Nightmare in the
by Craig Medred, ADN 7/6/97
"A fast slide into disaster". Even as the fast slide toward disaster and death began, Joshua W. Thomas thought everything would be fine. Last in a line of climbers descending from the summit ridge of 4,880 foot Ptarmigan Peak, only 15 miles from the heart of Alaska's largest city, the 20-year-old student in the Josh Thomas Mountaineering 1 class at the University of Alaska Anchorage held fast to a climber's most trusted tool, the ice ax. Twenty or 30 feet below, he had seen 18-year-old Jacob Franck fall on a steep snowfield that drops more than 1,500 feet down Ptarmigan's North Couloir, but Franck was securely roped to 30-year-old Eric Schlemme, and Schlemme was in turn tied to Thomas.
The way it was supposed to work, Schlemme would stop Franck's slide. And Thomas would simply back him up. Only seconds later, Thomas would realize he had just watched the crucial opening scene of what would become the largest climbing disaster in Chugach State Park history. On the last Sunday in June, two people would die. Twelve others who were injured, including Thomas, would become the subjects for the largest rescue effort ever conducted in any Alaska mountains. "I was using my ice ax as an anchor," Thomas said. "I was clipped onto it with a piece of nylon webbing, and also I was holding onto it with my arms. I was sort of my own anchor. Everyone was fastened to their ice axes in the same manner ... with two people anchored, there's no way one person can pull two people out."
With two-and-half feet of steel shaft driven into hard-packed snow, Thomas wrapped his fingers securely around the pick and adz, the only parts of the ax protruding from the mountainside. Below him, Franck continued to rocket downslope in his slick, nylon climbing gear, and Thomas noticed slack in the rope running back to Schlemme. "We had about 20 feet of slack out," he said. "It was about the worst-case scenario ..." Still, Thomas figured everything would be OK. Franck was starting to self-arrest, getting his body over his ax and forcing the pick into the hard snow to slow and then stop the slide. "It took him a minute because he was caught off guard," Thomas said. "He slipped and fell on his side. After he hit, my second man went for a self-arrest (position)."
Now, all three were on the delicate line that sometimes separates life from death in the mountains. A little luck, and they would end up survivors of one of those near misses that teaches a never-to-be-forgotten lesson. Then Franck hit the end of the rope. The line went taut. He was jerked off balance, ending his chance of stopping his slide. At the same time, Schlemme was popped loose from his hold. Suddenly, Thomas grasped how quickly the mountains can turn a tiny slip into a real life nightmare. A pleasant climb was coming all apart, and he was next.
"I just turned and put my face against the slope and leaned against my ice ax," he said. "...They hit very hard. They pulled very hard. I was hoping that I could hold it in against the hit. The ax almost held both their weight. It didn't hold ... because they had quite a bit of momentum. It just peeled a big trench out of the snow." Thomas joined the perilous skid of his two rope mates. He tried to maneuver his ax into a position to self-arrest, but the rope kept jerking him around. Everything was happening fast, and the rope binding him to the others was now his worst enemy. The way it kept pulling him, he couldn't do anything to stop his own slide, let alone help the others.
The trio sped toward 11 more climbers strung out on three different ropes in a narrow neck of the couloir below. The only hope of those climbers was that Thomas, Schlemme and Franck would somehow go on by. Those three were beyond saving. It was only a question of how much worse the accident would become. Looking upslope, 43-year-old Mona Eben watched disaster descend toward her rope team at a terrifying speed. Just above her, 38 year-old Deborah Greene, the class instructor and leader of another rope team, was screaming instructions at Franck, Schlemme and Thomas. "I remember the top team, the bottom person of the top team started slipping, and I just anchored myself into the snow and hung on because I knew he was headed toward me," Eben said. "(Deborah) was between our rope team and the upper rope team, and she saw them sliding, and she was telling them: 'Self arrest! Self-arrest now!' "
They tried, Thomas said, but by this time they were being violently whipsawed. Out of control, the top rope team hit the second rope team, tangled with it, and all became one on a still-accelerating slide down the mountain. "The teams were properly spaced," Thomas said, "but my team had gained a weird, sideways angle. We were kind of going at an angle (across the snowfield). I knew that at the speed we were going there was no way (the next team) could stop us. Somebody saw us coming at the last second. They heard us sliding, and one of the guys looked up and said, 'Here they come.' I remember a couple of students saying that ... and then we hit them. They were pretty much ready, but it wasn't enough to hold three people. Three people were too much force. We had reached almost full velocity. I hit somebody and spun around them and started pulling them with us, and that started the chain reaction that caught the whole group up."
Farther down the couloir, the remaining seven climbers now saw a mob falling toward them. "I lead my ax in the snow," Eben said. "I was secure. I had no idea I was going to be knocked off my ax." She hoped the others would go past or over. Instead, a body slammed into her, tearing her free of the mountain, entangling her and adding rope team number three to the fall. "What can I do against all these people coming down on top of me," Eben said. "It happened so fast, and the force was so strong there was nothing I could do."
