Parks Canada Should Investigate the Avalanche at Sunshine Village

Sometimes there are deep-seated instabilities in the snowpack that lie dormant, while all appears normal, waiting for just the right trigger to unleash disaster.  Likewise sometimes there are deep-seated and well-hidden flaws in safety management systems that have very much the same effect.  It will take an independent and objective investigation to see if that is what played any part in last Monday’s almost-killer avalanche at Sunshine Village.

In December 2010 Sunshine Village embarked on a labour relations strategy that was associated, to some extent, with an almost 100% turnover of the Snow Safety department responsible for avalanche forecasting and avalanche control.  It is this department that is responsible for the management of the avalanche hazard in the Delirium Dive area as well as the other big avalanche paths that affect the in-bounds advanced terrain at Sunshine Village.

At the commencement of the 2011/12 season only one avalanche technician remained on the Snow Safety team from the start of the previous season.  This was the result of a massive and wholly unprecedented turnover that included firings and resignations.

Normally employee turnover in the Snow Safety department is minimal with only one or two changes per season, if that.  This minimal turnover rate allows for gradual and progressive training and mentoring of new Snow Safety team members to develop the specialized skills, knowledge and judgement that are essential for the safe management of areas such as Delirium Dive.  It also allows for effective supervisory oversight and review of all information and an effective and essential well-informed, team-based, decision making process.

To compound matters, during the 2010/11 and subsequent season there was also considerable turnover within the Ski Patrol department which works very closely with the Snow Safety team.  Again this turnover was closely related to the labour relations strategy that affected the Snow Safety department.  Typically Snow Safety team members are chosen from  experienced senior ski patrol staff and both departments rely heavily upon each other.  At the commencement of the 2011/12 ski season the Ski Patrol department also experienced an unprecedented high turnover of staff and a large influx of very new and inexperienced ski patrollers.

The combined effect of this turnover was a massive loss of skills, knowledge and experience on both the Snow Safety and Ski Patrol teams.

Avalanche forecasting is as much art and judgement as it is science.  It relies on teamwork and a constant flow of information and observation and even “gut-feelings” from experienced personnel who are highly familiar with the area and the terrain and who know its history.  Employee certification is just the very start of this process.  Certification does not make anyone an expert, in fact there are very few lone “experts” in avalanche forecasting.  Team input, evaluation and critique is essential to sound decision making.

On March 31, 2014 two guests were caught and injured in a very large avalanche in Delirium Dive.   According to various news stories one guest was completely buried and both were seriously injured.

Milky Way (centre) - scene of the March 31, 2014 in-bounds avalanche at Sunshine Village that caught and injured two guests

Milky Way (centre) – scene of the March 31, 2014 in-bounds avalanche at Sunshine Village that caught and injured two guests. This was not the first time Milky Way slid while the Dive was open.

Sunshine Village says that everything possible was done to make sure the area was safe. Sunshine Village also says that it is investigating the incident.

The question that arises is will Sunshine Village honestly and objectively investigate to what extent the massive Snow Safety and Ski Patrol staff turnover may have weakened the training, mentoring and staff development of the departments responsible for managing the big avalanche terrain like Delirium Dive.

The next question that arises is, if that turnover did create weaknesses in the team, did that weakness play any part in the factors leading up to the serious avalanche incident on March 31, 2014.  If it did, would Sunshine Village admit it?

Aircraft accident investigators know that almost any incident is caused by a chain of factors and not one single factor.  Often those factors include human error, training issues and failures in the safety management system. This even occurs with highly professional and well-trained pilots and maintenance technicians.  That fact is not just applicable to aircraft incidents.

Air crash investigators leave no stone unturned to discover all the factors that lead to an incident.  That is the process that leads to true learning and true safety.

Will Sunshine Village conduct such an investigation?  More to the point – should Sunshine Village conduct such an investigation?  Sunshine Village has yet to complete any sort of investigation and make the results public but the company is already making public relations statements that appear biased and which raise more questions.

The CBC reports the following comments from Sunshine Village’s  spokesperson:

Over the past week, the resort used explosives and helicopter bombing to stabilize the snow and skiers criss-crossed the area to check the stability, said spokesman Crosbie Cotton.“In fact, on the morning of the incident, two trained avalanche experts were in Milky Way checking it, cutting it, criss-crossing it and they deemed it safe.”

Can the public trust this company statement as an objective and informed investigative conclusion or is it just more PR and marketing?  Is Sunshine Village’s spokesperson saying that this huge in-bounds avalanche slope was not checked and/or evaluated since that morning?  Hopefully that was not the case.

