Accident Report from Serre Chevalier

A snowHead

This is a double posting because I don't know if every one can see the post in SOPiB2014 :: Spring Off Piste Bash: 8th Mar, Serr Che, France thread.

We will write an accident report about what happen when Lars got injured and needed helicopter support but first I will give you a background why we are doing it and hopefully we can learn something.

Me and Lars have been doing technical diving for 10ish years. Tech Diving is diving in caves, mines,wrecks and deeper diving in ocean and with this kind of diving you need standards, protocol and skills. We are using a dive system called DIR diving. If you google it you will find tons of info. With DIR diving everything is standardized, in left pocket you have x thing, in right pocket you have y thing. If a persons light brakes it’s a protocol to handle the situation, if a person got out of air there is a protocol and we are practicing this protocols all the time. For us off-piste skiing and tech diving is pretty much the same and if something happening during a dive we are talking/writing a about it to learn something and hopefully prevent it from happening again. That is the reason we are posting this.

First off all we are not blaming anyone but trying to just give our story and things that we think could have been done in another way.

The idea with todays trip was to ski down to a little village and eat lunch. Then after lunch to drive to Puy Saint Vincent and ski a route there. This is the first time the complete group are having lunch together. It was 4 groups with one leader in every group (using the term leader for booth instructors and guides). When we were to start the decent from the top in Serre Chevalier, Pic Yret., two of the groups had to wait approx 20min for the 2 other groups to join. I don’t know the reason for the delay but before we had started we was approx 30min late. I think the decent down to the village took a little longer than expected and it resulted in a a new delay. Everyone came down to lunch and we had a fantastic lunch together. The only problem was that it took approx 2 hour to finish the lunch. After this delay we had to hurry to Puy Saint Vincent to get to the the top before the lifts closed. I think we made it to the top around 15:55. Some of the leaders we concerned about the time and how long it would take us to get down.

We all went skiing and we came to the only technical part when we traversed, we had to slide down a bit and avoid some big stones/rock, this took an extremely long time to get 24 people down and ready to start the decent in in POWDER. The sun descended behind the mountains and it started to get more chilly. When everyone was ready we started the decent and the leaders was worried about the light so they asked some of us to hurry. We were at the time 4 groups with 4 leaders. The powder had also started to harden(sneaky devilish crust).

Group 1 and 2 skied down to a natural place to stop and waited for group 3 and 4 to come. We waited for approx. 30min and it started to get more windy and darker when Admin tried to call group 3 and 4 by his cell phone. It was bad reception but one leader from group 3,4 told us that Lars had injured himself and could not ski anymore. Leader 1 called rescue service and told admin to get all the people down to us and only leave one leader and one skier (doctor David) with Lars.

After 20min or so the helicopter came and picked up Lars, the rescue team used around 5min to pick up Lars and I believe it was extremely professionally done. We waited for the 2 remaining people to get down to us and we skied together the rest of the way. When it was around 20,25 min left it was dark but luckily some skiers had headlights that could light up the path so we got home.

What could have been done in an another way?.

Its impossible to say if we would have done things in another way we would not have an accident but I believe some part of this contributed to the accident.

1. We should have a time when we was supposed to meet at top station. The groups that are not there at the right time will not follow or their leaders should guide them to the village.

2. Lunch: 2 hours are way to long when we already are delayed. At that time the leaders should call of the skiing for the rest of the day and return back to Serre or at least told us if we will have a dessert then we will not be able to ski in PSV.

3. When we was at the top at Puy Saint Vincent the leaders should have called of the skiing if they knew about the technical part where the rock was. At least checked with their groups if they were up for it.

4. All leaders should know the route and the plan (I don’t know if this is right or not but the feeling was that at least one of the instructors didn´t know the route and were hesitating)

5. When the accident happened, since we were 4 groups the leader should have had communication (radio) between them, not cell phones. So the leaders can communicate with each other when/if something happens.

6. After the accident we should have tried to get of the mountain faster. We had 4 leaders. I believe this had been the right scenario.
a. As soon as possible get one leader in front of the rest of the group and one leader in the back of the group.Leave on leader and one voluntary skier with headlamps.
b. Now we have 2 leaders and 2 skiers left on the mountain when Lars left with the helicopter. When the helicopter left the one leader and skier involved in the evacuation could join up with the 2 others and ski down as a small fast group.
c. If we had done it this way we would have less people on the exposed on the mountain when it started to get dark, and that makes the accident risk lower.
At least one other skier said he was sure that some on else would have an accident on the way down because of darkness,fatigue,conditions etc.