Seconds later, the ball of people, ropes flailing ice axes, arms and legs, engulfed the last rope team. What had begun as one small slip now involved 14 people falling headlong toward the jumble of boulders at the base of the snowfield in the North Couloir. The snow sandpapered the skin off their exposed faces as they slid and tumbled. Sun glasses shattered and flew off. People lost control of their ice axes and let them go. Watch bands broke. Cameras and water bottles and mittens came loose, leaving a trail of debris in the snow. "I remember everything," Eben said. "We hit a boulder, and at that point I decided I was dead because I hit it so hard, and I knew there was more to hit. I just basically gave up at that point. It was so fast. It was so fast. I can't remember hearing anything. It was just so terrifying. People were screaming. My instructor was saying, 'Self-arrest! Self-arrest!'"
"Nobody could do anything because we were being hit from right and left by other bodies," Thomas said. He and Schlemme got some leverage once when their feet hit soft snow, but they couldn't hold on. "We slowed it down a little bit," Thomas said, "but at that point two more people came by and pulled us off. From that point on, it was way beyond control. We hit quite a few rock outcrops on the way down. I could see every rock outcropping as it came along. You could see how nasty it was, and there was no way around it." Everyone knew what waited at the bottom of this 1,000-foot, free-falling elevator: a jumble of gray rocks, some the size of filing cabinets, every one jagged and deadly.
'THE MOOD WAS GREAT'
An hour earlier, they had been aglow with confidence as they ate lunch and basked in the sunshine smiling on Ptarmigan's summit ridge. "Oh, it was a wonderful, wonderful trip,' Eben said. The sky was a friendly blue, with just a bit of haze from the smoke of a distant forest fire. To the south, the ragged peaks of the Suicide Twins tore at the sky. Beyond them a jumble of mountains and wilderness marched all the way to Prince William Sound and the Gulf of Alaska. Many in the class had once thought such places behind their reach, but now they had claimed this one as their own.
"The mood was great," Thomas said. "Everybody was feeling excellent, up to their full potential, I would say. We felt better, as a group, than we had in any of the other classes." They had taken a long time climbing up the North Couloir. The class members had left their tent camp, 2,000 feet below, between 7 and 7:30 a.m. They reached the summit well it after midday. But they were flushed with success. "On the way up," Thomas said, "we had decided as a group not to go on to the summit itself." But now half the class members changed their minds and decided to press on to the top. It was absolutely flawless out," Thomas said. "It was pretty hot, I'd say, around 75, 80 degrees.... We were feeling great, joking around, good atmosphere."
"We went (on) to the false Ptarmigan Peak," Eben said. "We didn't go on to the summit peak because part of the group had not come with us. We knew that they were waiting for us." Both groups met back on the summit ridge about 5 p.m. - now almost 10 hours after the climb started. They discussed the steep descent down the North Couloir. From the ridge, it is hard to see much of the Couloir over the edge. The 40-degree slope is nearly as steep as Alyeska Ski Resort's North Face, the jumble of cliffs and falling hillsides beneath the tramway. But this was "the exact same way we came up," Thomas said. "We talked about how much time it was going to take us to get down, and what time we were going to reach the Glen Alps parking lot," he said. "The discussion there was what rope teams we were going to go into, and we decided that we'd stay with the rope teams we came up with. This was a student-run project, basically. (The instructors) said, 'OK guys, where are we going?' They were along for supervision."
With instructor Deborah Greene and field assistant Benjamin, her 34-year-old husband, supervising, Eben said the group decided "to rope together and plunge step down. We were kind of instructed in how we were to do that. I was impatient because I already knew how to plunge step and use my ice ax, but there were some students who didn't. There were some people who were scared."
Still, the sun-softened snow was near perfect for plunge stepping - a technique in which the climber kicks his boot heels hard into the hill to create miniature platforms on which to stand. "We had decided we would take extra care seeing as how this was a steeper than average slope," Thomas said. "Not everyone had descended something like this before, (but) even Mary (Fogarty) felt comfortable." Fogarty, an Alaska Department of Fish and Game anthropologist, was a unique case. Friends said she was taking the mountaineering course to help her overcome a fear of heights. She and 23-year-old Steve M. Brown would be swept to their deaths in the fall that began with one, small, missed plunge step. Asked to consider the Ptarmigan Peak accident, more than a dozen guides, veteran climbers and members of the Alaska Mountain Rescue Group focused first on the route selection and then on the decision to descend the Couloir in four rope-teams stacked one below the other.
Mountain rescue group member Soren Orley and others wonder why the group didn't just drop down the south side of Ptarmigan along a regularly traveled route with no snow and far less risk of a fall. From the bottom there, they could have easily circled back through a pass to the north and dropped down to their camp at the bottom of the North Couloir. But it had already been a long day for the climbers and, according to Thomas, the sun-softened snow promised a fairly quick and easy descent by plunge stepping down. Noting the soft leather boots some of the climbers wore - a poor choice for plunge stepping - members of the Mountain Rescue Group at the accident scene wondered about this decision. "It is kind of the standard mountaineering story that a lot of small things add up to the big accident," Jacobs said. "Most accidents happen on the way down. You've got a lot of tired people. They kind of let their guard down."
