21 May Spread vital lessons far and wide
For the past few years I have taken a ski mountaineering trip to the Alps with two good friends. We well recognise this is a hazardous activity with most of the obvious dangers coming in the form of avalanches, falls over crags, crevasses in glaciers and the weather (cold, poor visibility and high winds being the most obvious). In fact all the above are inter-related in some way, each potentially adding to one or more of the others to increase the risk.
I would describe us as experienced, well-practised in the appropriate skills and we have the right equipment and know how to use it. We’re acutely aware of the hazards we face and constantly reassess the level of risk as it rises and falls over time and as the terrain changes. We’ve maintained a very good safety record, which can be attributed to good preparation, well considered objectives and sensible execution of our plans with a flexibility to alter our itinerary according to changes in circumstances.
This winter, I didn’t go on the usual trip but my two regular partners plus a substitute went to Switzerland with favourable conditions promising a good expedition. So you may understand my alarm at later hearing that this well-prepared, competent team had been involved in a very serious incident whilst retreating across a high glacier due to impending deterioration of the weather.
An epic story
The short version is that one of the team fell through a snow bridge into a previously unseen crevasse. He actually fell 25 metres into the depths of the icy chasm, becoming completely wedged and rendered unable to move at all. The other two reacted swiftly and set up the necessary rescue systems and one of them descended into the narrow fissure in the glacier so that he could attach a rope and affect a rescue. But to no avail as the fallen person was so solidly wedged. Ultimately after a freezing six hour ordeal, with the aid of a land-based rescue team (initially the helicopter could not land) the victim was retrieved and evacuated to hospital.
A few weeks later, as soon as I heard that an incident had occurred I insisted that we get together so that I could hear the full story. This wasn’t a morbid interest or a desire to revel in the whole adventure but a chance to learn vital lessons that are available in the aftermath of an incident. In fact we used the opportunity of them recounting the whole saga as a form of debriefing or informal incident investigation. After I had heard the whole story my next question was: “so what are the learning points?” These were many and varied. They included route selection; equipment choice; team dynamics; communication channels; and personal behaviours.
The cause of the incident? As is so often the case this was a complex set of factors including all the above mentioned learning points. Could it have been prevented? Most definitely it could’ve been, and not just by avoiding the activity. Different assessments of the situation on the day along with different judgements at the time would have resulted in alternative choices of route and equipment use. Would I or these friends undertake a similar activity in future? Absolutely we would, only now with an additional set of lessons learnt that will add another layer of protection to the undertaking.
My greatest concern is that I’ve had the benefit of all these important, possibly life-saving lessons only because it was friends of mine that were involved. Whilst we occasionally hear of other mountain incidents, we rarely get a good enough insight into what actually happened and what the subsequent learning points are to prevent recurrence in the future. Sadly this is often the case in the workplace. Lessons learnt are far too often restricted to local teams, departments or sites and others miss out. Any opportunity or mechanism we can find to share these lessons with a wider audience should be maximised to benefit as many people as possible.
What is your experience of sharing lessons? What have you done to break down possible barriers to wider communication? Let’s share that learning as well.