Saturday, 9 November 2013

Mistakes in Avalanche Rescues

Worth sharing this old extract from the Avalanche Review
The Avalanche Review, Vol. 9, No.6, April 1991Copyright © All Rights Reserved; AAAP

Don't Create a Bigger Accident than Already Exists: 
Mistakes in Avalanche Rescues 

On June 14, 1987, a sheriff's rescue group responded to the call of a mountain climber buried by an avalanche on the slopes of Mount Borah. Even though trained personnel from Idaho Mountain Rescue were on hand at the staging area, the sheriff kept them from entering the field. He indicated that his personnel would go the site first and assess the situation to see what resources were needed.

According to the American Alpine Club's Accidents in North American Mountaineering, the sheriff's team of four, wearing blue jeans and sneakers and carrying one rope and a carton of soft drinks, could not reach the accident site, as the group lacked experience and the necessary equipment. 
With darkness approaching, the sheriff, concerned for his personnel, secured a helicopter to drop sleeping bags and food for his team. On a fly over at 4700 meters, the helicopter crew dropped the supplies. The rescuers at 3450 meters dove for cover. Needless to say, the supplies were well scattered during the 1250-meter fall.
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The rescuers survived the bombardment of supplies and survived the night, only to be chased away the next day by an electric storm. At that point, on June 15, the sheriff suspended the search. On June 19, the sheriff's small team returned, but this time with members of Idaho Mountain Rescue. Finally, after probing, they recovered the body the next day.

Mistakes, Errors, Slipups, Blunders
The first rule of any search-and-rescue operation is "don't create a bigger accident than what already exists." Though few avalanche rescue operations are conducted without any problems, trained and experienced rescuers practicing good decision-making, with a dose of flexibility, keep most rescues on track.

After reviewing the three volumes of The Snowy Torrents, reflecting on my own experiences on over 20 avalanche search-and-rescue operations, and speaking with other rescue types, I have put together a list of repeated mistakes made during avalanche rescues and I offer some solutions to avoid these errors. "Repeated mistakes" is the important term; all the mistakes identified have been repeated by others at different times and in different places. I follow a theme started by Dale Gallagher in the first volume of The Snowy Torrents to "point out the mistakes as lessons for us all, not as a criticism of the individuals involved."
Mistakes made by rescuers can be grouped into four categories: (1) poor organization, (2) mishandling the witness, (3) inadequate hasty search, and (4) mismanaged search. Most of the cases involve organized rescue efforts; I also looked at small group rescues where members of the party involved in the accident made obvious mistakes, usually at the hasty search stage.

Poor Organization
The four points listed below arise from a lack of organization and virtually guarantee chaos to some extent during the rescue:

  • no plan
  • divided or uncertain leadership
  • lack of proper equipment
  • failure to request available rescuers
Organizational problems generally arise from two sources: no plan or an unpracticed plan. Even volunteer search-and-rescue groups and ski patrols must have a written plan, so that all members understand their potential role in any avalanche rescue. Besides spelling out the personnel responsibilities, the rescue plan should cover equipment management and identify additional resources such as other rescue groups, helicopters, lighting systems, food, etc. Controlling the chaos arising from rescues is one of the duties of the rescue leader.

The lack of proper equipment, both rescue and personal, has slowed down many a rescue. A rescue plan will aid in having the rescue equipment where it's needed and when it's needed, but there is no substitute for an experienced watchful eye for making sure that individuals are properly equipped. For rescues in and near developed areas, being well equipped is not nearly as critical as it is for rescuers going into the backcountry. Be alert: trained rescuers are just as apt to forget a piece of equipment or clothing, or to not have the right gear, as volunteers. For example, soft-soled boots, like packs and snowmobile boots, are perfect for probing, but can be dangerous if one must climb a steep icy bed surface.

Using an ink board and Mylar overlays to track search efforts. Peak 7 accident near
Breckenridge C0, February 1987. 
Photo by Dale Atkins

Once again a rescue plan will help in securing additional rescuers. The plan should list other available rescue groups and at least two contact names and telephone numbers. Don't let pride stand in the way of performing the mission, as the sheriff in Idaho did. Ski patrols and rescue teams have suffered from this same affliction at one time or another. Not long ago in Colorado, during one backcountry avalanche search, one ski patrol would not call in a second one, even though the first had only four members available, and the second had 28 members waiting less than 20 minutes away. Call in all available rescuers. Rescuers would much rather be requested and then turned back while en route than not be called at all.

It is not known if an avalanche victim has died on account of a poorly organized rescue operation. But in one case, in 1958, in Utah, a rescuer was buried and killed in a second avalanche after the rescue command fell apart, lost control of the operation, and allowed column teams to scatter on their way to the accident site.