The Greenes remain hospitalized and, according to university officials and friends, unable to answer questions about the accident. Deb Ajango, the current director of the Wilderness Studies program, has spoken with the Greenes, but will not answer questions, according Tim Dillon, athletic director at the university. One question is why the students were roped. Roping beginners to nothing but each other on steep slopes is likely to offer a false and dangerous sense of security, said Bob Jacobs, operator of St. Elias Alpine Guides in McCarthy, a board member of the American Mountain Guides Association and a former instructor in the Wilderness Studies program. If beginners need to be roped for safety, he said, they should be belayed - fastened to a rope securely attached to the mountain.
"The whole deal with ropes is you put a rope on because you're going to attach yourself to the mountain so you don't fall," said Dan Hourihan, chairman of the Alaska Mountain Rescue Group and former chief ranger for Chugach State Park. "That gully's steep enough that if one (climber) pops off, you don't have control anymore," said Dave Staelhi, another Mountain Guides board member and a respected Mount McKinley alpinist. Both Staelhi and Jacobs have climbed Ptarmigan's North Couloir several times. The climb, an Anchorage area classic, is usually done unroped, though icy conditions can sometimes make ropes, anchors and belays necessary on the route, said Charlie Sassara, a veteran Anchorage climber.
"Mountaineering: Freedom of the Hills" - the book widely considered the climbers' Bible - warns that mountaineers must always be careful to weigh the benefits and risks of roping up: "As slopes steepen and snow hardens ... it becomes a matter of deciding whether the risks to unroped climbers of being unable to stop their individual falls exceed the risks to the team of roping up. These team risks are not trivial. They include the possibility of one person's fall pulling the entire team off the mountain." Todd Miner, until recently director of UAA's Wilderness Studies program, said it was not uncommon for Mountaineering 1 students to descend the North Couloir roped in teams. They have done so safely for years, he said.
Thomas said only one student on each rope team was supposed to move, while the others planted the shafts of their axes in snow and hung on. "Mountaineering" suggests a version of this sort of running belay called the "boot-axe belay." In the boot-axe belay, the shaft of the ice ax is sunk in the snow, the climbing rope is wrapped around the ax head, and the climber uses his boot to make sure the ax stays in place. The key to the technique is for the belaying climber to tend the line, making sure to keep it taut. "Despite some naysayers," the book says, "(this belay) has proven to be useful, provided its principal limitation is understood: It can't be expected to hold a high fall force."
Once Franck fell and began his accelerating slide down the slope, the slack in the line between him and Schlemme allowed considerable force to develop, yanking Schlemme off his feet and finally pulling Thomas along, too. "Probably what precipitated a lot of this is slack in that rope," Jacobs said. A group of university administrators interviewed Wednesday said they could not answer technical questions about university policy on climbing techniques. Miners said Wilderness Studies had no policy on the use of running belays. "That kind of thing is just so judgmental," he said. "We tried to avoid that cookbook type approach (to policy), and just hire people with good judgment."
Both Deborah Greene, the class instructor, and her assistant had extensive climbing experience not only in Alaska, but elsewhere in North America as well as the Himalayas, Miner said. "She's top-notch," Miner said. "She's climbed all over, won a national award for outdoor education." Friends describe the Greenes as happy, competent, engaging and well liked by students. No agency or organization is specifically charged with investigating fatal climbing accidents in Alaska. Chugach State Park officials said the only report they expect to see will come from the Alaska State Troopers, who toured the accident scene by helicopter.
New UAA Provost Dan Johnson and Renee Carter-Chapman, interim dean of UAA's Community and Technical College, said the Wilderness Studies' risk management team - a group composed almost entirely of people associated with the program - will also review the decisions involved in the climb. School officials said they might bring in outside experts to help determine the cause of the accident. Veteran climbers eluding nearly all of those quoted here - noted that it is easy to second-guess decisions made on the mountain. When to rope up, for instance, is "often an issue of trade-offs, weighing the pros and cons of both choices," notes the book "Mountaineering." "It becomes a delicate decision involving an evaluation of each climber's skills and the variety of alternatives for roped team protection." "My main concern is that no one be blamed for the accident," Thomas said in his first public statement the day after the accident. The Greenes, he said, were good instructors; the accident was a twist of bad luck at could have been far worse.
At the bottom of the couloir, he said, among the broken bones and bloody bodies at the end, "there were people suffocating under others. There were people choking in ropes." Some of them would almost certainly have died, but for three Anchorage skiers who happened to be headed for the North Couloir just as the accident began.
ALASKA WILDERNESS STUDIES PROGRAM -
PTARMIGAN PEAK INCIDENT
June 29, 1997
TO: University of Alaska - Anchorage
Chancellor's Office and AWS Program
RE: Review Team Report - Ptarmigan Peak Incident 6/29/97
The review team, consisting of Daryl Miller, Jim Ratz, and myself, have concluded our investigation of the climbing accident that occurred on June 29,1997 on Ptarmigan Peak.
