On
May 10th, 1996 Mount Everest played out one of its most dramatic 24
hours in its formidable history. The mountain claimed the lives of 8 people – 5
on the south side and 3 on the north, included within this were 3 expedition
leaders and 1 guide. Never before, even with Everest’s formidable reputation,
had the mountain provided such drama or poignancy. The culmination of a
harrowing 24 hours finishing with Expedition Leader from the Adventure
Consultants, Rob Hall, widely acknowledged as the worlds leading Everest guide,
dying alone on top of the world, the final twist of fate being a chance
satellite telephone call to his heavily pregnant wife in New Zealand.
In
my last blog I explored the hubristic decisions made by NASA prior to the loss
of the shuttle Challenger. Today I look closely at the Human Factors that were
present as 4 separate expeditions attempted to summit the world’s highest
mountain on the same day. Specifically I will examine the loss of situational
awareness from the teams who lost their expedition leaders on the South Side of
the mountain – Scott Fischer from Mountain Madness and Rob Hall from Adventure
Consultants.
Essentially,
as with most disasters, a culmination of many errors compounded to create the
necessary ingredients required for such a catastrophe. Colloquially referred to
as the Swiss Cheese effect (Reason 1990). As the title suggests, the many holes
of the cheese are a metaphor for individual mistakes which when compounded and
then repeated will sooner or later result in a number of holes aligning,
allowing a beam of light through the cheese - the disaster event. Often combinations
of errors will either go unnoticed or perhaps provide near misses, which may,
or may not be reported. The presence of a near miss, especially when repeated,
can indicate potential future disasters; unfortunately these near misses are
seldom reviewed and even less frequently acted upon. A culture of, ‘wow! We
were really lucky to get away with that; best keep it quiet to avoid
embarrassment’ presides over a culture of, ‘wow! We need to discuss and explore
what happened there to prevent a re-occurrence in the future’.
Unfortunately
on this day a culmination of multiple errors in judgement combined with a
terrifying storm at over 28,000ft. As ever, there are many contributing
factors, which resulted in this terrible loss of life that fateful day. Each
survivor tells their own version of events, complete with accompanying blame
proportioned towards different individuals. The mistake that ultimately
triggered all that came after was a simple, yet golden rule that was ignored.
· The turn around time, which is set in stone, was
1300 on the day; this is considered a fundamental rule for Everest summits, even
if the group is 100m from the summit you turn back at this pre-agreed
time.
·
This timing has many permutations; the reliance
on oxygen in the death zone, above 25,000ft means there is only a narrow window
to push up from Camp 4, summit, and then return safely to Camp 4.
· Physical exhaustion and the prospect of
potentially descending in the dark while completely exhausted from the summit
attempt.
·
Rob Hall was famous for obeying these agreed cut
off times religiously; he had, on occasions scolded other leaders for being
flagrant towards these timings, he had even turned climbers back within
touching distance of the summit. On this day he did not, in fact he was still
struggling to summit his last client, Doug Hanson, well past 1600 – 3 hours
late.
What
unravelled in the hours proceeding that fateful decision would never had the
opportunity to develop, had this cut off time been adhered too.
Within
Human Factors we teach, discuss and develop Situational Awareness (SA), this
can be accurately described as:
“An awareness and understanding of what you
are doing and what is happening around you combined with the Knowledge to
interpret this data to predict future events.”
The lack of oxygen while working at the
incredible altitude of Everest places more strain on the mental capacity of the
climbers, when climbers approach task saturation (overfilling their ‘mental
cup’ with information) simple decision making becomes laborious and unreliable
– this multiplied by the lack of oxygen available. Consider a time when you
perceived yourself working at your maximum capacity, you probably found
yourself struggling with basic prioritisation, the effect of this is – you can’t
seem to start anything and quickly become annoyed, anxious and irritable? If
you have, this is what occurs with task saturation. In an office environment, a
mildly annoying emotion resulting from trying to focus on multiple tasks
simultaneously – at the summit of Everest a matter of life or death.
These
simple decisions, which often lead to further exasperated problems, are not
uncommon in Human Factors. Often the loss of SA is, in and of itself, an
entirely unconscious process, the climber starts to suffer with tunnel vision
and fails to notice glaringly obvious flaws in their strategy. Some of the last
photographs of Rob Hall’s expedition approaching the Hilary Step clearly show
the impending storm approaching from behind the doomed climbers. With only a
basic knowledge of weather and geography a relatively novice mountaineer would
of quickly concluded that the summit attempt was not possible. Why then, did two of the most experienced high
altitude mountaineers lose such basic situational awareness?
Perhaps
both Scott Fischer and Rob Hall had different reasons for their individual loss
of SA. From the South Summit to the Hilary Step Fischer had become laborious
and had fallen behind is own clients, unheard of for such an extraordinarily
robust and strong guide. It is now
believed that Scott Fischer was in the grips of either High Altitude Cerebral
Edema (HACE) or High Altitude Pulmonary Edema (HAPE) – or perhaps both? Tragically
for him the naivety and lack of experience of his clients meant that correct
diagnosis was never identified, even though he was clearly displaying all of
the symptoms. Doug Hansen, on the other hand, was being cajoled and spirited to
the summit by his expedition leader - Rob Hall, while not far away Scott
Fischer was incoherently talking about jumping to his death Hansen and Hall had
hopelessly missed the agreed cut off time. The previous year in 1995 Rob Hall
had turned back Doug Hansen within touching distance of the summit, at between
$30,000 - $60,000 a summit attempt perhaps Rob Hall felt a ‘moral obligation’ to
summit the likable Doug Hansen.
On
reflection it is always easy to analyse others actions, in truth the most
experienced professionals will suffer from lapse in situational awareness. With
training these statistics can be affected, with every mistake a human is
capable of making we also possess the qualities to develop, learn and modify
our behaviour. Human Factors is this continuous developmental process of
understanding humanistic decisions and actions, especially when working in
challenging conditions.
Similar
to the Challenger disaster, the learning from Everest was short lived. Within a
decade the mountain would become the focal point of arguments about the
suitability and morality of allowing at times inexperienced mountaineers to be
guided to the summit of the earth - for the right price. Arrogance and greed fuelled by commercial
blindness at 29,000ft will always provide the theatre for such disastrous days.
The
Dark Summit brilliantly written by Nick Heil highlights this uneasy truth. In
May 2006 over 40 climbers either ascended or descended past David Sharp, a
young British mountaineer. While he lay dying from high altitude sickness his like-minded
climbers, all of which in the grip of summit fever or suffering complete
fatigue, callously ignored his plight. The moral question each of these
climbers asked of themselves was:
“Am I prepared to sacrifice my $50,000 summit
bid to save this young climber?”
Unanimously
they chose no.
