Labyrinth- the Art of Decision-Making
Page 10
The Adventure Consultants’ customers had been given cast-iron instructions by Rob Hall. Regardless of how the assault on the summit was going, there was a 2:00 pm time limit. No matter what happened, at 2:00 pm, they had to turn around and head back to Camp IV so that they had a good chance of returning safely and their oxygen wouldn’t run out. Those in Scott Fischer’s team had no such rule, because their leader worked on the principle that during an eighteen-hour assault, everyone should make their own decision about turning back.
Late in the evening of May 9, the weather began to improve, and the two leaders decided to set off. At 11:30 pm, the two teams left their tents and made their way onto the South Col, where the ridge leading to the summit begins. Soon after, four of the Adventure Consultants team took ill, and Hall decided they should return to Camp IV. The remainder continued their offensive. At about 5:30 am, the climbers got an unpleasant surprise: an extended section of the route had not had ropes fixed, even though both leaders had earlier been absolutely sure that the entire route had been prepared. The necessity of attaching the lines seriously delayed the push, and in the following hours, the two teams spread out, with the stronger climbers making brisk progress and the weaker ones lagging behind. Around noon, the first of the group arrived at the Hillary Step, a roughly 39-foot-high, vertical rock face, the toughest technical obstacle along the route and a spot where lineups had a habit of forming. 6 At almost precisely 1:00 pm, the first three climbers—Krakauer, Harris, and Boukreev—reached the summit. Less than an hour later, they were joined by Neal Beidleman, Martin Adams, and Klev Schoening. They were the only ones who managed to reach the summit before the 2:00 pm deadline imposed by Rob Hall.
Meanwhile, in the area below the summit, a dramatic scene was playing out. Rob Hall, who was personally assisting his good friend Doug Hansen, suddenly realized the time and ordered Hansen to return to Camp IV. Hansen, who had been on the Adventure Consultants expedition the year before and had been sent back a mere 300 feet from the summit, refused. He wanted to carry on at all costs, even if that increased the risk of running out of oxygen and putting himself in danger. Hall was ultimately swayed and continued the ascent, his friend following some way behind. Hall reached the top at about 2:30 pm as part of a group of six, and waited for Hansen, who ultimately achieved his dream of conquering Everest—at 4:15 pm. Half an hour earlier, an extremely exhausted Scott Fischer had reached the top and then almost immediately begun his descent, supported by Lopsang. The others also set off down the mountain.
First to reach the relative safety of Camp IV, at 5:00 pm, was Anatoli Boukreev, one of the guides. Boukreev—in accordance with his years-long principle—had earlier refused Fischer’s request to take supplemental oxygen with him on the climb. He argued that he had to descend quickly, recover in his tent, and then set off back up the mountain to take oxygen bottles to the group to help them on their way down. Many experts later criticized the decision, saying Boukreev should have stayed with the group the whole time and absolutely should have had oxygen with him to give immediate help to any of the tired climbers whose bottles were empty. 7
At about 5:00 pm, the weather suddenly took a turn for the worse. The upper parts of the massif were enveloped in cloud, visibility fell to only a few feet, and worst of all, a brutal wind whipped up, meaning the temperature with wind chill plummeted to a mind-numbing –100°F in the following hours. In such appalling conditions, both the paying customers and their guides got totally lost. By 8:00 pm, only Jon Krakauer and Martin Adams had made it back to camp. A large group of the climbers in their party, accompanied by two of the guides, Neal Beidleman and Mike Groom, were stuck a little way above the camp—and oblivious to how close to shelter they were. Realizing how hopeless the situation was, the four strongest people in the group (including both guides) set off to find a way down, finally making it back to the tents just before midnight. Anatoli Boukreev set off into the area above the camp three times in total. His bravery saved three people from the Mountain Madness team, Sandy Hill Pittman, Tim Madsen, and Charlotte Fox. Suffering from hypothermia, they reached the tents at 4:30 am.