The charge given us was to determine the causes of the accident and to make recommendations based on our findings. While this was our specific mission, we would also state that the overall mission in conducting such an investigation is to aid in the prevention of fatalities and permanently disabling injuries.
As this review is to be made public, we would ask that anyone who may use it for educational purposes or media reports consider the following: Mistakes and accidents in mountaineering, as in all endeavors, cannot be eliminated. When reviewing the mistakes that will be pointed out in this document, it is essential to consider the intentions of those who made them, and how, in the long run, the systems can be improved so that the future management of the inherent risks will be viewed as acceptable.
The description, analyses, recommendations, and suggestions found in this review are the result of the following primary sources:
1. The collective experience of the three reviewers, including extensive phone conversations among ourselves in conjunction with the review
2. Site visits to the North Couloir of Ptarmigan Peak by Daryl Miller (in July of 1997), Jim Ratz (in November of 1997), and Jed Williamson (several times in years past).
3. Documents provided by the U. of Alaska, Anchorage, as follows:
Ptarmigan Peak Accident Report - September 19,1997
Report of the Alaska Wilderness Studies (AWS) Review Panel - October 16,1997
Report on Ptarmigan Peak Climb - submitted by Northern Adjusters on October 17,1997
Report of the Rescue - Chief Ranger Jerry Lewanski, Chugach State Park, August 1, 1997 (including transcripts of interviews with nine of the participants
Syllabus for AWS 105 - Beginning Mountaineering (Summer 1997 and Fall 1997)
AWS Policies & Procedures Manual & Employee Handbook (February 1997 edition)
C.V.'s of Deborah and Ben Greene
4. Interviews with the following:
Deborah Ajango - Coordinator of AWS (all three reviewers)
Deborah Greene (all three reviewers) and Ben Greene (Miller & Ratz)
The surviving participants with the exception of Andrew Murphy and Juanita Palmer
Secondary sources of information have included the following:
I. Review of the following documents:
AWS Mountaineering Faculty Meeting - September 18,1997
AWS Risk Management Committee Meeting - September 22, 1997
U. of A. Anchorage Assumption of Risk and Release; and Acknowledgment of Risk forms
AWS Incident Reports 1983-1997
Report by Ken Zafren, M.D. dated September 22,1997
Article on the incident in Air Guardian, October 1997
Various newspaper reports from the Anchorage Daily News
Mountaineering, Freedom of the Hills, fifth edition, published by The Mountaineers
Accreditation Standards for Adventure Programs, compiled by Jed Williamson and Michael Gass, published by Assoc. for Exp. Ed.
2. Discussions with various others, including former and current AWS instructors, local guides, etc.
II Review of the Incident
1. Orientation to AWS 105 - "Beginning Mountaineering." This course is intended for students who have already demonstrated competency as backpackers and wish to expand their base of knowledge to include climbing and travel in mountain country. The curriculum is largely based on selected readings in "Mountaineering: Freedom of the Hills," classroom discussion, direct observation, and participation in various climbing techniques and actual climbs during weekend outings. The Ptarmigan Peak climb was listed for the June 28-29 outing.
Keeping in mind that details for the route and plans for Ptarmigan Peak were not listed, the review team saw nothing in the syllabus or other course materials per se that seemed inappropriate in relation to the experience levels of the students. In general, we believe they were provided with adequate descriptive materials.
2. The Participants: Eight students were interviewed by the review team. The student enrollment seemed well matched to the course description and goals. Screening of participants was appropriate in terms of providing them with descriptive information - including the prerequisite of backpacking skills, asking for pertinent medical information, and providing adequate warning in terms of potential hazards and dangers. Up until the time of the accident, students confirmed that the instructors and students were working well together and pleased with the course. Some students and some friends of one of the deceased (Mary Ellen Fogarty) indicated that she was fearful on the day of the climb, especially on the descent. One participant indicated that her primary motivation to continue with the course was that she needed to obtain the twelve credits. And as will be noted again, another participant - Jacob Franck - was reported to have had difficulty performing the self arrest.
The reviewers' experience tells us that the class as a whole was a fairly typical cross section one could expect to find in such an offering.
3. The Instructors: The instructors, Deborah and Ben Greene, have long history of mountaineering and teaching. Deb Greene was the lead instructor. She had worked as an assistant instructor on the previous summer's AWS 105 which also climbed and descended the North Couloir. Deb Greene had not climbed or descended any other route on Ptarmigan Peak prior to the accident.
Both of the Greenes are dedicated teachers who expressed strong feelings regarding their student's' education and safety.
4. The Supervisor: Deborah Ajango, as the Coordinator of all AWS programs, is responsible for monitoring courses in terms of such matters as policies and procedures, course descriptions, and instructor selection and supervision. Given the number of field programs offered, she must rely upon instructor judgment in the field. Given the backgrounds of the Greenes, the reviewers believe that it was reasonable for the supervisor to assume they would make appropriate judgments in the field.
