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.

Born From Hubris - Learning The Lessons of NASA

When the inevitable dust of disaster settles only the sour taste of humility remains with some burning questions, who or what was to blame? Often the urge to proportion blame eclipses the real elephant in the corner, procedures are examined and training is prescribed, however, does this prevent further disasters? Albert Einstein once postulated that to repeat the same action over and over whilst expecting a different result is a sign of insanity. Procedures do not make mistakes; the humans interacting with them do. If this is true is it not then unusual this human error by reviewing, amending and adding new layers of complexity to the procedures?  

Human Factors is the relationship that connects man, machines and the surrounding environment, the balance of livewire and hardware, or more accurately the breakdown of this delicate partnership. There is no such entity more brilliant and contrived than mankind, capable of brilliance one day and complete incompetence the following. We as a race, conquer any challenge accepted - or is this my own hubris talking? 

Human Factors is much debated, discussed and indeed taught in the Aviation Industry. The product of NASA’s space programs, it has been adopted by both the Civil and Military Aviation Authorities (CAA & MAA) before spreading into other industries such as NHS, Financial Sector and Oil & Gas. It has been claimed through much credible research, over 80% of all accidents can be attributed to the human interaction with technology. History it seems gives us lessons, which, through our foggy hubris we seem unwilling to learn?

“Hubris means extreme pride or arrogance. Hubris often indicates a loss of contact with reality and an overestimation of one's own competence, accomplishments or capabilities, especially when the person exhibiting it is in a position of power.”

The most poignant sentence here is the last one, ‘especially when the person exhibiting it is in a position of power.’ There are many examples to examine this hypothesis, SS Titanic and the battlefields of the Somme from the early part of the century, Piper Alpha within the Oil & Gas Industry or maybe the National Coal Board’s (NCB) questionable leadership and management before, and after, the Aberfan landslide of 1966? Perhaps, tragic as they are, all of these disasters would suffice and hubristic leadership and attitudes were certainly present alongside systematic safety violations that had become common practice. It seems appropriate, somehow, to use an example from NASA itself.

If NASA can be described as the father of Human Factors, then Human Factors was born in the womb of hubris!

On the 28 January 1986 Space Shuttle Challenger exploded 74 seconds after launching from Kennedy Space Centre. The disaster resulted in a 32-month hiatus in the shuttle program and the formation of the Rogers Commission, a special commission appointed by the then President Ronald Reagan. The launch was beset with problems from the outset, extreme low temperatures, a punishing launch schedule, media scrutiny, which was intensified by the first ‘teacher in space’ astronaut, Christa McAuiliffe. All of the ingredients of a flawed decision making strategy were present. Ironically one of the contributing factors to the reluctance further delay the launch was that Mrs McAuiliffe was due to teach students across America from space. Had it been delayed another day there would have been no children to teach as the mission would of fallen over the weekend, astonishing with hindsight!

So where does hubris fit into this?

NASA managers had known since 1977 that there was a potential fault with the rubber O-rings which seal the Solid Rocket Boosters (SRB’s), in fact they had launched dozens of times knowing this potentially catastrophic flaw. Added to this it was also known that in colder temperatures performance of these O-rings was further reduced. The coldest recorded launch was 12 C, with a predicted temperature for the Challenger launch at -1C, even at 12C there had been extensive damage on both the primary and secondary O-ring. Should both O-rings fail there was no back up device making this a Criticality 1 Component (it is forbidden by NASA to rely on a backup system of a C1C). These SRB’s were designed and manufactured by a contractor called Morton-Thiokol, who, the night before the launch after much discussion concluded that it was absolutely not possible to launch in the predicted temperatures. However, Thiokol managers under extreme pressure from NASA overturned this decision (Morton-Thiokol were in contract negotiations to renew the SRB contract, worth an estimated $10 Billion), going against the advice from their own vastly experienced engineers. The engineers accurately predicted that extreme low temperatures would result in the SRB fragmenting gas, known as blow-by, resulting in the O-rings being unable to seal the gasses within the SRB’s and certain death for all on board with no hope of escape for the astronauts.

The engineers could not prove this prediction outright without known data, as they had never launched below 12C, thus had no data to support their claims. It was decided, by the Thiokol management (under pressure from NASA) that because previous launches had been a success, albeit with varying damage to the O-ring seal in the aft SRB’s, they should continue with no further delays.

Institutional hubris, with catastrophic consequences.

The Rogers Commission was damming in its findings, citing multiple failings from both the Management of NASA and Morton-Thiokol. President Kennedy gave NASA 30 days to act on the nine recommendations from the Rogers Commission. Unfortunately though only 17 years after Challenger the same managerial failings resulted in the Shuttle Columbia disaster, much to the dismay of those involved in the original Rogers Commission. Somehow the same level of mismanagement and blind arrogance had permutated back through the upper management of NASA. The question still remains, does hubristic attitudes and decisions take place in your work place. Evidence would suggest that usually, when disaster strikes, the person in the position of power, has to some extent, become the victim of their own hubris.

NASA may be the father of Human Factors but stills bears the petulant child of hubris firmly on the bosom of its glory (and disasters).