by Pawel Motyl
An excellent example of how easy it is to get fixated on the symptoms, and so not take the appropriate action, comes again from the world of medicine. For many years, it was considered that the trigger for stomach ulcers was excess acid, caused by having too much spicy food or being too stressed. The treatment of ulcers was therefore to give sufferers drugs to reduce acidity and to tell them to take things easy. From the perspective of the pharmaceutical companies, the prescription of antacids was great news because it created a market that was valued in the second half of the 1990s at over $8 billion. From the patients’ perspective, things weren’t quite as rosy, as the treatment recommended to them wasn’t very effective and often ended in their needing surgery. But nobody questioned the treatment method and nobody looked for an alternative cause of the problem, because it was widely believed at the time that it was impossible for bacteria to survive in such a strongly acidic environment as the human stomach, so they couldn’t possibly be a cause of stomach ulcers.
The breakthrough only came at the beginning of the new millennium, although its origins can be traced back to Australia, almost twenty years earlier. In 1981, two doctors from the gastroenterology ward of a Perth hospital, thirty-year-old Dr. Barry James Marshall, a clinical fellow, and forty-four-year-old Dr. John Robin Warren, discovered something unexpected in the stomachs of twenty patients suffering from ulcers: bacteria resembling Campylobacter. For many months, the astonished scientists tried to isolate it in the lining of the stomach and then grow it in laboratory conditions to subject it to further testing, but to no avail. Then they had a lucky accident: after one of the biopsies they’d been conducting, a test tube was left in an incubator for three days longer than it should have been, but this mistake turned out to be the missing link, as the extra time gave the bacteria time to grow. As a consequence of their oversight, the Australians discovered Helicobacter pylori and, in 1983, they put forward the thesis that the bacteria could be the main cause of ulcers in the stomach and duodenum. Marshall even demonstrated it in a somewhat drastic manner, deliberately infecting himself with the bacteria and observing an inflammation develop in his own digestive tract. Although the researchers faced a great deal of resistance not only from their peers, but also, not surprisingly, the pharmaceutical companies, their tenacity and dedication were finally recognized when they were awarded the Nobel Prize in Physiology or Medicine for 2005. Today, ulcers are treated with antibiotics to destroy the bacteria that cause them.
Our concentration on looking at symptoms and natural reluctance to search for root causes are a result of several factors. First, in business, we operate constantly under time constraints, and RCA is quite time-consuming, as it demands thorough testing of numerous aspects of a problem and frequently involves many people. Second, we don’t like to analyze failures, because they demand that we face up to something we’d much rather forget about. This leads to the trap of denial—we push away unpleasant memories and focus on more positive things instead. Third, we have a natural tendency to blame people, not processes, so we try to identify the specific person responsible for a mistake. This means that, even though the underlying cause of a failure was someone’s poor decision, we tend not to consider the factors that led to that bad decision being made. Finding a scapegoat usually ends the discussion, and we focus more on punishing than on drawing conclusions and learning lessons. These three factors lead to our not making use of one of the most important tools in improving decision-making processes, one that helps us draw in-depth conclusions from the mistakes we and others make.
RCA is an extremely straightforward method. The analysis aspect is governed by a set of rules known as the 5 Whys, a series of questions to ask to get beyond the symptoms to the root cause of a problem. The first Why questions the cause of, or reason for, an error; the second Why is asked to analyze the underlying causes of the immediate cause. Then it’s the turn of the causes of the causes of the immediate cause (the third Why) and so on. (The “five” in the name of the approach is arbitrary. We could equally stop the analysis at the fourth Why, having found the root cause, or continue on to a twenty-fourth.) Such an approach creates a kind of logic tree whose branches hold successive links in a chain of cause and effect. RCA therefore makes it possible to discover dozens of underlying causes of a problem, and consequently effectively prevent it from recurring.
A thorough RCA reveals the chain of events leading up to an event, which gives you the information you need to reject false (although frequently obvious-looking) conclusions that could result in bad decisions being made again in future. To paraphrase Mark Twain, a cat that sits on a hot stove lid not only won’t sit on one again, it won’t sit on a cold stove again, either. RCA enables us to identify such misleading simplifications before they do any harm.
It’s worth looking at how the RCA approach works in the context of a specific event that was caused by a tangle of causes and the kinds of mental traps I’ve described in the preceding pages. Let’s take a look at the infamous 1996 tragedy that hit two commercial expeditions on Mount Everest. 1
Climbing has always aroused strong emotions, from admiration for the bravery of the daredevils, heading up the highest peaks on Earth, to disdain for the risk-takers and disapproval of the unnecessary risks involved. Every death in the high mountains is followed by harsh commentary, generally suggesting that climbers are all to a greater or lesser degree quite mad, seeing that they are prepared to risk their lives in the pursuit of adrenaline and glory. 2
No matter how you feel about the climbers, the events that played out on Mount Everest in 1996 rocked the world of Himalayan climbing, and inspired numerous books and films. The disastrous outcomes for the Rob Hall and Scott Fischer commercial expeditions up the highest peak on Earth had a common denominator: bad decisions were made during the planning and execution of the entire undertaking. None of the participants died from an act of God, like a sudden avalanche, falling into a crevasse, or the sudden breaking of a fixed rope. All the victims were the result of mental traps that led to poor choices and the direst consequences imaginable.
Peak XV in Nepal didn’t immediately spark much excitement. It was only in 1856, when the Great Trigonometrical Survey conducted by the government of India estimated its height, by using theodolites, at approximately 29,000 feet, that it became apparent that the mountain known to the locals as Chomolungma (“Goddess Mother of the Land” is just one of its English translations) was the highest point on our planet. In honor of the British surveyor Sir George Everest, one of the leading surveyors of India between 1830 and 1843, the mountain was given his name, and from then on, the race to become the first to climb the world’s highest peak began in earnest.