5. Clothing and Equipment. An appropriate list of clothing and equipment was provided for participants. Comments regarding individual items will be referred to below.
6. Classroom Instruction and Practical Experience. Prior to the Ptarmigan Peak outing, appropriate topics were covered in the classroom. The practical sessions prior to the attempt of Ptarmigan Peak focused first on techniques associated with rock climbing. The principles of belaying, rappelling, and anchoring apply in general to snow and ice venues. The third class included the use of the ice ax, including self arrest techniques, and the first day of the fifth class included more snow and mountaineering (travel on mixed -snow, rock - terrain with ropes) techniques, including a review of the self arrest.
The reviewers believe that the instruction up to this point was properly sequenced and adequate.
B. The Climb
1. The Mountain and the Route: Ptarmigan Peak ( 4,880') peak has a number of recognized climbing routes of varying difficulties, including the North Couloir and Southwest Face. The 1,200-foot, "S"-shaped North Couloir averages 30-45 degrees in steepness and typically has snow for at least the upper 1,000' throughout the summer. Parts of the couloir are narrow with a width of approximately 50'- 60'. Various rock outcrops and a boulder field at the base of the couloir with sharp and loose scree present hazards that can inflict serious bodily injury if a climber fails to self-arrest on the snow.
The North Couloir is a long, moderate to steep snow gully that is often climbed by local mountaineers. The popularity of the route is probably due to its easy proximity to Anchorage, the fact that it holds snow throughout the summer, and its access to a walk-off route. The lack of a safe run-out is the principal potential hazard during the summer months. While rockfall is always a potential hazard within a couloir, local climbers do not consider it to be a significant problem on this route. Most climbers the reviewers spoke with elect to descend Ptarmigan Peak via a walk-off route rather than the couloir.
AWS climbing history includes one previous ascent/descent of the North Couloir by a 105 Beginning Mountaineering class in the summer of 1996. Prior to 1996, climbs of the North Couloir by AWS were ascents only with AWS 205 Intermediate Mountaineering, and those classes descended via the walk-off route.
2. The Ascent: On the morning of the climb the instructors divided the group into four roped teams and distributed snow protection - flukes and pickets - to each group. They then began to ascend sometime between 7 and 8:00 AM, each roped team using a separate route but spaced close enough to allow for easy communication between groups. Students were lead climbing each roped team, setting and pulling protection as they made their way up the couloir.
The instructors gave students the option of staying in camp if they did not want to participate on the climb. The instructors also stated that they would probably be using the couloir as their descent route. Their rationale was that it would offer the best means of practicing descent skills. Students were aware there were alternative, non-technical routes off the mountain.
Weather conditions throughout the day were clear and warm. At various times during the day different parts of the couloir were in the sun, warming and softening the snow as the day progressed.
All participants reported the ascent went efficiently albeit slowly. The groups topped out of the couloir at some time between 2 and 3:00 PM. Some members of the group hiked to the peak's false summit while others rested. The roped teams reformed, made some adjustments with a few members changing groups and began to descend sometime between 4 and 5:00 PM.
C. The Descent
(Note: There are conflicting opinions among the participants about the events immediately prior to and during the fall which make it difficult to be precise on minor details such as time, distances and positions of rope teams within the couloir. Nevertheless, in regards to more substantive details, all participants reported very similar observations allowing the reviewers to build a probable mechanism that caused the accident to occur.)
On the descent there were again four roped teams with two teams of four and two teams of three. The teams of three had all student members and were placed second and fourth during the descent.
The reviewers noted a lack of consensus regarding the influence of time pressures on the decision to descend via the couloir. It seems that it was generally understood in the morning that the group would try to be down and back at the parking lot by 5:00 PM, but the relative importance of that goal was interpreted differently by different members of the group. Some considered time to be a major influence on decision making and others, including the instructors, thought it had little to no influence.
Before the class began the descent, there was some informal discussion involving some of the group members regarding the relative merits of descending the couloir versus the walk-off route on the other side. It was decided the walk-off route would be longer and might confront the group with unforeseen challenges as compared to the more familiar couloir.
The first team to descend included instructor Ben Greene, with students Jerilyn Pomeroy Peterson, Kirsten Staveland and Jay Chamberlin. They were always beneath the other three teams on the mountain. The second roped team to descend included students Juanita Palmer, Andrew Murphy and Steven Brown. The third roped team to descend consisted of Instructor Deb Greene, with students Mona Eben, Mary Ellen Fogarty, and Bernadino Lagasca. The top roped team and the last to start the descent had three students, Jacob Franck, Eric Schlemme and Joshua Thomas.
The members of each rope team were separated from one another by approximately 15-20 feet of rope. All climbers had an ice tool or ax in hand. The four teams had various distances between them and all teams were in sight of each other. The estimated distances between the rope teams varied from 15 to 30 feet at times with up to 150 feet or more of distance from the bottom team to the top team. At the time of the accident, the teams had descended an estimated 300 feet to 500 feet down the couloir. Several students and instructors were carrying pickets and flukes but were not placing them for protection. Each rope team was aligned at an angle to the slope with most students using the plunge step as they were descending.