An avalanche area deemed as safe in the morning may not be safe in the afternoon.  This is especially true in spring conditions when mid-day solar heating often plays a significant role in snowpack stability. An avalanche path like Milky Way needs more than just a morning check.  It needs regular evaluation during the day by knowledgeable staff who can feed pertinent information to the decision process. Sunshine’s statement, at least as reported by the CBC, leaves this in doubt and it needs to be clarified.

It’s not the first time that Milky Way has avalanched while Delirium Dive was open to the public.  Was this fact known and taken into account by all the ski patrol and snow safety staff on March 31, 2014?  History and experience matters and it takes time to pass that on and time to learn it too.  A ski area can’t turnover snow safety and ski patrol staff the way it does ticket sellers and lift operators – not when it routinely opens big avalanche terrain like Delirium Dive.

This is no small thing.  People nearly died.  A near miss doesn’t get any closer than this.  It is Parks Canada that is ultimately responsible for public safety within Banff National Park.  Parks Canada should independently and diligently investigate the incident and publish its findings in a formal and reviewable report to the public.  This is not a matter than can be left to a private corporation with a vested interest in the outcome.

How long does it take to replace the combined effectiveness of decades of experience, skill, knowledge and cross-departmental teamwork? Quite possibly an objective investigation will find that the massive loss of experienced Snow Safety technicians. ski patrollers and senior mountain operations staff during and shortly after the 2010/11 season played no part in the incident that occurred on March 31, 2014.   But the point is, we won’t know unless someone takes an honest and objective look at that particular factor as part of an independent and thorough investigation.

This was not just a public safety incident but also a workplace safety incident.  It may not have directly affected any workers but it affected their workplace and their work tasks and process.  Accordingly Alberta OH&S should also take a close look at this incident.

Media Update:  Avalanche survivor owes rescuers ‘the world’ (Calgary Herald – April 4, 2014)

Public Safety and the 2010 Opening Day Incident

A cautionary tale about how two simple errors and an unforeseen chain of events can have significant safety consequences and what the lesson implies for public safety in Banff National Park.

One of the regulatory requirements for operators of aerial ski lifts is that each lift must have a back-up drive in ready, operating condition.  The prime mover, or engine that normally drives the lift can fail.  If it fails it immediately strands the passengers on the lift who are suspended in the freezing air.  Even at reasonably moderate winter temperatures, the threat of hypothermia is real under such a circumstance.  So the regulatory standards require that each lift have an auxiliary motor capable of promptly moving a fully-loaded lift until all passengers have safely unloaded.

As a last resort, in the event that the lift cannot be moved at all, a rope rescue is required. Rescue personnel lower the passengers to the ground.  In the case of Sunshine Village it is not just a lift safety regulation that adequately trained and competent rescuers be available, it is also a requirement of the company’s lease agreement with Parks Canada.

On Opening Day 2010, Sunshine Village was proudly opening its new Strawberry quad chair for the first time.  Everything was ready, or so it seemed. Eager guests rushed to ride the new high-speed lift.  Only an hour after the season started and the lift opened, a new power transformer with an incorrect connection exploded in the parking lot and power supply  failed at every lift and building on the mountain.  All the lifts stopped dead including the fully loaded Strawberry Express and the 5km long gondola.

Very quickly it became clear that the power supply would not be restored promptly.  The gondola and other lifts began to run on auxillary.  The Strawberry Express did not.  Neither did  the Standish chairlift which, although it was not yet open to the public, did have Sunshine  trail crew  and ski patrol employees on the lift.

As the minutes ticked by lift staff discovered that the fuel tanks for the auxiliary motors had not been filled prior to opening to the public.  Suddenly a relatively simple problem had just become much more complicated.  Most transportation equipment emergencies are the result of multiple causes combining to exceed safety and response capabilities.  Now, only an hour into the new season, Sunshine Village staff were faced with a fully loaded lift and no way to move it.   Employees scrambled to transport the necessary fuel to the lifts, fill the tanks and start the auxiliary motors.  All that took time.  Meanwhile, Sunshine Village’s paying guest hung on the chairs in the freezing air, and so did the employees on Standish.

In accordance with the written emergency response procedures, ski patrol evacuation teams  were positioned at designated locations on the Strawberry lift line to prepare for a last resort rope evacuation.  Eventually however the shiny new addition to Sunshine’s fleet of “super-lifts” began running and an hour after the initial failure all the public were clear of the lift.  Shortly afterwards some very cold employees were finally clear of the Standish lift.

The point of this article is not to point fingers at any individual or department.  Mistakes happen.  In fact, mistakes should be expected and anticipated.  No-one is perfect.  “Human error” is the root cause of most disasters despite even the best efforts of highly trained and competent safety personnel.   The point is that a series of simple oversights and an unforeseen chain of events can lead to a life-safety emergency.  On a ski hill this kind of thing can arise in a hundred different ways  and despite the best efforts of trained and experienced employees, sometimes these things do happen.  In fact they happen more often that the public realizes.  Only occasionally does the incident even make the news, as it did with the Whistller gondola incident in 2008.

