Living In a Shadow

I have frequently tried, unsuccessfully, to write an article about the Aberfan coal disaster of 1966. Without doubt, its one of the most tragic disasters to recount, and perhaps this is why it is so difficult to write a neutral and balanced article about it? Recently I have finished reading the brilliantly insightful ‘Wilful Blindness’ by Margaret Heffernan, which ‘nudged’ me to finally complete this blog. Throughout the book, without actually referencing Aberfan, there are examples immediately recognisable to the conditions that led to that fateful day in 1966. Aberfan was a disaster so great it scarred a community still felt today and wiped out an entire generation of children. 

There are seminal moments in time that are so significant they scar your memory with your location and what you were doing when you first heard the news. Tragic, or triumphant, they become ingrained in memory. The Twin Towers, or the assassination of JFK. England winning the world cup, or Andy Murray winning Wimbledon, they become psychological watersheds in your timeline; for better or worse. The Aberfan coal disaster is such an event.

For over 50 years the National Coal Board (NCB) deposited millions of cubic metres of colliery waste on Merthyr Mountain above the village of Aberfan. These ‘slag heaps’ lay on porous sandstone rock, which in turn contained multiple natural springs below ground, and streams above. Villagers and miners had expressed their concerns about the natural springs that lay beneath the nearly 800ft high waste tip for years. These concerns were dismissed by the NCB who reassured the local community what they were doing was safe practice. On the morning of 21 October 1966 after days of continuous rain a process called thixotropy occurred beneath the slagheap, this released around 40,000 cubic metres of unwanted coal and rock drenched in rainwater onto the village below. Before reaching the Pentglas School it destroyed 20 houses and a farm. The children of the School were taking part in the morning assembly, while singing ‘All things bright and beautiful’ the rumbling of the fast approaching landslide was heard. On this terrible morning 28 adults and 116 children between the ages of 7 – 10 were killed.

This abhorrent wilful blindness and callous hubris from the NCB management, and in particular it’s Chairman Lord Robens, created a ticking time bomb of unimaginable proportions.

The tragic irony of the wilful blindness exhibited by many involved in the months leading up to the disaster was the transparency of the problem. The dangers were clear for all to see, and furthermore many villagers and miners intuitively knew this practice would sooner or later fail. Transparency is a good thing within any risk managing industry, with transparency comes accountability. Often in the presence these conditions people do the ‘right’ things; without it present the opposite can occur.  There is a paradox of transparency with the Aberfan disaster however. On one hand there can be nothing more openly visible and transparent than an 800ft slack coal heap, lay on springs and clearly marked on OS maps of the area. On the other hand, the information known by the NCB was concealed within the shadows, both before and after the tragedy. Large human factor accidents are rarely the work of criminals, more likely repeated examples of human fallibility and misadventure, or at worst gross incompetence by few. The leadership and management of the NCB came in for scathing criticism during the Davies inquiry and subsequent report, particular blame was attributed to Lord Robens who had shown a complete lack of honesty both before and after the disaster. Amongst the worst acts of dishonesty, Lord Robens denied knowledge of the springs beneath the tip; this infuriated the villagers who knew this not to be true. He also claimed they were not to a contributing factor to the disaster. Lord Robens also staunchly refused to pay the £150,000 needed for the removal of further tips, adding further distress to the grief stricken community. Eventually this bill was paid by the disaster relief fund set up to give financial aid to the village, this would be a heinous wrong that would remain so until the incoming Labour government of Tony Blair, in 1997, instructed the money be paid back. Press intrusion in the aftermath further increased the suffering and distress felt by the villagers who were placed under an intrusive media spotlight. Claims by some of the villagers that a journalist had been heard encouraging a child to cry for her lost friends to enhance the drama of a photograph were appalling, to say the least.

This was contrasted by the public outpouring of sympathy for the grief striken community, which resulted in nearly £1.6 million being raised. To place this into context this would be over £21 million today without the Internet, social media or constant news coverage.