The number of people on each roped team moving simultaneously was directly correlated to the steepness of the couloir and the abilities of each roped team. The instructors modified the descent technique as the couloir steepened and narrowed. Soon after starting the descent, the instructors noticed that some students were having trouble plunge stepping and were falling and either failing to self-arrest or arresting with some difficulty. At the couloir's steepest point, just before the accident, one person on each rope team descended while the other members faced into the slope, bent over their buried ice ax, with their hands gripped around the top of the ice ax. The shaft of the ice ax was plunged into the snow at an appropriate angle to the slope and buried to top of the shaft. The ice axes averaged 65 to 70 cm in length, although two students reportedly had ice tools that were 50 cm or shorter. The ice axes were attached with leashes to either wrists or harnesses. (Either option was permitted by the instructors.) Unlike the conditions experienced on the ascent, the snow conditions on the descent were described as soft, with each person's boot plunging six to ten inches or more into the snow on the descent. As one climber moved down, the other rope team members faced into the slope in their "anchoring" stance. When the climber in motion reached the end of their rope, he or she faced in, plunged the ice ax into the snow and anchored for the next person to move.
The roped teams descended oriented at an angle to the slope with different distances between each of the teams. There was some bunching of the top teams in the narrow portion of the couloir. Almost from the beginning of the descent until the actual accident occurred, there were several incidents of students slipping and arresting their own fall or someone else on their roped team stopping them.
The immediate mechanism that caused the accident was initiated when Jacob Franck, who was moving down along side teammate Schlemme, slipped and was unable to self-arrest. When Franck's rope went tight, Schlemme was pulled backwards, landing on his back with his ice ax in his hands. Franck and Schlemme attempted to self-arrest but were falling out of control and pulled Thomas backwards so that he also landed on his back with his ice ax in his hands. The secondary mechanism that caused the accident was that the protection/anchoring system failed.
There was an estimated 30 feet of distance between the top team and the next team with instructor Deb Greene. The top team of three climbers fell out of control hitting the next roped team member Mona Eben, who was standing closest to the center of the couloir. She was knocked onto her back with ice ax in hand. At that point Franck, Schlemme, Thomas, and Eben were falling out of control pulling Fogarty, Lagasca and Deb Greene out of their stances and onto their backs. The seven climbers attempted to self-arrest but failing to do so fell into the next team of Murphy, Brown and Palmer. This third team was not moving at the time and were all faced into the slope over their ice axes. When the group of seven entangled climbers struck Murphy, Brown, and Palmer they too were pulled off their stances. The entire group of ten continued out of control down the couloir heading for the bottom team.
The bottom team of Ben Greene, Staveland, Pomeroy, and Chamberlin were able to see and hear the falling teams and, with no time to move, braced themselves for the impact. All four members of the bottom team were pulled off their stances and dragged down the couloir with the other ten climbers in an entanglement of ropes, ice axes and people.
III. Analysis For purposes of looking at various components that caused or contributed to the accident, we will refer to the bolded items found in the matrix below.
POTENTIAL CAUSES OF ACCIDENTS IN OUTDOOR PURSUITS
(From a Matrix designed and Revised by Dan Meyer and Jed Williamson - 1979-97)
Conditions: Actions: Judgments:
* Falling Rocks/Objects
* Area Security
* Physical/Psych Profile
* Swift/Cold Water
* Unsafe Speed
* Desire to Please Others
* Following a schedule
* Disregarding Instincts
1. Falling Rocks/Objects. Students and instructors were wearing helmets. The primary purpose of a climbing helmet is to protect against falling rocks or objects. Climbers would not expect a helmet to provide protection in the event of a long fall such as occurred.
2. Area Security. The snow conditions during late afternoon became softer and less consolidated as the sun heated up the upper portion of the couloir. This caused the ice ax anchors to become less reliable as they pulled out of the snow easier and became questionable as a means of protection. Additionally, the softer snow made self-arresting more difficult as the pick of the ice ax found less purchase.
3. Equipment/Clothing. (See comment on helmets above.) Jacob Franck's boots were inappropriate for the activity the group was engaged in at time of the accident. The thin and flexible soles on Franck's boots possessed inadequate tread and purchase for the type of climbing found in Ptarmigan Peak's North Couloir. While other students slipped and fell during the descent, it was observed by his roped team members that Franck was falling much more frequently than others and lacked the ability to self-arrest.
Some individuals have commented on the fact that crampons were not used. These reviewers would not recommend the use of crampons for the conditions described. One reason is that snow would merely ball up in the crampons, and another is that beginners/novices are as likely to spike themselves - and others - until they have had sufficient practice on low angle snow slopes.
