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.

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

The Human Factor in mountaineering and snow sports – Going beyond FACETS.

The Human Factor in mountaineering and snow sports - Going beyond FACETS.

Human Factors – “it’s all about the Human Factor, init [sic]”

For many winter sports enthusiasts the acronym of FACETS will need little introduction, especially for those who have undertaken any avalanche training. Interest in Human Factors among winter sports enthusiasts, has rocketed in recent years. It is an in vogue subject.

Here lies the problem, in our search for answers we are applying concepts from other sectors with little understanding of Human Factors (HF) as a scientific discipline. We have an early awareness of Human Factors, but the application of HF is far from understood in a snow sports context.

What are Human Factors (HF)?

Human factors and ergonomics (commonly referred to as human factors) is the application of psychological and physiological principles to the engineering and design of products, processes, and systems. The goal of human factors is to reduce human error, increase productivity, and enhance safety and comfort with a specific focus on the interaction between the human and the thing of interest. Source: An Introduction to Human Factors Engineering. Wickens, Gordon, Liu, 1997.

HF is clearly a broad area with its basis in various areas. Stephen Shorrock summarises it well as ‘Human Factors’ emerged from many disciplines, with none dominating completely. Human Performance is related primarily to psychology, physiology, and sports science, with psychology dominating industrial applications. Source: Human Factors and Human Performance is there a difference?

Human Factors (HF) in Avalanche

So what about Human Factors in avalanche terrain, snow sports and mountaineering? Historically our understanding has been framed by heuristics and the work of Ian McCammon in the early 2000’s. McCammon researched avalanche incidents and identified six human factors that were significant factors in avalanche incidents.

Ian McCammon proposed the main human factors (effectively heuristics) that may influence decisions as: Familiarity, Acceptance, Consistency, Experts, Tracks/Scarcity and Social Facilitation. These factors form the acronym FACETS. For more details on this from Avalanche Canada.

Heuristics are simply short cuts to decision making which allow us to make decisions quickly and efficiently. Very simply they are “rules of thumb”. Frequently these work in our favour, but sometimes result in error. Also referred to as cognitive bias, there are many at work.

More recently the Cognitive Bias codex proposed 180+ cognitive biases. The reality is that the situation is more complicated than the six general influences listed in FACETS.

Heuristic Traps in Recreational Avalanche Accidents: Evidence and Implications – FACETS

Ian McCammons original paper can be found here at: Heuristic Traps in Recreational Avalanche Accidents: Evidence and Implications. I would recommend reading the full paper as a seminal work on the subject of Human Factors / Heuristics. For those who want a two minute summary this video runs through FACETS in two minutes:

Powder Magazine: The Human Factor Intro

Quite rightly this seminal work has seen the widespread adoption of the FACETS acronym worldwide, from avalanche training courses to introductory winter skills. But it remains a broad brush stroke approach to a much bigger and nuanced subject, the reality is it’s complicated!

The bulk of this blog post was written after a conversation with Karl Klassen of Avalanche Canada at the Snow and Avalanche Foundation of Scotland (SAFOS) conference in autumn 2019. Why? Because we both speculated that despite an increased awareness of FACETS that there hadn’t been a significant change in behaviour in the field. I should point out that’s an opinion, but we should perhaps ask what’s going on?

Roll forward to autumn 2020 and I have just digested this paper from Jerry Johnson et al : Rethinking the heuristic traps paradigm in avalanche education: Past, present and future.

I would recommend reading it, and then reading it again!

Jerry Johnson: Rethinking the heuristic traps paradigm

In rethinking heuristic traps, Johnson reviews McCammons work which has been widely adopted over more than 15 years.

He points out that the initial research was conducted into avalanche incidents alone, and while that may identify the root cause of incidents fails to take account of the wins. As such incidents (or accidents) might not be the best window into decision making on the ground.

This builds on Laura Maguire’s lecture Maguire, L. (2020). Cognition in the wild: Supporting avalanche professionals through cognitive systems engineering . Canadian Avalanche Association Spring Conference which is available below.

In short, taking a systems approach to the “nerd fight”, you can view this video here at https://youtu.be/M3HR_Uuvqf4

Changing the narrative around Human Factors

Human Factors is a broad term and at a practical level we should be talking about the application of non technical skills by mountaineers and skiers.

I think 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. Understanding decision making is likely only by adopting a systems approach to our “wicked learning environment”.

As a Mountain Guide and instructor I am focussed on the practical application of these skills on the mountain, I am no psychologist. Even if people understand and recognize human factors, indications are this knowledge does not effectively change behaviour in the field. If there is any chance of affecting these behaviours it is through a consistent and solid planning process that, hopefully, produces a trip plan that keeps people out of situations where human factors might have a negative influence! [Avalanche Canada].

Johnson is arguably on point with the final section of his abstract: We end with a discussion, and a call to action to the avalanche research community, of how we could move towards resolution of these weaknesses and add value to prior work on human factor research. Our aim is not to disparage the seminal, paradigm shifting work by McCammon, but rather draw attention to how it has been operationalized and how the industry needs to move beyond this paradigm to see further gains in our understanding of avalanche fatalities.