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.
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.
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)