Mishandling the Witness

It is within this category that the greatest number of mistakes have been made. Blame cannot be a fixed to a witness, but rather to the rescuers for how they handle, interact, interview, and interpret the words of the eyewitness. In one extreme case a zealous sheriff, shortly after a large accident, told the press that the two eyewitnesses, who also triggered the slide that buried and killed four skiers, would be arrested and charged. Rumors hinted at felony manslaughter. Fearing the law, the two quickly went into hiding; it took the better part of a day to get the witnesses to come forward to assist in the rescue. No charges were ever filed.

Common mistakes regarding witnesses are the following:

Inaccurate information regarding the:
  • last seen area
  • number of victims
  • location of the accident site failure to return to the same vantage point
  • failure to hold and question witness emotionally unstable witness
  • failure to keep track of the witness at the accident site

Though a witness would never purposely give bad information, experience and the record show that inaccurate information is not uncommon. Poor interviewing skills on the part of the rescuer is a problem, as well as the uncertain witness who did not carefully watch the accident happen.

Because of inaccurate information we no longer use the phrase "last seen point," but now use "last seen area." Buried avalanche victims have been found above or well to the side of the last seen point, out of the anticipated flow line. Several times I have found that witnesses identify the place where they last saw their buddy somewhere between the actual last seen point and the point to which the person was headed.

For example, in 1987 two snowmobilers were headed towards a stand of trees when they triggered the slide. They marked the last seen point immediately next to the trees. In reality the two snowmobilers were caught several hundred feet away from the trees.

One of the first questions asked by a rescuer is "How many people are buried?" What seems like a simple question, requiring one simple answer, is not always so simple. Witnesses have given inaccurate information on the number of buried victims. Inaccurate counts seem to arise when a witness, typically caught in the same slide, thought that other people were close by but did not know the others. The point is that when the witness knows the people nearby, he or she pays closer attention to who they are and where everybody is on the slope. Rescues have ended prematurely, only to have the rescuers called back hours later to search for and then find someone who was reported missing later in the day. If there is any question as to the number of victims, search the entire debris area.

Though rare, in two cases the witness was too emotionally unstable to give information to the rescuers. Usually witnesses are very willing to assist, and often, if rested, make good searchers. In 17 years of mountain rescue work, I have not encountered this discomfiture, but a situation I have experienced is the grieving loved one who arrives at the command base. Both situations-the grieving person and the emotionally unstable witness-require giving comfort and support. If faced with either situation, arrange for a clergy member to come to the command base and meet with the person. Having a man or woman of the cloth present seems to offer greater emotional support than a caring rescuer, sheriff's deputy, or social worker.

The failure to hold and question witnesses has caused grief for several rescue leaders. Though it is sometimes easier said than done, be certain that you hold the witness and make sure to get names, addresses, and telephone numbers of all witnesses. Assign someone to keep track of them, since, with no record, once a witness leaves, so do the answers to your questions. Only a few weeks ago, in Colorado, a slide buried a portion of US 40 on Berthoud Pass. It was suspected that two out-of-bounds lift skiers might have been trapped in the debris. Three separate groups of skiers reported the slide, and all were allowed to slip away with not even one name or phone number recorded. If that happens and you think someone might be buried, search the avalanche first and ask questions later. Do not waste time trying to track down unavailable witnesses.

Getting the witness back to the same vantage point is critical for getting accurate information. A witness trying to identify tracks or place the last seen point from somewhere other than the spot from which he or she saw the accident will make mistakes. It will require extra effort but get the witness back to the original vantage point as soon as possible.

Once you have contacted the witness, keeping track of him or her is very important. During a search next to a ski area a number of years ago, a witness, who was riding a lift, slipped away for more skiing. In this case the missing witness caused only a minor inconvenience to the search operation because the search area was very small. However, during a rescue in 1967, an eyewitness wandered away from the accident site. Hours later the witness, a boy, was found dead from hypothermia less than a mile away.

Inadequate Hasty Search

A hasty search performed by survivors or witnesses of an avalanche is being done while the clock is ticking on buried victims.

Therefore mistakes made may truly have deadly consequences. Four types of mistakes made during the hasty search phase are:

  • not doing one
  • not searching the entire area
  • missing visual clues
  • not being proficient with avalanche rescue beacons not finding the accident site
The first two points are related. In some accidents, members of the party left the site without doing a thorough hasty search and missed visual clues that might have saved a life. In December of 1984, two backcountry skiers were caught in a slide near Aspen, Colorado. The survivor dug herself out, made a fast check of the debris and left the site to notify rescuers. Hours later, a hasty search by the rescue team revealed a ski tip sticking from the snow. The victim, shallowly buried, had died.

Organized rescue teams have also done incomplete hasty searches, or not hasty searched the entire area, before starting the probe lines. Only later as the probe lines marched up the debris did rescuers spot an obvious ski or pole sticking out of the snow.

