Thursday, May 1, 2014

1996 Everest disaster and a lesson in “design as if implementation matters”

When I finished reading “Into thin air: A personal account of the Mt. Everest disaster” by Jon Krakauer a couple of weeks ago, it was still considered the worst Everest tragedy. It is a story of a disaster that happened on May 10 and 11, 1996 on Mt. Everest in which eight people died in a single storm including two expedition leaders: Rob Hall and Scott Fischer. However, as I am writing this blog, it is no longer the worst tragedy. Friday before last, on April 18, sixteen Sherpas got killed in an avalanche. Climbing Mount Everest continues to be a risky affair and no amount of learning is likely to completely eliminate the risk. In the words of Krakauer - On Everest, it is a nature of systems to break down with a vengeance. That doesn’t prevent people like me in deriving learnings from the 1996 disaster story. Here is my key take-away from “Into thin air”.

Rob Hall was world’s leading Everest guide running a company “Adventure Consultants”. By 1995 Rob had assisted thirty nine clients reach the top of the mountain and return back safely. In 1996 May expedition his team had clients some of whom had paid as much as sixty five thousand dollars in order to get to the world’s tallest peak.

Rob was disciplined and meticulous. He had fine-tuned an effective acclimatization plan that would enable the team to adapt to the paucity of oxygen as you go up. Rob knew that timing is crucial in Everest expeditions. He lectured the team repeatedly about the importance of having a pre-determined turnaround time on the summit day. It would be 1pm or worst case 2pm. Everybody was to abide by it no matter how close one was to the peak. “With enough determination, any bloody idiot can get up the hill,” Rob would say, “The trick is to get back down alive.”

On the summit day, Rob reached the summit after 2pm and waited for his team member Doug Hansen to reach the summit till 4pm before they began their descent. Doug was so tired by the time he reached the top, he didn’t have much energy left to come down. As luck would have it, he ran out of his oxygen too. Both Rob and Doug got caught in the storm that followed and didn’t make it down. How could a disciplined expedition leader like Rob Hall make such a mistake of not adhering to a predetermined turnaround time?

As Krakauer writes in the book: Lucid thought is all but impossible at 29,000 ft. In addition, the intensity of the desire of achieving the goal – for you and for your clients - is much higher than the cold-blooded process adherence and turning back at 2pm. In short, your thinking is heavily biased. But equally importantly, it is known apriori that your thinking is going to be crooked as you climb up. Then why not plan taking into account such a possibility? Is it possible to create a plan that accounts for the distorted thinking during its implementation? This is the central question when you want to “design as if implementation matters”. To use the Elephant-Rider metaphor of the mind, it is like the Rider planning for a situation when the Elephant has taken over. How do we do it?

Here are a few options none of which is fool-proof: One, responsibility of the turnaround decision can be delegated to a place where the mind is less emotionally charged and has more oxygen e.g. the base-camp or camp-one. Two, after the predetermined turnaround time, everybody coming back takes the responsibility of requesting the up-going climber to turn around, despite your position in the pecking order.

Three, each expedition team performs pre-mortem before the expedition begins.  In this exercise everybody in the team imagines a situation in the future when the project has been a massive disaster. In Everest expedition, it means imagining your own body lying around 28,000 ft and several other casualties. And then listing down what all went wrong. That leads to various precautionary measures and a common understanding of the importance of a protocol such as turnaround time.

“Design as if implementation matters” has significant implications for the design of business strategy.  A strategy which gets finalized in an offsite in cosy settings may fail to take into account the emotional biases of the team during its execution – just like Hall’s Everest team.

No amount of planning can eliminate the risk in Everest expeditions or in business. However, techniques such as pre-mortem may help increase the “Margin of safety”.

A related video
Mt. Everest - The storm (1996) - A PBS  documentary on the 1996 disaster directed by David Breashears, one of the members of the IMAX team who climbed Everest during the same season and also helped the teams caught in the storm. 

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