2014 Incidents and Near Misses

Lake District scene
Written by John Cousins 27/1/15

This 2014 report is the first time we have produced a summary of incidents in the hope that all our users are reminded of key safety messages for themselves, the groups they lead and the training that they provide. In our view some of these incidents will make excellent case studies when training new leaders, instructors, guides and coaches.

1. 2012 Fatal Accident Inquiry on Skye

The Sheriff presiding over the inquiry into the death of Graham Patterson in 2012 published his findings in December 2014. He reinforced the importance of party members being equipped to deal with the possibility of an accident occurring to the leading member of the party. More details of this incident can be found using the link at the bottom of the page.

Mountain Training’s view: Court cases investigating leadership issues in mountaineering are extremely rare and are always therefore worth reading carefully. Leaders are reminded that involving group members in decision making, route finding and the carrying of group equipment is not only good practice but it also improves everyone’s chances in the event that the leader is incapacitated. In a separate incident one of our trainers reported straining a muscle in his right calf at the end of a training session on moving in difficult terrain. This facilitated an excellent discussion on changing plan and self-extraction with the aid of the group.

2. Climbing Wall Judgement

Leeds Wall has recently been found not guilty in an action brought by a climber who suffered a ground fall whilst climbing at their facility. The judge concluded that the procedures and training in place at Leeds Wall met or exceeded its obligations to the Duty of Care to their customer. However the belayer was found to be liable and instructors, coaches and wall operators may gain some valuable insights from reading the report.

Mountain Training’s view: Of particular note is the way the two climbers were paired up by staff at the wall and this role of ‘matchmaker’ needs to be considered very carefully since it could be seen to be taking responsibility for that groups ability to look after each other.

3. Near Miss on very steep ground with a teenage group

Investigations by HSE and one of our membership associations have now concluded after a very serious near miss. A Mountain Leader, who also held additional Mountain Training qualifications led a group of six mixed gender and mixed experience youngsters on a day walk up a popular British mountain with the intention of descending via a slightly different route. A route finding error in descent resulted in the group re-ascending the mountain and straying in to very serious steep ground, which ultimately led to the group requiring roped rescue by Mountain Rescue.

Mountain Training’s view: When things start to go wrong Leaders are reminded that they need strategies for dealing with their groups that allow them time to consider their situation and avoid hurried action that only compounds their problems. In particular they should:

- Use first principles to relocate and establish ones position.
Know the upper limits of the remit of their award for operating in steep terrain.
- Have an incident management plan
- Maintain up to date CPD and Log Book.
- If working for multiple employers ensure all documents used originate from the same employer

4. Accidents on Winter Mountain Leader Assessment

A candidate on assessment sustained a soft tissue injury as a result of sliding several hundred meters down a snow slope while under assessment. During a separate assessment a candidate was demonstrating self arrest and illustrating a 'bigger' slide with a rucksack on when they tumbled to the left and put both feet down, injuring their knee.

Mountain Training’s view: Assessors, Instructors and Leaders are of course responsible for their clients even in an assessment situation and they therefore must think very carefully before subjecting those in their care to situations where unprotected falls can have serious consequences. All assessors are reminded of the need to consider the potential consequences resulting from errors made by those under their supervision. George McEwan has noted that: “Trainers who strive for realism should always consider the outcome of an unguarded moment or a lapse of concentration”.

5. Gas canister explosion on Mountain Leader Assessment

This incident happened on a very still day where the stove had been used about 10 mins before the explosion, was turned off and still had the stove screwed into the canister. We believe the stove was turned off properly but may have been not quite tight enough. It seems that because it was a very still day and there was no wind (which is not normally an issue in our hills), the gas was leaking slightly from the canister but not dispersing. Gas of course is heavy and sinks to the ground and runs downhill so when the assessor lit his own stove outside his tent. about 10 metres away from the other stove, it almost instantly caused the other canister to ignite and explode about 10 metres into the air. It caused a small shock wave and also sent the pan, stove and canister into the air. The group collected all the bits and thankfully no one was hurt.

Mountain Training’s view: No one should assume that gas canisters are fool proof. On very still days a small amount of gas can linger in the vicinity. It is worth thinking about storing canisters detached from the stoves and if in any doubt move them away from camp for storage.

6. Mock Candidate Injured on Single Pitch Award Assessment

Mock candidate on Single Pitch Award re-assessment stepped on a very small patch of wet rock and toppled backwards. The candidate fell from a shelf approximately 60cm high into a pool of salt water approx. 20cm deep. She continued with the day saying she was OK, but after she visited the doctor was diagnosed with a jarred coccyx and a sore shoulder.

Mountain Training’s view: There are a number of reasons why some of our courses will involve members of the public who are not our candidates but in all cases the trainer or assessor is ultimately responsible for the group.

7. Poor Equipment on Mountain Leader Assessment

A candidate on Mountain Leader assessment chose not to bring waterproofs, relying only on soft shell, without informing the assessor. There were some issues regarding fitness, which were then compounded by not appearing to look after himself at the campsite. He got wet on day two and combined with previous issues became hypothermic. The team dealt with this on the hill by use of group shelter, spare kit, food etc. then headed to a bothy to dry out and subsequently completed the expedition.

Mountain Training’s view: Three day expeditions are clearly very committing journeys and kit checks, even with very experienced assessment candidates may be a wise precaution.

8. Candidate Injured on Mountain Leader Assessment

A candidate was out night navigating on the first day of the expedition and whilst descending a steep grassy slope they slipped and sprained their ankle (the assessor did not see the actual incident). Five minutes after this the group pitched tents for the night. The next day the candidate navigated the group down to a bothy that was close and then spent the second afternoon and evening of the expedition there. The other candidates continued with leadership and navigation into the second evening.

Mountain Training’s view: Mountain Training support all assessors in having to adapt their plans and programmes in the event of unexpected incidents. Syllabi and sample programmes will often have to be adapted because of the circumstances of the day and provided this is reported effectively the outcomes will always be endorsed.

9. Near Miss on a Single Pitch Training Course

On the second day of a Single Pitch Training course an anchor was removed in error by a trainee from another party's bottom rope (a three part anchor). The leader of this separate, informal group informed the Trainer of this, since until that point they were unaware of the actions of their candidate. The Trainer apologized sincerely to the informal group at the end of what had been a very good natured session and then shared the incident with all the Single Pitch Award trainees and led a 'lessons learned' discussion.

Mountain Training’s view: This was a worrying near miss, which may have had serious consequences. Trainers are expected to work alongside and wherever possible accommodate other crag users, without compromising any aspect of safety. It is essential that trainers ensure any briefing given to their candidates is crystal clear.

Mountain Training has many training providers and they are now obliged to report accidents to us, as well as being encouraged to share near misses. The four membership associations (AMI, MTA, BAIML and BMG) also have various mechanisms for reporting incidents and beyond our immediate network various court cases and major incidents come to our attention. Members of Mountain Training Association, AMI, BAIML and BMG and approved providers may find more details via their forums and web pages.

If you’d like more general information on lessons learned go here. For more information on coaching, instructing and the law see this popular article from Ed Douglas on the BMC website. For more information about the Fatal Accident Inquiry on Skye see our article. The Leeds Wall court judgement can be found here. If you would like to contribute to future summaries please contact any of the technical staff within Mountain Training or email info@mountain-training.org

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