Neither of the two leaders made it back, as they were stuck in different places on the upper reaches of the mountain. Rob Hall twice made contact with the climbers in Camp IV, the first time informing them about the deaths of Andy Harris and Doug Hansen, and asking for oxygen. The Sherpas tried, but the dreadful conditions meant they couldn’t reach the New Zealander. Despite this, Rob Hall survived the entire day, and at 6:20 pm, the second time he made contact, he asked for a satellite connection to his wife. That was his last conversation.
The following days revealed the true scale of the disaster. Five people from the two teams died on the mountain, including both leaders, and one of the Sherpas contracted HACE (high-altitude cerebral edema) and died a few days later in hospital.
A discussion about the causes of the tragedy ensued in the media, which led to several books being written by those involved, either directly or indirectly, in the tragedy. Despite the differences in opinion and different points of view presented in the books, there was agreement on two things: first, the tragedy was a result of numerous poor decisions and not an unforeseeable incident (like, say, an avalanche). Second, many of these errors occurred during the early stages of the operation, and their accumulated negative consequences manifested in those last, desperate stages of the assault on the summit.
If we apply the logic of an RCA to this, together with the 5 Whys method, it’s quite easy to identify the most serious groups of errors. For the sake of clarity, I shall present them in chronological order, although an RCA is most often carried out in reverse order, starting from the final mistake, which led to the failure, and then going back, looking for the cause of that event, then the cause of that cause, and so on. In a chronological approach, there is another question alongside “why?”: “and what were the consequences?”
The first group of causes were related to the approach to organizing the expedition. Both leaders went about organizing their expeditions in a startlingly routine manner, making light of the risks associated with it. The project they were intending to carry out was extremely difficult: it meant taking amateurs, who had never experienced comparative conditions or altitudes, into a highly dangerous and unpredictable world. The situation demanded a thorough, robust inquiry approach, risk reduction and buffers for unexpected situations, preparation of several alternative scenarios, and the testing of processes against potential black swans. However, the leaders did the exact opposite. They sold their expeditions in a way that made light of the risks. The famous claims of Hall and Fischer in conversation with clients and the slogans from their brochures left no doubts: “100% success!” 8 “We’ve built a yellow brick road to the summit,” 9 “We’ve got the big Everest figured out, we’ve got it totally wired,” “Experience is overrated” 10... My impression is that the tragedy was set in motion the instant the leaders began to believe their own publicity. Unconsciously, they began to regard climbing Mount Everest with an unfamiliar bunch of amateurs as a pretty straightforward thing. They viewed it as a simple, routine project in a predictable environment.
Here is where the next “why?” should appear. How is it possible that experienced Himalayan climbers like Hall and Fischer could make such a fundamental error? They were perfectly acquainted with the risks involved in expeditions on the highest peaks on the planet. In my opinion, two things lay at the root of their misjudgment: first, Hall’s earlier expeditions were (mostly) spectacular successes, creating a dangerous turkey effect, gradually making the approach to organizing and running the expeditions routine. Krakauer recalled a moment in which he expressed his uncertainties and concerns, and Hall made light of them, saying, “It’s worked 39 times so far, pal.” 11 Second, the prospect of celebrating yet another success, especially in light of the PR machine in the form of Krakauer and Pittman, had become a priority, putting the two decision-makers und
er additional pressure. The entire world would be informed in real time of their victory (or failure), which clearly affected the decisions they made.
The heart of the problem lay in shifting the level of acceptable risk to a point that turned out to be deadly. In the name of increased profits, the leaders accepted numerous risks that simply would not have been considered acceptable if the venture had been properly assessed. They applied a purely commercial, routine approach to a quest being conducted in the realm of the black swan.
Organization and logistics also played a role. The commercial approach meant that profit margins were the key motivator. This means maximizing income and cutting costs, which in this case meant the protagonists agreeing to increased risk. The end result was whole series of mistakes, which only emerged too late to circumvent.
