the mountains

In the mountains the normalisation of deviance is likely to be more subtle, especially given the dynamic nature of the mountain environment. With an absence of rigid rules in the mountains we are left to make judgements which are supported by consensus, accepted practice and even norms that remain uncommunicated. But that doesn’t mean that the consequences are any less significant.

So perhaps think “drift” rather than deviance, but remember the quote in the Challenger Inquiry Report when describing Russian Roulette. In our dynamic environment we are not dealing with a fixed number of variables:

…We don’t even know how many bullets are in the gun.

Richard Feynman

Vermicelli

Back to ‘Vermicelli’ and the avalanche was a surprise. It should not have been, but I had drifted away from the normal behaviour after two weeks of ice climbing (and multiple trips).

Ceillac was well known to me, and was regarded by us all as an “avalanche safe” venue. More than that it was the “go to choice” and was relatively easy to utilise even in challenging conditions. We had been able to climb here before in heavy snowfall using protected stances with bolt belays. We were of course making our choices based on our previous successes.

My experiences here predate smart phones! We checked the Avalanche Bulletin from Metro France when we could, but we relied on a printed copy outside the Tourist Information office. I can’t remember if we looked at the avalanche forecast that morning, but in my mind it was Category 2 Limité (Moderate) and we had been climbing in higher risk conditions at Ceillac before.

Reflecting on it now, I think I read the avalanche forecast, but didn’t process it. How often do you read something, but actually it hasn’t really entered your head?! There had actually been fresh snow overnight on strong winds.

But the choice to go to Ceillac wasn’t made on the avalanche forecast, or any other defined criteria. It was made as a “go to choice” and one that had, up to this point worked for us before.

The Consequences

With a step forwards we body swerved possibly the biggest avalanche I have ever seen up close. Pelted with chunks of snow, we lost equipment rather than our lives. The ski area didn’t fare quite so well as the avalanche destroyed trees, crossed the road and a ski piste, luckily with no impact on anybody else. Make no mistake we were lucky!

How can we avoid the Normalisation of Deviance?

  • Don’t make choices based on previous success.
  • Try and make plans that build in safer choices rather than accepting risk.
  • Talk often and be prepared to listen to alternative perspectives of a situation. If you are on your own think about how you might explain your own perspective to a colleague or climbing partner.
  • Be clear about standards – talk about norms and acceptable practice. Address the elephant in the room (or on the mountain) and define under what situations you would feel like you were letting your colleagues, or the community down. If you are in a domain where professional standards and/or consensus statements exist, remember that they are there to help you do the right thing.
  • Set an example. If you are an instructor or guide forcing a day in challenging weather or stretching the norms remember it isn’t always the best picture for your clients.
  • Think about how we describe the situation to others. Do phrases such as “avalanche safe”, “benign”, “you can always get to or do x,y,z” really reflect the dynamic situations in the mountains?

If you liked this article you may wish to read Attentional Narrowing: Why mountain guides and pilots know it can put you in harms way. Check out Assured Training or E-Learning.

Attentional Narrowing: Why mountain guides and pilots know it can put you in harms way

I levelled the wings and pointed the glider back towards the tarmac triangle of the three runways. The uncomfortable truth of my situation was glaring back at me. Attentional narrowing meant there was a good chance I might not make it back to the airfield…

The day had started as a normal but mediocre gliding day over the flat fields of Staffordshire, but as I was having a conversation with the aero-tow pilot the radio burst into life with some talk of thermal lift close to the airfield. 

An essential skill of glider flight is the ability to seek out lift to remain airborne, especially given the absence of an engine. Being able to judge conditions is as important for a glider pilot as it is to a mountain guide finding the best snow on a power skiing day. 

Attentional Narrowing
(Above) An essential skill of glider flight is the ability to seek out lift to remain airborne, especially given the absence of an engine.

We decided to launch and after a few checks I was being pulled along the runway behind another aircraft on a long tow rope. The aero-tow was unremarkable and we continued upwards towards 4000 feet with no airspace restrictions. Suddenly, there was a ripple of the wings and we lurched upwards a fraction behind the aircraft in front. The feeling was unmistakable, we had flown into “wave”, orographic lift created by air hitting the mountains of North Wales or Long Mynd and being pushed upwards.

I pulled the hook release three times releasing the rope and the aero-tow aircraft accelerated away in a steep curving descent in preparation for the next task. Pulling the glider around in a 180 degree turn I searched for the invisible crest of the wave that would allow me to surf upwards.

The glider sat suspended silently in the air, there was nothing. I turned 180 again in the hope of feeling the unmistakeable ripple if lift. Again nothing!

This situation is normal in gliding. It was back to my original plan of searching for the thermal lift that had been mentioned over the radio. Soon enough I got some success and the audible beep of the variometer indicated that I was going up, slowly. Thermals are rising bubbles of air, so in an attempt to stay in the rising column I had manoeuvred the glider into a tight spiralling turn.

Round and round I went a couple of knots away from stalling speed, suspended in the rising column of air until the variometer went quiet. Just about maintaining height, I was doing ok. My attention was focused on my airspeed. If I let the speed drop by a couple of knots there would be a good chance the glider would enter a spin.  It is raw, technical flying much like leading that just adequately protected pitch on the rock.

The altimeter showed I was maintaining height whenever I gave it a glance, and I was keeping a good lookout for other aircraft as I was drifting, albeit slowly, towards East Midlands Airport.