7. The leader who was with Lars had a booty-bag/bivybag. A really a good thing.

Summary
Can we stop accident from happen now I don’t think so but we can trying to minimize them by doing thing the right way. What’s right and what’s wrong is not for us to decide , but honestly believe we in SnowHeads can create protocols we can use in skiing. I also think it should be a requirement on SnowHeads Off-piste Bash. We can be an example how to ski safety. Maybe one person in every team should have http://brooks-range.com/All-In-One-Rescue-Sled-Tarp.html . Maybe Snowheads should have that as an requirement that the leaders have it. If we are skiing off-piste maybe 2 persons should know the route. What are we doing if something happens to the leader. Or even better a short briefing before the run.

Please do not see this as criticise but as working document and maybe we can change something in the ski world.

Tor and Lars

A snowHead

Thanks for posting

I was not there. I assume many regular posters may know some of the leaders and may be slow to join in for fear of causing offence.

But tbh, if how you are describing things is accurate, the whole carry on sounds crazy.

? 2 hr lunch after already some delays so time pressure

? Starting a descent at 1555

? Taking on a difficult technical ski when sun has gone down and snow getting hard with mixed ability group

? 24 people all waiting for each other

You were lucky no delays with helicopter. I have heard some HORROR stories re this

I don't mean to offend and please don't anyone get all offended and defensive. I realize this might be delicate thread

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No friends on powder days Twisted Evil

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There are some valid points in this.............

Anyway, snowHeads is much more fun if you do.

peanuthead:
We are not try to blame anyone, what we are trying to do is enlighten this so everyone can learn, I also hope we can have a serious debate about how we should preform off-pist skiing in terms of safety protocols, info before skiing, what kind off equipment should we have. Since I have been a technical diver for more than 10 years I would like to have same open debate has we have in that community. I know how I would like things to work. I am pretty sure that everyone is just trussing the guide and don't think about how to manage an accident.

Tor

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errr, how is Lars was he badly injured, is he recovering well?

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Must have been a great lunch!

After all it is free

Were the leaders qualified mountain guides or instructors qualified to take groups off piste?

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kitenski, 2 were mountain guides, 2 were top level instructors

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tjorgensborg, your 7 listed suggestions all seem very sensible, however these things often seem so straight forward and simple after the event. Was anything discussed with the leaders along the lines of your suggestions?

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I think the biggest issue here is for everyone to know not just their technical limits but their physical limits and to know when it is time to call it a day, I know in the past when I've gone beyond what I should have done in the day the tiredness just seems to suddenly jump out at you and then all your limbs feel like lead so even the simplest runs suddenly seem daunting, people need to be aware of this and know that just because there is time for just one more run it doesn't mean they should choose to do it, an awful lot of accidents occur towards the end of the afternoon and often after a good lunch.

Obviously this is especially important when doing more extreme runs or runs that even normally take a while to do

The 7 suggestions are all valid

Here i am still in a cast, bored out of my mind but recovering well. For those who may wonder I broke my fibula bone, calf, bone i think its called? I came in what at least felt like high speed on powder and it went from powder to nasty, evil, Swede-eating crust. My left ski either cut through or hit something and started to twist my whole leg violently. I could feel that something broke in the first hits and twist but my ski didn't release until the 3rd hit.
No friends on a powder day? well man the f**ck up then because there where plenty of friends there who did an excellent job helping and supporting me, thank you all again I miss you all.

You know it makes sense.

I think a really thing to know is something I read about in one of the avalanche posts fairly recently, it was in an article about a fatal avalanche involving a large group.

Apparently large groups can make poor decisions because they all egg each other into the choices, there is some kind of a safety in numbers that makes large groups take risks that small groups wouldn't

Otherwise you'll just go on seeing the one name:

tjorgensborg,

point 6 - I don't know what the correct protocols are in this sort of situation (and think the size/sort of group was rather unusual to start with), but I assumed that the mountain guides were effectively the 'senior' leaders and would therefore have some form of overall responsibility. Although the rest of us had to wait for a while it makes sense to me that the guides would wait to ensure Lars had been evacuated on the heli before leaving the area. If the heli had been unavailable or unable to complete the rescue would the guides be responsible for coordinating/facilitating another rescue strategy ? and then two mountain guides would probably better than one.

A snowHead

Skiing offpiste in a group of 24 is ridiculous.