There were many lessons learnt after Aberfan. The Davis Enquiry was rightfully scathing of the management and leadership of the NCB and particularly Lord Robbens. Incredibly, however, Lord Robens kept his job and its perhaps his conduct after the tragedy that draws the most criticism. Most of all there was an incredible lack of transparency displayed by the NCB leadership. Transparency is a wonderfully honest quality, when behaviour is transparent it is usually honest and correct. Even when the behaviours are wrong, they are more often unintentional and can be corrected without serious reprimand. Consider this, can you ever recall getting caught doing something wrong. The instant reaction is to cover up and conceal the truth, human behaviour tells us people don’t conceal or cover up their actions when they’re doing the ‘right’ thing.

I can’t help but wonder that had there been more transparency in 1966 we may have been able to avoid one of the most tragic events of the 20^th century?     

The Cost of Uncertainty

The recent downturn in the price of oil has sent shock waves through the Oil & Gas industry worldwide. The prolonged and steady fall in value since June has left the industry with an end of year price of less than $60 per barrel. There are many ways to look at the cause and effect equation of this, for many countries that import oil this signals good news with the price of fuel tumbling in recent months. In fact any industry that requires fuel to operate should be reaping the fruits of this crude oil tumble in value. The international politics of this current situation is seismic, the UK with than 1.8% of the world production is dually concerned, also it furthermore highlights the precarious wealth enjoyed in Aberdeen – what will the city do after the Oil & Gas is finished? 

If this is the political effect of the drop in value, what is the upstream cost to the safety of those working within this dangerous industry?

When shares tumble companies usually look to streamline operations in various fast and arguably effective ways. Reduce the workforce, stop hiring, and reduce training and development are all viable options to weather the storm.  All of these have produced disastrous safety consequences in the past however, both financially and reputational. There can be no uncertainty; safety and profit should never be confused. Lord Cullen emphasised this in his enquiry after Piper Alpha, and the same charge was given to the Deep Water Horizon platform. NASA has also felt this pain periodically with major shuttle losses within their space program in different decades, both with the same charge - compromising safety because of profit. CEO’s should be under no illusion that the message they give to their executives is resonated through the managers and magnified throughout the installations. This is especially prevalent during a period where the mainstream media appears to be fuelling concern for the future of the industry in the UK. Strong and dynamic leadership is imperative, as many working in this sector will be counselling caution for the forecasted growth uncertain times lay ahead. This uncertainty can be the final component needed to create the conditions required for a big accident. BP felt this pain with their CEO’s confusing ‘every dollar counts’ message, which was the precursor for the Macondo blow out. 

In fact many of the biggest accidents experienced in industry are found in the company of investment cuts and uncertainty.

This current downturn should not be the catalyst for a compromise in safety training; in fact we believe it can have a contribution to the cost effectiveness and profitability long term. Effective Human Factors training has many benefits; the Aviation industry knows this and regardless of fluctuation in share prices all aviation pilots and cabin crew must complete regular Crew Resource Management (CRM) training. Since mandatory CRM training was introduced this industry as seen a huge reduction in near misses and accidents, the upstream effect of this improved profit projections. When this training is applied alongside simple and effective management software the result is a safety culture that understands the human element contributing to accidents. 

There is a secondary gain from a safety culture; a reduction in accidents is an increase in profits. In these challenging times this can only be seen as a positive?  

Straightening The Deck Chairs On The Titanic

It is always preferential to have foresight where possible, as opposed to hindsight. Working today to prevent the accidents of tomorrow seems to be a sensible approach to Human Factors. With this in mind the irony of our blog writing has not escaped us, constantly we find ourselves looking backwards for examples of accidents to use within the articles. Often these examples are very tragic and sometimes difficult to relive, this is also something that does not escape us. This is important because to develop clear foresight requires an occasional touch of hindsight. The past is where our questions wait, and more importantly the answers to these questions lay, we need to shine a light on these shadows to illuminate the lessons.

                                             The crew of Titanic including Cap Smith

The Titanic presents, in our opinion, the single greatest lesson in Human Factors. When examined, nearly every strand of modern Human Factors is present within this single story. The Titanic lesson is so strong it has now become a metaphor for Human Factors.