I was glancing at the map while an insidious and subtle chain of events where rapidly stacking up against me.

Situational Awareness and Attentional Narrowing

The variometer was working fine, it wasn’t making any audible indication of lift because there wasn’t any. There was no loss of height indicated because it was so small. I had dropped out of the rising bubble of air and was slowly sinking.

The altimeter was faulty and the needle had temporarily got stuck indicating that I was maintaining height. Sadly, I wasn’t. 

I had lost all situational awareness, my attention was focused on the small cluster of instruments in front of me. I didn’t have a full comprehension of what was happening and I hadn’t yet perceived that I was running out of height. Although the chain of these events were subtle, I was suffering from attentional narrowing. The consequences were however obvious: I was in effect not far away from flying a perfectly good glider into the ground.

Glancing out of the cockpit I looked down for the first time in too long. The world rushed back, I was too low and never before had I seen livestock look so large from the air. Levelling the wings I pointed the glider back towards the tarmac triangle of the three runways. The uncomfortable truth of my situation was glaring back at me; there was a good chance I might not make it back to the airfield.

Aviate – Navigate – Communicate

With my limited experience I had never before seen the airfield at such a shallow glide angle. I had drifted downwind and was too far away. Now too low to fly a normal approach circuit, it was time to use the mantra Aviate – Navigate – Communicate. 

Pushing the nose forward to 70 knots I cut through the descending air in an attempt to trade horizontal distance for a bit of height. Then reducing the airspeed I trimmed the glider up to get what marginal gains in performance that I could. My only option was to fly in a straight and direct line back to the airfield. This technique was reserved for competition gliding and glider pilots who were much more experienced than me.

Keying the PTT on the radio I remember the transmission … “Glider Echo Golf Zulu, final glide runway 26”. Some confusion followed as it wasn’t a standard call saying that I had entered a normal right hand downwind leg of a circuit. But I had been spotted and things started to happen on the ground. 

Meanwhile I started picking fields (and noting obstructions) where I could land a glider. Luckily there were a few options each of which quickly fell away behind as I got closer to the runway threshold. I completed my checks called “finals” and pulled the airbrakes to soften my landing onto the runway.

The landing was soft enough and the glider sat on the tarmac for a few seconds, the gentle breeze holding the wings level and free from the ground. Now stationary, I let the wingtip drop onto the runway and opened the canopy to let the atmosphere of failure and fear dissipate.

Val said nothing. As a really experienced instructor, she shared the silence and like any good coach let me reflect on the events that could have orchestrated our deaths. If there was one saving grace it was that she hadn’t intervened during this pre solo check flight. Clearly the situation wasn’t quite as bad as I felt, but I had learnt some valuable lessons and I wouldn’t be going solo just yet.

Attentional Narrowing – Avalanche on Aonach Mor

Fast forward 15 years and I was about to experience attentional narrowing (also referred to as task fixation) and degraded situational awareness again, this time in the context of an avalanche.

The first day of a week of introductory Scottish winter climbing was a tricky one. The weather was forecast to deteriorate by mid afternoon with significant drifting. Using the gondola at Nevis Range seemed like a good choice to access the snow line and make the most of the days coaching and instructional aims. My two clients were keen and able so accessing the area around Aonach an Nid was straight forward.

We had a productive morning revising snow belays, and safe travel with intelligent use of the terrain to mitigate the avalanche hazard. Moving up and down some rocky ribs, there was some thin windslab just a few centimetres deep that we could avoid by keeping to the rocks.

The weather wasn’t too bad so we decided to head towards the summit plateau, doing a little navigation on the way. Here we were able to look into ‘Easy Gully’ and notice the tell tale signs of new windslab accumulation on the lee side of the corniced edge. We decided together to finish the day by building some emergency snow shelters, a useful skill for anybody to have in the winter mountains.

To deliver such coaching excellence I needed an area of deposition where the snow had accumulated, preferably at a reasonable angle so it was easier to dig into the slope. With this in mind we descended back to the rocky ribs bounding ‘G&T Gully’ that we had used before.

The area looked subtly different, our footsteps obscured during the hour which we were absent. I started to descend, my clients just behind sticking to the rocks. There looked to be some good patches of snow lower down and the windslab was shallow, perhaps only 5cm deep at my feet next to the rock rib. Spotting the next group of rocks I stepped onto the other side of the rock rib and was suddenly up to my waist in fresh snow.

Whoommppff – a split second later and the tension crack appeared near my hips propagating across the slope for a hundred metres or so and out of sight. The snow around me seemed suspended for a second despite breaking into big blocks, but then accelerated away taking me with it.

I managed to stop myself but watched with a fixed stare as the snow slowed but covered the flat bench below me. We were all lucky not to be carried down, in part by careful, habitual route choice.

Avalanche at Aonach Mor, Attentional Narrowing and Situational Awareness
The avalanche triggered at Aonach Mor.

How can we improve our Situational Awareness in the mountains?

  • Practice and drill routine tasks to create more bandwidth for the bigger picture.
  • Minimise distractions, use or request a “sterile cockpit” if you need to. More details can be found in CASM v3.0.
  • Consider other factors that reduce situational awareness: protect yourself from the elements, avoid fatigue and ensure you and your group are adequately fed.
  • Most importantly be bothered, and actively look for new information and clues to changing conditions. Communicate these observations often.
  • As all glider pilots know, avoid being “head down”.

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.