Colorado avalanche investigators learn from accidents
When Brian Lazar returned a backcountry skier’s gear to his family, he brought his own laptop, too.
The skier had died from traumatic injuries after being caught in a small avalanche on Torreys Peak in the Front Range in 2011. After the accident, his family had traveled to Colorado from the South. They knew little about backcountry skiing and struggled to understand how their loved one had ended up in a place where an avalanche could kill him.
Lazar, then in his first year as deputy director at the Colorado Avalanche Information Center, or CAIC, opened his computer and began showing them photographs from the scene. He didn’t start with a list of questions.
The family wanted to understand where the skier had been and what had happened that day. The photographs helped them visualize the terrain and piece together how he’d ended up there.
“I could see how much comfort that brought them,” Lazar said.
It was a turning point in how Lazar would approach accident investigation. Although every accident report relies on a checklist — an avalanche’s dimensions, the depth of the crown, the location and the contributing snowpack and weather conditions — Lazar realized that giving people the opportunity to ask questions, or letting survivors tell the story in their own way, often provided most of the information he needed. The remaining questions were a matter of filling in the gaps.
On Sunday, the CAIC will begin issuing its daily avalanche forecasts for the winter season. When an avalanche that involves humans is reported, the center has another responsibility: reconstructing what happened, examining the factors that contributed to the accident and identifying lessons that might help prevent injury or death. (A skier was partially buried Sunday on Mount Bross in the first recorded avalanche of the season; the skier was rescued by their traveling companions, the CAIC said.)
The work draws on the CAIC’s five decades of accident investigations, but the way the agency explains those accidents has evolved. While early reports often simply recorded the facts and left readers to draw their own conclusions, today investigators use a more standardized format to explain contributing factors, put decisions in context and identify lessons for other backcountry users.
“The idea being that we can learn from people’s mistakes to try and avoid those from happening to us and our friends and loved ones,” Lazar said.
What a report used to look like — and what it looks like now
For a long time, getting avalanche information meant picking up the phone.
In the early 1990s, when Lazar was using CAIC forecasts for his own backcountry missions, users relied on the center’s daily hotline. Prerecorded forecasts were divided into northern, central and southern mountain regions, and callers had to listen to “essentially a really long voice message” covering conditions across the entire state.
The internet eventually made forecasts easier to access, but the hotline continued operating alongside the website for years. CAIC shut it down about a decade ago, Lazar said, much to the chagrin of a few “old schoolers,” even though most people had already moved online.
Accident reports were shared differently. For decades, accounts of avalanche accidents appeared in the book “The Snowy Torrents,” first published in 1967 by the American Avalanche Association. A few years ago, CAIC undertook a major project to digitize the Colorado accidents documented in “The Snowy Torrents.” Reports dating to 1951 are searchable through the agency’s online archive.
The archive makes it possible to trace the history of individual accidents, but also to see how investigators have described them over time. The reports show a remarkable consistency in the underlying details — the measurements, avalanche dimensions, and weather and snowpack conditions used to reconstruct what happened.
What has changed more noticeably is how investigators explain what those details mean.
“For years, the accident reports were pretty dry, ‘just the facts, ma’am,’” Lazar said. “We’d go out and measure the avy, take all the forensic stuff, tell the story of how they got caught in the avalanche — and that was the report. It was just black and white.”
Over time, he said, users began asking for more. “They wanted to know, ‘What do you think? What happened? What’s your opinion?’” Lazar said. Over the past decade or so, the CAIC began addressing those questions in the comments section of its reports. The goal isn’t to speculate about why someone made a particular decision or to judge whether that decision was good or bad but rather to try to connect the evidence to recognizable factors that contribute to avalanche accidents.
“We will put in comments on what we think happened if there is a discernible, concrete learning outcome that we can comment on,” Lazar said. “If there is not, we’ll leave it out. Even if we think someone made a really poor decision, you’ll never see that in our reports, because there’s not a learning outcome there.”
From observations to lessons
It only takes looking back at an archive report from the avalanche that killed Meta Burden in 1972 to see how much the language has changed.
The details about the avalanche — with a width of 150 feet and a vertical drop of 600 feet — read much like a modern report. So do the descriptions of the weather and snowpack: “6.5 inches of new snow had fallen at the Aspen Mountain Ski Area” and, statewide, “a snowpack weakened by extensive depth-hoar formation existed.”
The comments section, however, reads markedly differently from today’s reports.
Comments
Burden was an excellent skier with considerable experience in skiing potentially dangerous slopes. Cristy Gully was a permanently closed, avalanche area. Burden knew the dangers involved and ignored them. She then compounded her error by skiing the slope alone. Ironically, her father had died in an avalanche in Europe 20 years earlier.
Reading the passage today, Lazar said he was struck by the lack of structure. The comments read less like an explanation of the accident than “addendums, notable nuggets they (the reporters) attached,” he said. The agency now uses a more standardized format, substituting proper names with labels like “skier one” and using more “delicate” language.
Lazar said some of the details might still be relevant today. Traveling alone, for example, can increase a person’s vulnerability in an avalanche. But modern investigators would explain why it matters rather than simply label the decision an error.
“We wouldn’t have said ‘compounded,’” he said. Instead, a report would explain how traveling alone increased the skier’s risk.
Other details likely wouldn’t make it into the public report at all. Calling the skier an excellent skier, Lazar said, wouldn’t be relevant unless her ability helped explain a contributing factor. The reference to her father’s death might be preserved in internal records, but it wouldn’t help readers understand this particular accident.
There’s also a difference between describing a decision and claiming to know the thinking behind it.
“There’s more to that story than ‘oh, she knew the risks and ignored them,’” Lazar said.
Helping backcountry travelers see themselves
Modern reports aim to explain how an accident unfolded without assuming investigators know why someone made a particular decision. That means looking beyond a single choice to the conditions, circumstances and group dynamics that shaped what happened.
But explaining how an accident unfolded requires investigators to interpret the evidence. How does CAIC make sure those interpretations are grounded in facts, rather than assumptions?
That interpretation is reviewed by other members of the CAIC team, Lazar said. In Colorado’s close-knit backcountry community, investigators may know someone involved in an accident; when that happens, the team discusses whether the investigator should participate or if he or she would rather step aside. Internal review also gives colleagues a chance to examine how the report’s conclusions are drawn.
The aim isn’t to assign blame for a single decision, but to understand how a series of decisions can combine to create a dangerous situation.
“It’s rarely some major mistake that leads to an accident,” Lazar said. “It’s an accumulation of small errors from the planning process all the way through the moment the avalanche happens.”
A group might deviate from its original plan, overlook a concern or make a series of decisions that seem reasonable in isolation.
By connecting those details, Lazar said, investigators give readers a better chance of recognizing themselves in the story — and of seeing how a similar chain of events might unfold in their backcountry travels.
“The take-home is rarely about the avalanche conditions themselves, it’s about how we as people make emotional decisions all the time,” he said. “Where did this group fail and how can I put some resiliency in my own group to avoid this accumulation of small mistakes that led to a really tragic outcome?”