Even if that 24 is split into 4 groups, it sounds like you were all effectively skiing together (groups waiting for each other). Makes no sense to me, and defeats the object of splitting into groups. I guess the last group must have been skiing really poo-poo tracked snow all day...

A snowHead

This was a sad and frustrating day and could easily have turned out worse, I hate to see anyone injured. I have skied this route before and the entry off the ridge was much trickier then, with a lot of stepping down over rocks, which would have made it even slower than it was for all 28 (?) of us this time.

I am a firm believer in small autonomous off-piste groups - max 6 + guide and each group should always ski separate from any other groups. By all means ski the same route and meet at the same finish but keep well apart in space and time on the mountain, this avoids the frustration of waiting by those at the front and the pressure to keep up for those at the back resulting in nobody skiing at their comfortable pace. And it has to be safer than a great crowd of people skiing a face together.

I must confess to being a very boring person and only wanting a 30 minute or so stop for lunch (and no alcohol) to keep the flow going!

Hope you are on the road to recovery Lars, at least it wasn't on the first day Smile

Well, the person's real but it's just a made up name, see?

I agree with inspark that guided groups should keep separated, because it makes the skiing more fun - less hanging around. This trip was exceptional because of the logistics in getting us to the lunch and afternoon skiing area from the morning descent meant prior organisation of cars and vans, so was probably only worth doing with multiple groups. However I have experience (as a SCGB leader) of having had to "encourage" professional guides NOT to organise multi-group meet ups for lunch (which sometimes they think the punters want to do, or perhaps they just like the company of fellow guides) because it tends to lead to different groups all skiing in the same area at once in one mega group, which is no fun.

I agree with Tor that one guide should have taken most of the group down immediately after Lars's accident in the daylight, to avoid the risk of further injury in increasingly difficult snow and bad light. However the decision was influenced by the fact that the two instructors in the back group didn't know the way out, and the two guides who did know the run out were ahead, in the front group, and Lars was in the back group when his accident happened, unfortunately. Hence the front group waited until the heli had arrived and done its stuff.

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Well theres another "problem" hawing the only knowledge of the route in front. To refer to diving again where we always put the weakest link in the middle, you box it in. If someone is uncertain of the way they go in the middle, if someone has a problem they go in the middle etc.
i still think that you could haws left one guide and one skier to join up with the "rescue-team" left behind as described in our report.

Anyway, snowHeads is much more fun if you do.

Good to read that you're recovering well Legendary Lars.

Good points raised tjorgensborg, and some very valid and sensible replies. For the most part.

The hardest part of all these adventures is the ability to walk away when it's not on.

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This sensible principle seems to be much neglected in skiing. Typically the "strong skier" husband will ski ahead of the "nervous" little woman, stopping only to look uphill impatiently at junctions and setting off the moment she catches up, leaving her no time to take a break. And it surprises me how many parents ski well below wobbly kids (and hope that some other skier coming down the hill will pick them up and untangle their legs if they end up in a heap). I always like to have a stronger skier behind me if the going is difficult, and if I find myself the strongest skier in a group on piste (it does happen) I always stay at the back.

After all it is free

pam w,

I'd agree that the glaring error at the outset was trying to ski in too big a group. A group of 6 is plenty big enough and has plenty to think about without considering liasing with three other groups.

Ski-ing off piste, I would tend to have the second MOST-EXPERIENCED skier at the back. It's more experience than technical ability because it's not about pretty turns but mountain judgment with dependable technique/tactics. Generally the most-experienced skier (or guide/instructor) goes first because they need to read the terrain, route find and keep the group away from trouble.

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an an accident report the op doesnt actually explain the accident at all, 1000 words of build up, 1000 words of what happened after but nothing of the event itself....

Accident are chains, break one link and they dont happen.

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Some random thoughts:

* Unless I'm missing something, everybody got off the mountain okay - even Lars who was injured and had to be choppered off. This was a succesful outcome in spite of the accident so the procedure followed actually worked.

* $hit sometimes happens, it's how you deal with it that matters. Anyone who has clocked up more than a few winter walking days in Scotland will have come down in the dark. I can remember struggling through waist-deep snow following a bearing down to Tunskeen bothy in total blackness. It's what epic days are made of.

* 15:50 does seem to be a late start but everyone still chose to go. Did everyone have standard mountain kit including bivibag, headtorches and food with them?

* I would suggest that diving and skiing are completely different environments with different types of risk. Athough some principles will transfer, others will not.

* Daylight is your friend and shouldn't be squandered.