The initial hasty search of the avalanche just a few weeks ago on Berthoud Pass (mentioned earlier) consisted of a beacon search. Probelines were begun immediately on the roadway so that the road could be opened as quickly as possible. Only later were the likely burial areas, about two dozen different trees, searched. Fortunately no one was found in the slide.

The best documented case of probing too soon happened in Washington in late 1962. Shortly after probe lines were initiated, a ski pole was found in the snow. still attached to the skier. The skier, unconscious when dug out, quickly regained consciousness and made a complete recovery.

Avalanche rescue beacons are lifesavers but require practice, practice, and practice. Chaos struck a group of experienced and well-equipped backcountry skiers in Utah, in 1979, when one member of the group did not switch his beacon back to receive after two other skiers in the group were buried. Confusion of the three signals caused a delay of several minutes. One skier survived, but the other did not. The time lost because of the beacon confusion cannot be directly linked to the skier's death, but it is certain that a less experienced group would have been hopelessly confused and two fatalities would have resulted.

Lady Luck was with a group of four backcountry skiers in Colorado in 1988, when three of the skiers were completely buried in a small slide they triggered. The group was well equipped, and all had beacons and shovels, but only one of the members was trained and practiced in the use of an avalanche rescue beacon. Two others in the group had very limited training, while the fourth had no training whatsoever. It was this fourth member who was not caught in the slide. Relying on instincts, rather than a beacon he did not know how to use, he quickly spotted a hand protruding from the snow and dug out the most experienced member who in turn used his beacon to find the other two buried skiers. They survived, and today all are very proficient with avalanche rescue beacons.

Remember to listen as you search the debris, as dozens of shallowly buried avalanche victims have been recovered alive when rescuers heard yells coming from under the snow. In one case a tired shoveler moved away from the search area to rest. As he sat down on the snow, the still conscious buried victim heard him and yelled. The startled rescuer quickly alerted the others and soon the man was free after a four-hour burial.

If the hasty search fails to turn up clues or enough clues to establish the likely burial areas, go back and redo the hasty search. The more clues, the smaller the search area. Once probe lines begin, the speed of any rescue falls dramatically.

Even with a coherent witness, locating an accident site in stormy weather can be difficult, and nightfall might make it impossible. It was mentioned above in the section on handling witnesses, and it deserves additional comment here: incomplete questioning has misled a number of rescue leaders in determining the exact location of an accident. Some hasty teams have wasted time in trying to get to an accident because of vague or poor directions. More careful questioning might reveal the easiest and safest access for the hasty team.

Mismanaged Search
Typically, once the probe lines begin, few serious mistakes occur while searching the debris. Minor setbacks do arise, such as rescuers dropping personal clothing on the debris and someone else believing the piece to be a clue. But four serious mistakes have arisen from time to time:
  • not probing the entire debris
  • not starting at the toe
  • not digging where dogs alert
  • contaminating the debris for search dogs
The first is not probing the entire debris. Imagine the surprise of one highway department heavy equipment operator clearing a road when he unexpectedly found a buried station wagon. The driver of the buried car had been buried eight hours, and now was saved more by providence than by plan. Rescuers, hours earlier, had probed part of the debris and stopped after deciding no other vehicles were buried.

In several rescues probe lines were not started at the toe of the debris. Perhaps there was some clue that warranted searching higher up, but in several cases the victims were found later, in the toe of the debris.

The nose of a trained avalanche dog is perhaps the most efficient search tool a rescuer has. On several occasions dogs alerted only to be pulled away because the spot was not where the human rescuers expected to find a buried victim. Trust the dog.

The contamination problem arises from sloppy rescuers. Not always is it possible to get a rescue dog to the accident site with the first wave of rescuers, so it is important to keep the debris clean. Sure, a trail of tobacco juice marks where the probe line searched, but the extra scent makes the dog's job even more difficult. Do not allow rescuers to throw food scraps, spit tobacco, or relieve themselves on the debris.

Some Final Thoughts
Many more lives will be saved by education, avalanche control work, and precautionary measures than will be saved by rescuers. Most buried victims will not survive long enough, no matter how well organized, prepared, and equipped the rescuers are. But some buried victims do survive, and all victims should be given the benefit of the doubt that they might be found alive.

Mistakes and problems do arise in avalanche rescues, but we can learn from the misfortunes of past rescues to prevent future mistakes. Organized rescue groups must have a written rescue plan and have the correct equipment already located in strategic locations. Persons who may assume leadership roles must know the plan. Every season the plan must be practiced and updated. Conduct simulated rescues and practice sessions periodically to keep rescuers sharp. An organized, prepared, and well equipped rescue team may make a difference and can save someone's life-maybe your own!

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