Recently it was suggested that investment in ‘prevention focused’ training should be measured against the likely occurrence of a ‘big’ event becoming reality. Is it better to surrender to the hand of fate and hope that chance smiles on you (and potentially save money), or invest and prepare for an unlikely reality? This statement mirrors the corporate mentality of the White Star Liner when designing and building the Titanic. Discussing all of the contributing factors into this disastrous trans Atlantic crossing, from design and build to its maiden voyage, could not be achieved in one blog. With that in mind we would like to focus on one particular contributing element; the mindset and attitude of those involved.

Most organisations that have experienced a sizable accident will of held the mindset of ‘it might never happen’. Added to this investment in preventing something that might not actually become a reality is sometimes a difficult expense to swallow. This can create a paradox of planning and training for an unlikely event, hence the title ‘tidying the deck chairs on the Titanic’. The further paradox with this mindset is you can’t measure the accidents you never had!  

Is it better to ‘appear’ you are serious about accident prevention while really focusing on the more immediate and pressing issues associated with operating a large business? Surely as long as there is a measured approach that complies with industry recommendations this is fine, isn’t it?

Perhaps not?

The designers of the Titanic thought they had created an unsinkable ship, this provides the perfect conditions to test such profound humanistic statements. There is a famous saying that nature does not respect the qualifications or the competence of men. This statement can be applied to avalanches in mountaineering, fog and high winds to airline pilots and, as with Titanic, icebergs and ships Captains. Nature does not recognise their competence nor does it spare them when the time of reckoning comes. The Titanic had lifeboat capacity for only half of its passengers, because they presumed it was unsinkable. Recent evidence has surfaced that before departing Southampton a civil servant called Maurice Clarke expressed serious reservations about Titanic’s lifeboat capacity. His superior’s threatened Mr Clarke’s job and the original recommendation of increasing Titanic’s lifeboat fleet by 50% was overruled. Had this come to light during either the British or American enquiry there may have been a stronger case for corporate manslaughter against the White Star Liner?

                                                Computer regeneration of Titanic 

This ‘invincible’ mindset was intoxicating; the passengers believed it, the ships builders believed it and the crew did also. Even immediately after the iceberg struck still many felt safe. Perhaps the most poignant example of this wilful blindness was that of Wireless Officer Phillips. He was responsible for sending and receiving messages on the one radio channel that Titanic had, he chose to prioritise wireless transmissions of the super rich 1^st class passengers over the iceberg warnings. Mr Phillips went down with the ship, sending SOS messages to the end.

                                                 Both parts of Titanic on the sea bed

Although this seems an extreme example from over 100 years ago, do we still exercise this ‘wilful blindness?’ The answer in short is yes, albeit rarely thankfully. We need look no further than the Costa Concordia for a stark reminder of the hubristic inclination of man.  Part of this fallibility is our romance with courting chance, whether in a casino, bungee jumping off a bridge or performing a flamboyant manoeuvre with a large ship.  Human Factors learns the lessons of the past so to implement today for a safer future. Working with risk will always require measuring the consequence against the likelihood; this process helps us plan with foresight. A safety culture embedded within operational excellence allows for a clear and transparent vision for the future. We need only use hindsight once to know that one Titanic is enough.

"Eternal Father, strong to save, whose arm hath bound the restless wave,

Who bids't the mighty ocean deep its own appointed limits keep;

Oh, hear us when we cry to Thee, for those in peril on the sea!"

REMEMBERING OUR LESSONS….

The Challenger Shuttle Disaster 1986

When I was growing up my friend lived an old fashioned cottage, the entrance to his cottage was particularly low and in my opinion ergonomically poorly designed. Every time, without exception, when leaving his cottage I would bang my head on the oak beam above the door. My pal would always laugh and ask me “will you ever remember the door frame?” – “obviously not” would be my predicable sarcastic retort.