When emergency incidents happen in the mountains, minutes make a difference.  The critical factor is the availability of a sufficiently trained and experienced team of responders.  Earlier this year, the Calgary Herald reported on an exchange of communications between Sunshine Village and Parks Canada in which Parks Canada formally complained to Sunshine Village that the company had failed to meet the safety response requirements of its lease when it operated with a greatly reduced ski patrol presence on January 19, 2011.  On that day a large number of ski patrollers did not report for work for reasons related to the firing of yet another ski patroller and concerns about safety.

Sunshine responded to Parks Canada and very quickly the whole matter was swept under the carpet.  Apparently all was well in paradise.  But was it really?  What concerns did Parks Canada raise?  What claims did Sunshine Village make in response? To what extent did Sunshine Village push the safety capability envelope that day?  And to what extent did Parks Canada ensure that the claims made by Sunshine Village were in fact valid and sufficient to meet the lease obligation, not just on paper but in real-world public safety response capability?

If the 2010 Opening Day lift incident had happened on January 19, 2011 instead, would Sunshine Village have been capable of responding adequately to protect the safety of its customers and employees?

Sunshine Village Watch has obtained copies of all  the communications between then Parks Superintendent Kevin Van Tighem and then Sunshine VP of Operations and acting Mountain Manager, Ken Derpak.

Parks Canada has a prime obligation to protect the life and safety of each park visitor.  In this respect, Parks Canada has a fundamental regulatory obligation to ensure commercial operators meet the safety and response provisions of their lease obligations not simply on the basis of semantics but on the basis of real life response capability.

This is an issue regarding the provision of public safety services by commercial operators in Canada’s national parks.  It is also an issue about the diligence of Parks Canada in ensuring that the lease obligations of those operators are being met and that the lease provisions are sufficient to ensure that people are in fact as safe as possible when they visit a commercial operation in the park.  In the end, the buck stops with Parks Canada and the federal government.  Are they doing their job?

It is improbable that the power transformer connection and auxiliary fuel tank oversights will combine and re-occur.  The real question is what will be the next chain of events that lead to a public safety incident and is Parks Canada and Sunshine Village fully prepared for it?

 

Exodus of Experienced Employees From Sunshine Village

The Facts
On December 29, 2010 Sunshine Village fired the Mountain Manager, Avalanche Forecaster, Lift Operations Supervisor and a senior ski patroller.

In the 4 months since that date, Sunshine Village has seen an unprecedented mid-season loss (through more firings or staff quitting) of many long-term senior operations and maintenance staff with direct safety-related responsibilities and duties. This list does not imply any individual motives for departure. It simply records the total attrition, regardless of reason or motive.

The total loss since December 29, 2010 to date includes the following:

  • Mountain Manager
  • Avalanche Forecaster & Snow Safety Supervisor
  • Lift Operations Supervisor
  • Senior Ski Patroller
  • Dispatch Supervisor
  • Dispatch Supervisor (replacement)
  • Snowmaking Supervisor
  • Terrain Park Supervisor
  • Snow Safety (avalanche control) specialist (1)
  • Snow Safety (avalanche control) specialist (2)
  • Snow Safety (avalanche control) specialist (3)
  • Full-time Ski Patroller
  • Part-time Ski Patroller / Paramedic
  • Security and Risk Management Supervisor (notice given for May 4th, 2011)
  • Assistant Lift Maintenance Supervisor

Sunshine Village Corporation Public Relations Position

In the midst of this on-going exodus of experience, an unamed Sunshine Village spokesperson stated on the Sunshine Village Blog that “Sunshine Village is operating in a fully safe manner, and is closely supervised by appropriate authorities. Contrary to what you may have read, we have safety staff on duty with decades of experience.” (11 February, 2011)

On the same blog Sunshine Village VP Operations and GM, Ken Derpak stated that “Today, we have a more cohesive, cooperative and customer-focused resort as a result of the difficult decisions we made in December”   (March 03, 2011)

“This is all about running a safe, efficient and effective ski resort.” said Al Matheson, the new Mountain Operations Manager (March 03, 2011).

We would like to believe Mr. Derpak and Mr. Matheson but it’s a difficult safety management strategy to understand, as it seems to involve a rapid and considerable loss of long-term experienced key-players and leaders for whatever reason.

Public and workplace safety are key considerations of public concern for any company operating within Banff National Park. Sunshine Village is no exception to that concern.  Sunshine Village Watch extends an open invitation to any representative of Sunshine Village to provide an explanation of the safety strategy at Sunshine Village and how the loss of so many senior staff impacts that strategy. Comments may be made directly to this post or use the contact form and we will post the comments here.