That is how long it took for me to hear about the next anchor point failure.
End of this afternoon, I got a phone call from a health and safety person about a different matter, when he told me about an anchor point failure that had just arrived at his desk. Details are thin on the ground – and are ultimately not so relevant, the fact remains, the root of this accident was, again, a poor call by the climber whilst selecting an anchor point.
It’s time pressure, you say.
Ok, I accept, that may be one factor in play: that moment when you decide not to pull the throw line, despite the fact that it is not quite in the spot you wanted it to be because you have just spent an unsuccessful half hour attempting to score that point – and a visibly ever more impatient client/ foreman/ boss is breathing down your neck. So, against better judgement, you decide to go with second best.
Yet I believe this is by far not the only reason for this cluster we are seeing.
One factor in play is certainly a confirmation bias. What I mean by this is the sentiment that can creep in that suggests that it was ok yesterday, was ok today, and therefore will also be ok tomorrow. When the truth actually is that it was not okay on any of those days, it was always sketchy. Yet in a sense the outcome was positive: nothing happened. Or to look at it the other way round, there was no negative outcome to disprove that all was good. So there is your confirmation bias, a positive outcome is perceived as being a confirmation for the fact that all is well – when actually it is not.
We are not alone to fall foul of confirmation biases. NASA, a multi-billion dollar enterprise was blindsided in a most dramatic fashion by such a bias when Challenger burned upon re-entry into Earth’s atmosphere. The reason for this was missing ceramic insulation tiles on the belly of the space craft, the engineers were aware of the issue, yet as this had happened before with no further consequences, the assumption was that it was would also be ok this time. Tragically for the astronauts on board the Challenger, it was not.
A further mechanism in play is risky shift. This is a form of group think that gradually and imperceptibly shifts perception of risk, resulting in individuals being prepared to take higher risks in the context of the group than they would ever have contemplated left to their own devices. Many sectors battle this phenomenon, from the banking industry to extreme sports, from military organizations to alpinists.
Everybody else is doing it, so it must be ok. Until that day when it is not.
What I find so troubling is how little margin people seem prepared to leave themselves… all it takes is, for instance, a small defect on the upper side of the limb that is impossible to see from the ground to load those dice against you, culminating in a catastrophic failure of an anchor point.
Every anchor point matters. Every single one. This is not a game of three strikes, you are out. Once can be enough.
So again (at the risk of repeating myself): we have to start talking about these very real issues, in our teams, with out team mates, at safety briefings, in the company, at industry meetings, conferences and conventions. Because as much as it is true that our bad calls are the root of the problem, without a doubt at the same time we also hold the key to being part of the solution!