Sometimes we have painful lessons, which enable us to draw the necessary knowledge to move forward and develop, personally or professionally.  Occasionally though we are met with such a painful lesson that the learning is etched into the minds of those present. NASA felt this pain with the Challenger disaster in 1986 and the Oil & Gas industry with Piper Alpha in 1988, painful lessons that could not be forgotten easily – but they were forgotten though? When the Columbia Shuttle broke up 16 minutes before landing in February 2003 the ensuing report was highly critical that NASA did not learn from the Rogers Commission, set up in the aftermath of the Challenger disaster. NASA’s disregard for the safety of its Astronauts brought particular criticism, especially once the Commission discovered that NASA had known about the fatal flaw in the rubber O ring seal for the Solid Rocket Boosters (SRB) since 1977. Many mistakes were made and many promises were undertaken to ensure space exploration was as safe as viably possible.  In the aftermath of Challenger, the Rogers Commission made specific recommendations to NASA surrounding the governance and management of the space program. In 1996 only 10 years after Challenger NASA returned to old practices to save money much to the dismay of the head of Space Shuttle Program at NASA, Brian O’Connor, who argued at the time:

Columbia Crew 2003

“Its is a safety issue, we’ve ran it this way (with the program management at HQ, as recommended by the Rogers Commission) for 10 years without a mishap and I don’t see any reason why we should go back to the way we operated in the pre-Challenger days.”

O’Connor’s concerns fell onto deaf ears and NASA chose to ignore his outspoken opinion, he felt this left him no other choice than to resign from NASA. Although both accidents are unique from a physical perspective, they are eerily close in managerial errors; this did not go unnoticed by the Columbia Accident Commission which was highly critical of the middle management hubris of NASA. In both examples a fatal flaw to both Shuttles, which was known by NASA, became watered down and a culture of acceptance of risk overtook the desired culture of safety first – without compromise.

Challenger Crew 1986

Deep Water Horizon 2010

It seems that this short term memory is not uniquely preserved for NASA, the Oil & Gas industry have a similar example with Piper Alpha in 1988, and the Deep Water Horizon (Macondo blow out) in 2010. Once again although the physical elements of the disaster have their uniqueness, the human factors bear similar resemblances – specifically with regards to the acceptance of risk in the presence of profit, although NASA's problems lay in the opposite end of the spectrum - maintaining the output with less financial resources.  It is this desensitisation of this risk acceptance, which runs through all 4 examples, in all cases the associated issues that contributed to the final event, became acceptable.

Can an organisation fully commit to a safety first culture while management decisions clearly reflect a profit first mind-set?

What signal, be at the conscious level, or unconscious level, is sent by organisations to the work force?  

My honest belief is no to the first question and the wrong one to the second, and so is Lord Cullen’s who led the enquiry into the Piper Alpha disaster.

           

Piper Alpha 1988

The similarities between these 4 catastrophes are striking from a Human Factors perspective. Effective decision making in the aftermath of both Challenger and Piper Alpha were criticised by the respective enquiries, however, it only took 17 years for NASA and 22 years for the Oil & Gas Industry to forget some of the vital lessons learned.

Once again the lessons taken from Columbia and Macondo are raw to those working within these risk related industries. In the immediate aftermath of such events motivation is at it’s most intense to ‘turn the corner and improve safety’. The pain of loss can be viewed as a metaphor for ‘the stick’ in motivation; this represents an organisational ‘away from’ motivational preference. It represents a motivational system which is at it’s most intense after the event - however there is another way to approach safety?

The ‘carrot’ which represents a ‘towards’ motivational preference encompasses an organisation continually moving towards a complete safety culture. Each day, week after week, the organisation works towards a common vision communicated throughout the workforce and embodied by the management.  This avoids the spike in activity, which inevitably follows a significant accident, more over acts as bow wave of activity continually evolving with relentless energy and without pause.

My stick typed lesson when banging my head on my friends door frame eventually became embedded, there was only so many times I seemed prepared to endure the pain associated with my clumsiness. My hope in the future is NASA and other risk related industries do not require persistent 20-year ‘bumps’ on the head.

  

THE TIME FOR DECISION IS NOW, OR IS IT?

Timothy Galloway, in his book ‘The Inner Game of Tennis’, explores the possibility that concentrating too much on a skill has profound negative effects – especially during the coaching phase of skill acquisition.  In short you can concentrate too much creating the conditions of indecision, or paralysis by analysis.