4. Physical/Psychological Profile. In general, the students appear to have been in relatively good physical condition. It is noted that Jacob Franck had an identified knee problem and was on an anti-inflamitory medication. As we understand it, he had been cleared to participate by a physician. We noted elsewhere that Mary Ellen Fogarty appeared fearful and concerned about the climb and descent. Deb Greene's management of this was to place Ms. Fogarty next to her on the rope, and to have her descend using a technique with less exposure.
1. Technique. Deb and Ben Greene's decision to use an untested descending technique with no back-up system contributed to the cause of this accident. At first glance it appears that having two or three climbers "anchoring" the rope team while one member descends is a secure method. Had the slope been less steep and snow conditions more favorable (that is firmer), their improvised system might have been sufficient to hold a fall.
It would have had an even greater chance for success if this system had been enhanced by having each climber anchor him/herself with their climbing rope to their ice ax using a small diameter rope on an overhand knot in the climbing rope close to the harness. In this manner, when climbers were in the anchoring stance, the force of a fall would be transmitted to the ax/anchor instead of to the climber's harness.
The mechanism of failure was probably due to the following: When Jacob Franck fell, the next climber on the roped team, Eric Schlemme, was pulled by the rope from behind and below. Schlemme had his toes kicked into the snow, with his upper body pressing downward on the ice ax while gripping the top of the ice ax with both hands. It appears the toes of his boots served as a fulcrum as the downward force of Jacob Franck pulling at Schlemme's waist caused Schlemme to be jerked backward and away from the slope while he instinctively held on to the ax, pulling it from the soft snow. The third member of the roped team, Joshua Thomas described a nearly identical mechanism of failure when Schlemme and Franck pulled him off his stance. When the topmost team slid into the next roped team, it initiated the same sequence of failure that continued until all the teams were in an uncontrolled fall down the couloir. It is significant that nearly everyone interviewed said that they found themselves on their backs with their ax in their hands immediately after they were pulled or knocked from their stance.
In hindsight, the instructors should have elected to use more traditional methods, such as setting their pickets and flukes as fixed protection, or lowering the students from a multi-anchored belay. The safest alternative would have been to descend via the walk-off route.
2. Protection. Roped teams on steep snow with no fixed protection contributed to the magnitude of the accident. Roped travel without fixed protection is usually done on the relatively flat surface of a glacier as a precaution for crevasse falls or on uneven terrain where at least one climber can obtain a secure position. On rare occasions a guide may rope to a client without fixed protection when the guide is confident of holding a fall.
It has been observed that climbing teams roped together on steep terrain often have a false perception of security. A high percentage of mountaineering accidents that involve climbing falls share three common factors: (1) descending, (2) roped together and (3) no fixed protection. A rope without fixed anchors invariably becomes the primary mechanism of multiple injuries during a fall.
The descent system lacked redundant safety. (See, for example, previous comment on the ice ax/loop technique.) All mountaineers recognize the need for redundant safety systems while climbing, and in particular while teaching others to climb. Deb and Ben Greene mistakenly thought that the combination of the students being roped together, their newly learned ability to plunge step and self-arrest, and the "anchoring" technique described earlier represented a redundant system. In fact, with no fixed protection, each roped team was dependent upon every person to perform flawlessly. Thus any uncontrolled fall could have resulted in an uncontrolled descent of the entire roped team. Considering the minimal experience the students had, they should not have been relied upon as a critical component of a "safety system."
3. Instruction. Students reported that all instructions that were provided were clear and understood. They carried out the instructions, but were unable to perform the self arrest and belay under the conditions encountered.
The next appropriate step in the instructional sequence would have been for the instructors to confine their activities to the lower third of the North Couloir.
4. Position. With only 15 feet between each student the reaction times for self-arrest are very limited, making it harder to stop a fall before weighting the next climber in line on the rope team.
Short roping students is often used in steep snow conditions. However, the more traditional technique involves short roping only the students, leaving a long section of rope between the students and instructor. The instructor then sets a belay and lowers the group of students.
The rope teams were inadvertently stacked above each other creating a "net" like effect and contributed to the magnitude of the accident. The North Couloir's narrow, funnel-like contour made it difficult for the tightly grouped rope teams to stay out of each other's "fall-line" and inevitable that a fall by the uppermost rope team would capture the rope teams positioned lower on the slope.
In situations where rope teams must descend a snow slope, it is imperative each rope team stay clear of the other's fall line. Maneuvering through a narrow chute presents special problems that usually involve groups descending one at a time and clearing the fall line before the next group descends.
The lack of a safe run-out contributed to the severity and magnitude of the accident.
5. Supervision. When determining an appropriate ratio of students to instructors, several factors are taken into consideration. These include the terrain, the skills of the participants, and the overall profile of the participants. The relatively large student to instructor ratio of 6:1 seems inappropriately matched to the difficulty of the climb and experience level of the students and may have contributed to the accident. With only two instructors for four rope teams on a steep, narrow couloir, it seems almost inevitable that rope teams would climb close together for the sake of communications. Additionally, a large group of students in difficult terrain presents an instructor with a significant amount of information to process in a very short period of time. Keeping track of six students in two separate groups, some of whom are falling, scared, or practicing improper technique, would be extremely difficult under the best of circumstances.
