Climbing Accident Reports: How (and Why) to Read Them
Reading the AAC’s “Accidents” Could Save Your Life
by Tom Kirby
AAI Instructor and Guide
What is it about climbing accidents that so fascinates us? Magazines regularly run covers touting “Climbing Epics”, and the best-selling books about climbing and mountaineering – think of Into Thin Air, Touching the Void, and Annapurna, among others – always involve fatal or near-fatal incidents and injuries – frostbite, exposure, avalanches, rock-climbing falls. Is our fascination with mountaineering accidents just so much gloating? Is it that adventure stories sound contrived unless something truly awful takes the adventurer by surprise? Or is there something about accident accounts that helps to season us, that makes us better able to cope with future challenges?
The American Alpine Club's "Accidents" is the definitive guide to the dark side of climbing in
I ponder these questions each summer as I await the delivery of Accidents in North American Mountaineering, the single most tangible benefit I see in most years from my American Alpine Club membership. It arrives as a supplement to the 400 plus-page American Alpine Journal; but it’s a fair bet that, page for page, Accidents has been by far the more popular publication. Barely over 100 pages long, it represents a careful cataloging of all the noteworthy and/or documented mountaineering, ice climbing, and rock-climbing accidents in North America for the preceding year, organized by state/province and tagged with keywords like “slip on snow” and “exceeding abilities”. (It's now also available as a searchable online climbing accident database.) Published since 1943, it is the closest thing to a definitive record of the dark side of mountain climbing on our continent.
When I first saw Accidents in a library years ago, I wondered why any climber would read it, let alone buy it. Now, I wonder why any climber wouldn’t.
Why Should We Read Accident Reports?
The study of decision-making has received a lot of attention in recent years. Traditionally, decision-making was seen as a highly intellectual activity, in which explicit knowledge and logical reasoning ability played the dominant roles. But beginning in the 1970’s, the work of psychologists like Gary Klein and Nobel laureate Daniel Kahneman, among others, demolished this traditional view. The new research has thrown light on the ways in which emotion and non-rational modes of thought play integral roles in most decision-making, for better – or for worse.
In the field of outdoor education, Ian McCammon’s study of the role of cognitive biases in avalanche accidents has had an enormous impact on teaching across the industry. His article, "Evidence of Heuristic Traps in Recreational Avalanche Accidents", set in motion changes in the way avalanche safety is taught in the United States and set a new standard for thinking about safety in all outdoor sports.
"The Power of Mental Simulation"
“Stories drawn from accident reports strengthen our ability to detect ominous patterns in the physical and human environments – patterns like weather deterioration, team discord, or progressive fatigue – that intensify inherent risks.”
A growing body of evidence suggests that, especially in many time-sensitive or crisis situations, good decision-making begins not with systematic adherence to rules or procedures, but with the ability to quickly imagine how decisions might play out. In his book Sources of Power, Gary Klein calls this skill “mental simulation.” He argues that expertise develops from a combination of deep, hands-on experience and informed reflection on that experience. In what he calls Recognition Primed Decision-making (RPD), an expert relies on the ability to quickly recognize situations in which past experience can offer solutions to current problems.
Reading accident reports enriches our mental database of experiences. Though not a substitute for real-life experience in the outdoors, the mental simulations we produce when we are working to understand an accident report can multiply the value of real-life experience.
Stories drawn from accident reports strengthen our ability to detect ominous patterns in the physical and human environments – patterns like weather deterioration, team discord, or creeping fatigue – that intensify inherent risks. The ability to recognize those signs quickly when you're in the mountains, and to "flag" them with negative emotions that motivate you to take appropriate action, could one day save your life.
How to Read an Accident Report
It’s tempting to read accident reports with a combination of pity and scorn, and to dismiss many cases under the heading “What were they thinking?” Reports of injury or death in the mountains are always hard to accept, and we muster unconscious psychological defenses to distance ourselves from the threat to our belief that the mountains and the sports we love are reasonably safe.
What were they thinking? It’s the right question to ask, but it needs to be asked with an open mind, free of judgment. The mental pathways by which people come to bad decisions are often far from obvious. Until the chain of events is understood, passing judgment complicates the analysis. The hard truth is that most accidents happen to people who are not vastly different from us. Indeed, most of the accidents we hear about could, with very slight changes in luck and circumstances, happen to any of us.
The goal of reading an accident report, then, is to get to the point where we can say honestly:
“I can imagine how this accident might have happened to me.”
There will always be cases that defy this approach – call them "epic fails" – but in most cases it will be possible, with a little effort, to see yourself in the victim’s shoes. To get to this point, you need to use a combination of careful analysis and imagination.
Accident Report Analysis: An Exercise
Begin by browsing through Accidents in North American Mountaineering. Read a handful of reports. But don’t stop there. You’ll get the most out of it by selecting an accident to analyze in depth. As you browse, you’ll find that many of the accidents reported will be relatively thin on details. These accidents may not repay careful study.
