Mary Fogarty
Steve Brown
Nightmare in the
Chugach
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.
REVIEW
ALASKA
WILDERNESS STUDIES PROGRAM -
PTARMIGAN PEAK INCIDENT
June 29, 1997
December 9,1997
TO: University of
Alaska - Anchorage
Chancellor's Office and AWS Program
RE: Review Team
Report - Ptarmigan Peak Incident 6/29/97
Background
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.
I.
Introduction
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
A. Preparations
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
* Equipment/Clothing
* Physical/Psych
Profile
* Weather
* Swift/Cold Water
* Animals/Plants
*
Technique
* Protection
* Instruction
* Position
* Supervision
* Unsafe Speed
* Food/Drink
* Distraction
* Misperception
*
Desire to Please Others
* Following a schedule
* Fatigue
*
Disregarding Instincts
* Miscommunication
Conditions:
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.
Actions:
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.
Judgments:
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.
IV. Recommendations
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.
Conclusion
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.
Respectfully submitted
Jed Williamson
Jim Ratz
Daryl
Miller