The previous summer's AWS 105 class had a slightly smaller enrollment than the 1997 class, but included was a volunteer instructor with a long history of assisting mountaineering classes. While they too climbed and descended the North Couloir, it is noteworthy that each roped team had an instructor.
It is also important to note that it is inappropriate to allow beginning students to lead and / or to be on a roped team independent of instructors under conditions where the safety of the students would be compromised should a fall occur.
While the instructors possessed a long history of mountaineering plus experience instructing for Colorado Outward Bound, their teaching experience in the mountains over the last five to ten years was not as extensive as earlier in their careers, and that may have contributed to their failure to recognize the serious nature of descending the North Couloir or the consideration of alternative safety systems or descent routes.
6. Unsafe Speed. The potential for unsafe speed in the event of an uncontrolled slide in the couloir has been covered.
1. Misperception. The instructors believed that the improvised system they had decided upon due to the condition of the couloir and the skill level of the students would work. This was based on their understanding of anchoring and belaying principles. This proved to be a misperception for the given conditions, terrain, and technique.
2. Desire to Please Others. We know this is always a potential factor in any trip. Engaging in activities beyond our ability and agreeing with decisions are affected by how we may think others will perceive us. While not a direct cause in this case, it may have been a contributing one.
3. Following a Schedule. As stated before, we are still not clear as to whether there were agreements as to what time the group would return to the parking lot, and therefore whether this affected the route chosen.
4. Fatigue. It had been a long day, and, as has been mentioned, although it was sunny and warm, some people may have been fatigued to the point where their physical abilities were diminished.
As an introduction to the recommendations section, the review team would like to indicate that it agrees with the AWS Review Panel that it is appropriate for the University to offer a wilderness studies program. But we believe that a number of the existing practices, policies, and procedures within the program should be reviewed thoroughly before offering mountaineering courses to the public again. The team applauds the steps that have been begun in this direction by way of the recommendations that came out of the AWS Mountaineering Faculty and Risk Management Committee meetings. The following, then, are our recommendations.
1. The AWS mountaineering courses should be suspended temporarily while appropriate changes are made to improve the delivery of their program.
2. The concept of Challenge by Choice used by AWS should be a philosophy that applies only when used in mountaineering with high-perceived risk and low actual danger. Comment: In new settings, students generally do not have the experience base and therefore the ability to judge whether the choice they are making is appropriate.
3. The upper sections of the North Couloir route on Ptarmigan Peak should not be used for beginning mountaineering students. Comment: While there are techniques that can be employed to protect a descending party on this route, it is the opinion of these reviewers that the North Couloir is suited for intermediate to advanced mountaineering students. While the choice of an appropriate route for a particular group of students is highly subjective, the length and steepness of the North Couloir coupled with the lack of a safe run- out makes this route very challenging to manage safely with a group of novices.
4. All mountaineering classes on routes with poor or unsafe runouts like the North Couloir should require fixed anchors, not just self-arrest or self-belay when students are involved. Comment: A secure anchor system with either a fixed line or running protection consisting of picket or flukes should be the minimum safety standard when teaching students. This prefixed anchor system should be in addition to requiring students to have the solid and the proven ability to assert self-arrest skills.
5. Before leading trips, instructors involved in a mountaineering class should preview all terrain to be used, analyze the objective hazards and current conditions, and become familiar with other potential routes to be used - such as the walk-off route on the back side of Ptarmigan Peak - prior to the class. Comment: Knowledge of the terrain is essential to make intelligent and judicious judgment calls regarding student safety and present conditions. The reviewers believe that the walk-off route would have been the best descent option given the conditions and participants.
6. For beginning classes, climbs requiring ropes should have a minimum of one instructor leading each roped team. Additionally, the instructors should have an alternative route or climb prearranged on less committing terrain if it is not possible to meet this safety protocol.
7. Turnaround times that are understood and agreed upon should be followed unless there is a compelling reason to do otherwise. Comment: Even in clear weather and with participants in apparent good spirits there can be factors such as fatigue and low energy affecting performance. Long hours of sunlight in Alaska in summer can also give a false sense of security.
8. All personal student climbing gear or anything related to safety should be inspected before a climb and meet predetermined minimum standards appropriate for the class. Comment: For example, an ice tool and a short ice ax were allowed to be taken in place of the recommended ice axes.
9. The AWS Program should reevaluate how it recruits, trains, and assigns its instructional staff.
10. The University of Alaska, Anchorage and the AWS Program should prepare a Crisis Communications Plan that could be adapted for any contingency.
We sincerely hope that our review will help achieve the mission it set out to accomplish, and that the education and healing process will continue. No one can undo the events and results of June 29. No one intended for events to unfold the way they did. It is now a matter of how to move forward in the most positive ways possible.
We thank everyone with whom we have come in contact as we gathered information and put this report together. We must conclude by stating that if any new information comes to light, we may wish to amend our analysis and recommendations.