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The most interesting case studies will be those that hinge on errors of judgment, rather than on things like equipment failure or unlikely chance events (although chance will often play a contributing role in more complex accidents).
Once you have found an accident that seems interesting and is well-documented enough to analyze, sit down and re-read the account, considering the following questions.
Knowns and Unknowns
1) Summarize the Known Information
After reading the accident report through, begin your analysis by noting (or even writing down) the information that is known with reasonable certainty. As you write, resist the temptation to put a spin on events. Keep to the facts.
2) Summarize the Unknowns
Of the many unknowns in this accident, which seem to be the most significant? Is there enough information to enable you to meaningfully analyze the accident, or do you have to content yourself with superficial observations?
Chance Events versus Human Error
3) What role might pure chance have played in the accident?
Identify actual or speculative causal factors over which the climbers could have had no direct control. (For example, unpredictable weather or natural rock-fall.)
4) What role might gross errors or mistakes have played in the accident?
Here, we’re looking at things that would have been within the direct control and responsibility of the climbers, like movement errors (for example, tripping over the rope); improperly placed protection; or sloppy navigation.
Direct Causes versus Contributing Causes
5) What causes may have contributed indirectly to the accident?
In the realm of simple causes and effects, we can learn a lot by breaking down the chain of events into direct causes and contributing causes. While direct causes are simple and intuitive – a trip over crampon points, a falling rock – contributing causes come in various forms and interact in different ways with each other. Some things to consider:
Contributing causes can be things like fatigue, low blood sugar, or poor visibility, that make errors more likely. When these are the results of human error, we can further specify them as secondary errors. Failure to provide adequate redundancy in a safety system is a classic secondary error that can contribute to tragic outcomes.
Intensifying factors worsen the effects of accidental events after the fact, like wet weather that can put victims of an accident at further risk of hypothermia.
Mitigating factors lessen the impacts of an accident, as when a professional rescue crew is available on short notice, or when weather is mild.
Many bad accidents, when reconstructed, exhibit a pattern of successive errors that seem to build on each other and multiply over time, in a chain of what are termed cascading effects. In hindsight, it is sometimes possible to trace a major accident back to poor decisions made hours or even days earlier.
Errors of Judgment
6) What role might misjudgment have played in the accident?
Is it possible to reconstruct stages in the party’s decision-making process?
Here we would include cases where a climber took a “calculated risk” or “rolled the dice” – for example, deciding not to rope up for fourth- or fifth-class terrain, or choosing to climb across a loaded avalanche path. Be as specific as possible about what risks were underestimated or misrepresented.
Though it is not usually possible to see inside a climber's decision-making process, sometimes clues emerge of precise ways in which judgment failed. Comments made by the climbers or by others who witnessed the run-up to the accident can hold rich clues about what went wrong. If this kind of information is available, sometimes it is possible to break errors in judgment down further, as follows:
Misjudgment of Risk: For example, think of a climber who is caught just below the summit by a late-afternoon thunderstorm. Unaware that the danger of lightning normally persists for some time after the rain has stopped, he waits for the rain to let up, then quickly resumes his climb. Such a case could illustrate a misjudgment of risk: a prudent climber would wait for some additional interval to be sure the risk of lightning strike had passed.
Misjudgment of Value: Contrast the climber mentioned above with a climber in the same situation who does understand that the risk persists, but who consciously decides to "roll the dice" and begin climbing again immediately. While she understands the risk clearly, she could still be unconsciously exaggerating the value of reaching the summit quickly – or of reaching the summit at all.
This latter kind of judgment error is especially interesting, because it opens up questions of what we might call the unity of the self.
Do we really, as a general matter, want a risky way of life? Or do we show inconsistency, desiring high risk one day a week but wanting security the other six days? (Call it the Weekend Warrior syndrome.) Should my desire to reach the summit today be on equal footing with my desire to watch the football game with my friends and family tomorrow? – succeed in a work assignment next month? – or put my children through college ten years from now?
Many climbers, when on the mountain, give voice to gallows humor, suggesting that they are fatalistic and determined to achieve their climbing goals at any cost. This mind-set, even when intended as a joke, can distort decision-making in dramatic ways.
Bring the Story to Life
7) Tell the Story as if You Were in It
For the final part of the exercise, give your imagination free rein. Sketch out a scenario that describes an accident like this one from start to finish in such a way that you can imagine yourself playing a part in it. Like a storyteller, “suspend disbelief” and allow yourself to speculate about character, social relationships, and other wholly unknown factors.
Accident reports constitute a rich trove of case studies that climbers can use to amplify the value of their real-life climbing experience. Accidents in North American Mountaineering is available to buy from the American Alpine Club and a variety of retailers, and is delivered each year to members of the club along with the American Alpine Journal. By reading and thinking deliberately about accidents, we can strengthen our powers of mental modeling, improve decision-making, and possibly save lives – even our own.
If you'd like to learn more about mountain decision-making and other leadership skills, click the link to learn about our 6- and 12-day mountaineering leadership programs.