Both expeditions had to deal with a range of problems relating to supplies and logistics. Negotiations with Poisk, the company that was supplying the oxygen, dragged on. The Sherpas went on strike for higher wages. Finally, the truck bringing in the equipment was delayed at the Nepalese border. Each of these events was caused by the decision to take a commercial approach: the oxygen, vital for the safety of the amateur climbers, was treated as an expensive resource that needed to be economized on, like the Sherpas’ wages. Even more curious was the transport situation. It turned out that Scott Fischer had tried to cut back on expenses by having the expedition equipment transported in a truck traveling the same route with other goods, rather than paying for a truck of his own. The truck got stopped at customs because of its main load, not the climbing equipment, but of course, it couldn’t continue its journey.
Even worse, Fischer sorted these problems out personally, disrupting his acclimatization procedure, which later had lethal consequences. Why did he deal with it himself? In another cost-saving measure, he didn’t have a logistics team or expedition manager to carry out those types of preparations before the team set off up the mountain.
Many people on the mountain at that time also commented on the insufficient equipment carried by the leaders and guides. The radiotelephones were old, heavy, and highly unreliable, and there were far too few of them. In extreme situations, and in an inquiry mode, the flow of information between those involved in making decisions is vital; in the case of both 1996 Everest expeditions, there was no chance of this, because the vast majority of the decision-makers didn’t have access to the necessary equipment. Why? Because of cost cutting and underestimating the risks. (Why do we need expensive equipment on an expedition that is easy, straightforward, and safe?)
In addition, the media coverage of the expeditions also had consequences. Although the required radiotelephones weren’t taken, there was a place found for the heavy electronic equipment needed to help Sandy Hill Pittman get her live reports to NBC. That equipment was carried by Lopsang, who also literally supported the socialite during the summit, short-roped to her.
That short-roping also triggered a series of events that nobody anticipated. The leaders assumed that in the unlikely event of their having to fix ropes on a section of the route, Lopsang and Ang Dorje would be the ones to do it. When it turned out, to everyone’s surprise, that a very long section of the route hadn’t been secured, there was an ensuing period of confusion—Lopsang, who should have set about fixing the ropes, was still a long way away, helping a rapidly tiring Pittman. The guides therefore set about the task, losing precious time and energy.
And that brings us to another cause: the participants. The routine, commercialized approach to organizing the expeditions was also applied to the process of selecting who could participate in the expeditions. The two most significant qualifying criteria were to have both $65,000 (although some of the climbers got special discounts) and enough free time. There were no intensive fitness tests, and the clients’ medical history wasn’t checked. Why? Well, Hall already had numerous commercial successes under his belt, and it was only Everest, after all, so why bother with all that extra effort and expense? The case of Beck Weathers, a member of Rob Hall’s expedition who was fifty at the time of the climb, proved the flawed logic of this line of thinking.
Weathers, a wealthy pathologist from Texas, was trying to achieve his dream by conquering Everest. He had been working toward it for years. His application to join the Adventure Consultants trip was accepted unconditionally and he thus became part of Hall’s team. During the climb, the pathologist felt excellent, he was very fit and operating on the lower sections of the mountain didn’t cause him any difficulties. At Camp IV, just before the final push for the summit, he was still in good shape. He set off with the group and kept pace. At a certain point, though, his eyesight suddenly deteriorated; he could see less and less, and then, a little way above the South Col, he went totally blind. He couldn’t go on. Weathers admitted to the stunned leader, who immediately went to his aid, that he’d had an eye operation called a radial keratotomy eighteen months or so prior to the expedition. A combination of the enormous physical demands of the climb and the shortage of oxygen had rendered him temporarily blind. As Jon Krakauer recalls, this led to a highly illuminating exchange between Hall and Weathers. When the angered guide asked why Weathers (a doctor, after all!) hadn’t told him about the surgery beforehand, Weathers replied, “Well, you never asked.” Such unexpected consequences arise when we don’t use an inquiry mode, leaving us vulnerable to the prospect of lacking vital information at key moments in an undertaking.
