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”.