I have often wondered at which point in time is a human decision made? When, and how does a thought transmit into a behaviour, and equally important is a decision without a visible behaviour really a decision.  I once heard a story about the Commanding Officer of the SAS, he would personally interview new young Officers arriving at Hereford, and without exception he would always make the same statement.

“Right decision, well done. Wrong decision, unlucky; learn for next time. No decision, unacceptable!”

I have repeated this story many times when trying to coach someone into becoming decisive and taking action. Indecision is the friend of procrastination, delaying the call for momentum that acts as a precursor for a positive, or even negative, choice.

The question still remains, when does the decision take place, and is deciding to do nothing still a valid decision?

To help answer this interesting suggestion perhaps I could look at the decision making process of a TT motorbike racer, performing thousands of life or death decisions each lap of the infamous Isle of Man TT course. Athletes often describe a Zen like state called ‘flow’, in which everything falls into place without thought. The scientific minded people would ask how do we quantify this ‘flow’ and how do we know when exactly an athlete has it, what is present during flow that is not present without it?  The simplest explanation could be the surrender of the decision making process from the conscious mind to the unconscious mind. If the common hypothesis is true that the conscious brain can process around 7 bits of information (plus or minus 2), at any one time, surely there would be reliance on recruiting other resources needed to deal with incredibly fast processing of the world around at 180 mph. Decisions would need to be made instantaneously, without the benefit of hindsight, and without time for an effective review of the various options available – the right decision, every time, with no second chances.

Ayrton Senna once famously backed of a flying qualification lap; around a blind corner an accident had taken place without his knowledge. Had Senna attacked this flat out corner he would certainly of collided with the wreckage of the car in front, something told him to take is foot of the accelerator in a split second decision?  Somehow Senna had interpreted information outside of his conscious awareness leading him to make this incredible decision – he had effectively listened to his gut feeling! Senna at the time was the biggest star in F1; he was accustomed to all eyes being on him during races and qualification. This corner was different somehow, when the footage was reviewed of Senna’s approach to the corner the thousands of eyes usually looking at Senna were not, they were looking to their right at the crash scene, this piece of information, outside of Senna’s conscious awareness, was enough for him to abort the lap on the strength of a split second feeling inside his gut.

So, if an athletes ‘flow’ is achieved in the surrender of decisions to the unconscious brain could accidents occur when the conscious brain tries to muscle back in on the act? This can be quantified most clearly with footballers taking penalties under extreme pressure. Most missed penalties are a result of indecision that can be observed early in the attempt. Getting ‘caught in two minds’ suddenly becomes an ironic commentators pun. Contrast this 2 minded approach often seen by footballers taking penalties with that of the rugby player Johnny Wilkinson, he makes every aspect of the kick a ritual, almost entering a mild trance in which he can silence all around and hand over the task, in its entirety, to his unconscious mind.

The difference, however, between the decisions of footballers and rugby players should not be compared to TT racers. Richard ‘Milky’ Quayle once said, from his hospital bed after a 150mph crash, that the 37 mile course was incredibly hard mentally and that often he would have to battle to ‘stop his mind wandering’. This wandering of the mind could be the switch backwards and forwards between conscious decision process and unconscious decision process, science would suggest that travelling at 170mph through Kirk Michael village with houses either side added to the almost infinite other pieces of information, represents more than the 7 afforded to our conscious brain?

Science and neuroscience are providing us with some of the most incredibly interesting research on the point in time when a decision is made. Research from the Max Planck Institute for Human Cognitive and Brain Sciences suggests that a decision is actually made up to 7 seconds before we are consciously aware, which in and of itself provides ideas and theories to be explored in future blogs.

One thing is for certain though, through heightened awareness comes a heightened reliance on the unconscious mind. Information processing, situational awareness and decision making all require cognitive skill, perhaps there is no greater example of this than the men who average 130mph around a road circuit sandwiched between houses, hedges and stone walls.

Timothy Galloway discovered that rather than over coaching specific details, if he asked his tennis players to think only of bounce – hit, in time with the game, they had incredible results. The surrender of the skill to the unconscious brain allowed them to achieve the ‘flow’ so sought after by athletes.

When Money And Mountains Meet

On May 10^th, 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.