* Big groups are not impossible but need to be managed very carefully.

* Hurrying folks, especially the weaker ones, is a quick way to cause an accident.

* Options are always good and can stop you ploughing on with a plan regardless.

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I wasn't being entirely serious. But the bigger the group, the more likely that there will be an issue.

nothing in the original accident report caused the accident (because we havent been told im assuming Lars (and get well soon) nipped off halfway down to partake in some impromptu sky diving and suffered a partial canopy collapse.) they are factors that made dealing with the accident (rampaging ibex?) more difficult.

You know it makes sense.

ah found lars' post halfway down - hit a submerged rock!

Not sure what we can do about those...

Otherwise you'll just go on seeing the one name:

A snowHead

A snowHead

Ok some thoughts.

-The report states that the accident would probably have happened anyway but the interesting thing is what we can learn from everything surrounding it. Time-management, gear, group-size, procedures etc.

-Yes diving and skiing are not the same but some procedures can be transferred such as boxing in the week link, standard gear, time-management etc. We can draw parallels to other activities as well. I´m a climber and a Swedish mountain/wilderness-guide, I newer leave home without a headlamp and first aid kit. How many off-piste skiers have that with them?

-No the accident report did not contain the actual accident, that was a mistake of me and Tor ( English is not our first language so it was hard enough).
I´ve already posted this:
"For those who may wonder I broke my fibula bone, calf, bone i think its called? I came in what at least felt like high speed on powder and it went from powder to nasty, evil, Swede-eating crust. My left ski either cut through or hit something and started to twist my whole leg violently. I could feel that something broke in the first hits and twist but my ski didn't release until the 3rd hit."
I did not hit a rock. Most likely i got caught on a crust edge or ice.
For me personally i were really stressed up until we started skiing. The race through the lift system, the narrow traverse with a leader trying to speed it up and the lack of information of what we were actually doing made me cranky and stressed. As soon as we started skiing back in our original groups i was happy again and that leader did not stress us at all! Although the damage was already done and I could feel the stress all around.
The evacuation process after the accident were swift and professional. A leader and a skier ( a doctor!) stayed with me in a booty-bag and then the mountain-rescue team picked me up incredibly fast.

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AB SKI:

Anyway, snowHeads is much more fun if you do.

It was an excellent lunch though Smile

Lars, it was great to meet you and Tor and hope you are recovering nicely Very Happy

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tjorgensborg, being a smart back bottom, but nothing in your list would have prevented this accident happening....the pre-discussion to route would perhaps have reduced the group size, but who knows??

In my mind the 2 hour lunch and making a group size of 24 were the main errors. However even with no lunch and a small group who could say a freak accident like that wouldn't happen??

After all it is free

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So a quick picture of Lars in the booty-bag:

And my unordered thoughts:

* On the timings, my understanding is that we were at the restaurant for lunch only 5 minutes later than planned, and by my watch lunch in the small restaurant took nearer 2:15 than two hours. If we all skipped dessert/coffee that may have helped (but once the first person orders a cafe gourmand...)

* In terms of equipment, at least for the two groups who were near the accident site I think we group members were well equipped between us but none of us had absolutely everything. I think most people there will be carrying more in future just because we talked about it and could see why things might be useful. Hopefully threads like this will mean others will think about what a group needs without the hanging-round-in-failing-light-wondering-if-the-chopper-can-come-out-or-not bonding experience.

I hate myself for typing this because it feels a bit like a cringeworthy icebreaker from a corporate training course, but there's probably some merit in a group discussing what extra kit is in their backpacks beyond the shovel and probe, if only to avoid unnecessary duplication or spread ideas.

* I'd be interested to know how large a team we would have needed to get Lars off the mountain on foot that night, or whether that wouldn't have been advisable and first light would've been the call if the helicopter couldn't make it there and then.

* My main observation though is that although we skied as 4 groups logistically we were just one: we skied to a different valley and had pre-placed just enough vehicles for the (expected) number of us -- all the seats in cars and vans were spoken for so skis had to go in the vans and short of splitting groups and separating people from their skis we were all tied together. So it would have been very hard for groups to finish the pre-lunch run and drive to the restaurant early, or for groups to follow different plans after lunch.

So while it wouldn't have made the transition from powder to crust any different to ski, I think in situations like this each group having transport independent from the others will markedly improve flexibility and that flexibility is only ever going to speed things up and allow for more fine-grained decision making.

Help!!

Accident Report from Serre Chevalier

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