Beck Weathers himself suffered severe consequences from this. Hall decided that the pathologist, whose lack of vision meant he couldn’t move by this point, should remain on the ascent route and wait for his eyesight to improve. The leader promised to take Weathers back to the camp on the descent from the summit. Placing enormous trust in Hall (the authority trap!), the client waited. Many hours later, his eyesight began to return. The first people heading down the mountain from the summit passed him, but Weathers declined to descend with them, because he had it fixed in his head that he should wait for his leader. A leader who—it later turned out—never made it back.
Beck Weathers survived, and his story has since become one of the most startling to have played out on Everest. The doctor spent the night high above Camp IV, waiting for Hall and slowly losing grip on reality due to advancing hypothermia. He survived the night and was discovered on the morning of May 11 by Stuart Hutchinson. However, he was in a hypothermic coma at the time—he was covered in a layer of snow 4 inches thick, his coat was open, and he had lost one of his gloves, so his hand was totally frozen. He was still breathing, but he didn’t react to anything, and Hutchinson made the assessment that Weathers, like Yasuko Namba, who had been found nearby, had no chance of surviving, so he went back to the camp to relay the news about the death of both the Adventure Consultants climbers he had found. Over a dozen hours later, Beck Weathers came to and managed to stand. How he managed to descend to Camp IV, nobody knows. We do know, though, that Todd Burleson, an American climber on another expedition, came face-to-face with an apparition upon stepping out of his tent. In an interview given later, he says this:
I couldn’t believe what I saw. This man had no face. It was completely black, solid black, like he had a crust over him. His jacket was unzipped down to his waist, full of snow. His right arm was bare and frozen over his head. We could not lower it. His skin looked like marble. White stone. There was no blood in it. 12
The doctor’s condition was so serious that everyone expected him to die that night. The next morning, Weathers surprised everyone by leaving his tent and asking others to help him put on his crampons, ready to descend via the South Face of Lhotse. He was accompanied on this dangerous journey by Todd Burleson and Pete Athans, both excellent American climbers. On the way, they met the IMAX team, who, having heard about the drama engulfing the Hall and Fischer teams, had halted their own attempt and come to help. David Breashears, Ed Viesturs, and the Austrian Robert Schauer helped take the utterly exhauste
d Weathers all the way to Camp I.
Here, though, the rescuers faced an insurmountable obstacle. There was less than no chance of Weathers crossing the Khumbu Icefall under his own steam, and the technical difficulties of the area made it impossible to carry him as they had higher up. And they couldn’t organize a helicopter to rescue him, because the upper edge of the icefall was way above the maximum altitude for landing one.
Colonel Madan Khatri Chhetri of the Royal Nepal Air Force, though, took an enormous risk. Flying a severely stripped-out Eurocopter AH350 Squirrel, he managed to reach approximately 19,600 feet, a record altitude for helicopter flight at the time, and on only his second attempt, he managed to keep the machine stable long enough to get Weathers onboard. The colonel’s skill enabled Beck Weathers to make it safely to hospital in Kathmandu, from where he flew a few days later to the United States.
Let’s go back a few months now and look at how the teams prepared before setting off.
Another problem that later led to a number of bad decisions, in addition to those we’ve already looked at, was the lack of any team integration, in both Adventure Consultants and Mountain Madness. Members of both expeditions only met in Nepal, so there was no opportunity to develop relationships or trust.
It’s worth recalling here a distinction introduced into the business world by Jon Katzenbach. In an article published in 1993 in the Harvard Business Review, he introduced the concept of a workgroup, defined as a group of people who come together at the same time and in the same place to perform a similar task. However, for a workgroup to become a team, time must pass, trust must develop between group members, an awareness of shared goals and a sense of joint responsibility must appear, a feeling of psychological safety must be created, and there must be open communication. It’s important to bear in mind that in business, we frequently come across workgroups (e.g., workers in a call center) rather than teams, and there’s absolutely nothing wrong with that. Some workgroups should remain just that, as investing the time, money, and resources required to turn them into a team won’t provide any returns. Every manager, though, should be able to assess a situation and understand what kind of group they’re leading. Treating a workgroup as you would a team can turn out just as badly as treating a team like a workgroup.