In the first half of the twentieth century, the authorities in Nepal were not amicably disposed toward climbers, so all the teams attacked from the Tibetan side, the North Face. The ascent from the Nepalese side, also known today as the classic route, is far less technical, so we can probably risk saying that if the brave souls back in those early days had been able to attack from the South, they would have had a far greater chance of success. The first two significant attempts to conquer the peak took place in 1921 and 1922, with the second breaking the 26,000 feet barrier for the first time ever. 3 The team, led by Charles Granville Bruce, had no chance of reaching the peak, yet its achievements were lauded resoundingly by the European press.
In both cases, the expeditions included George Herbert Leigh Mallory, born in 1886, a British history teacher and, in my opinion, the greatest hero in the many years of attempts to climb Mount Everest. Mallory was an experienced traveler and alpinist who had climbed Mont Blanc in 1911, hence trying his hand at the world’s highest mountain was, to him, a natural evolution. He joined the 1921 expedition and ended his first encounter with Everest on the North Ridge, at an altitude above 23,000 feet. The following year he did even better, reaching a then-record height on the North Ridge of 27,000 feet. While both attempts ended with th
e team’s turning back before reaching the summit, Mallory analyzed the experience he had accumulated and decided to make a third attempt in 1924, setting off with Andrew “Sandy” Irvine, a twenty-two-year-old member of the Oxford University Mountaineering Club. According to Noel Odell, who observed their efforts from base camp, the two climbers were making good time and were close to the so-called First Step on the ridge at an altitude of almost 28,000 feet when they vanished into cloud. That, sadly, was the last contact anyone had with the two climbers. Neither Mallory nor Irvine returned to base camp, and for many years no one knew whether they had died on the way to the summit or on the way back down. Mallory’s body was finally discovered in 1999, by a US expedition led by Eric Simonson; a little above the frozen remains, close to the Second Step and spread out at a height of 28,000 feet, were the two men’s oxygen tanks. Irvine’s body still hasn’t been found. Neither has the camera that the Englishmen were using, and which could have provided evidence of them reaching the summit. Most experts therefore consider that Mallory didn’t conquer Everest, but some point out that in the intact wallet found on Mallory’s frozen remains, the photo of his wife, Ruth, which he had intended to place on the summit, was nowhere to be found.
In 1950 and 1951, two British expeditions explored the possibility of attacking the summit from the South Side, in Nepal. A year later, a very well-prepared Swiss expedition led by physician and alpinist Edouard Wyss-Dunant, and which included the Sherpa Namgyal Wangdi, generally known as Tenzing Norgay, arrived on the mountain. While Norgay and the experienced Swiss mountaineer Raymond Lambert managed to set an altitude record of 28,000 feet, the pair didn’t reach the peak.
The following year was a breakthrough one in the history of Everest. In March 1953, a well-equipped British expedition led by Colonel John Hunt and comprising over four hundred people, mostly porters, had begun operating in Nepal. The expedition set up a series of camps on the massif, and finally, on May 26, the first attempt to reach the summit began. Two British climbers from Hunt’s expedition, Tom Bourdillon and Charles Evans, were selected for this honor. In the opinion of many, this was not the best decision Hunt could have made, as they were not seen as either the strongest or the best prepared of the group. Hunt, though, felt that the British should have the first crack of the whip, and so up they went. Bourdillon and Evans almost made it, however, as they were merely 300 feet below the summit when they were forced to turn back due to Evans’s faulty breathing apparatus. On May 28 another attempt was made, this one led by the pair considered to be the strongest: twenty-eight-year-old New Zealander Edmund Hillary and thirty-eight-year-old Tenzing Norgay, who had returned to Everest following the failed Swiss expedition of 1952. On May 29, 1953, at 11:30, the two men stood on the summit of Chomolungma, the highest peak on the planet; fifteen minutes later, they began their descent. They made it back safely to camp and immediately became heroes. The leader of the expedition, John Hunt, also basked in his share of the glory, as the newly crowned Queen Elizabeth II made him a life peer. 4
In the years that followed, Everest was conquered by successive expeditions. In 1978, the legendary Reinhold Messner, the first to complete the Crown of the Himalaya, reached the summit without the use of supplemental oxygen, and two years later he completed the first solo ascent. That same year, Everest was conquered in winter by two Polish climbers, Leszek Cichy and Krzysztof Wielicki.
In 1985, the next frontier—one not entirely connected with alpinism—was pushed back in no uncertain terms. Top US climber David Breashears guided the Texan oil baron Richard Bass to the top of Everest, with Bass covering most of the costs of the expedition in return for being taken along for the ride. Bass, despite having no experience of being at such extreme altitudes, was very well-prepared for the expedition both mentally and physically and made it to the top with Breashears. The event was reported widely, among both business people and mountain climbers, with the latter seeing a chance to earn some cash. And that is how commercial expeditions on Mount Everest became a new and lucrative business involving ever more people. In the following years, it was often decided to include one or two wealthy adrenaline junkies in the expedition teams.
At the beginning of the 1990s, two New Zealanders, Rob Hall and Gary Ball, decided to go a step further and set up a firm organizing commercial expeditions to the top of the Earth. They named their company Adventure Consultants. They decided it was worth starting ambitiously, so their first expedition for commercial customers was an ascent of Everest in 1992. The undertaking was an unarguable success: on a single day six people, not counting the guides, stood on the summit. The following year, seven customers went up, following in the footsteps of an expedition up Aconcagua and Mount Vinson in Antarctica that had ended successfully. These successes brought Adventure Consultants a lot of publicity. Its reputation survived the death of Gary Ball on Dhaulagiri in 1993, and over time Rob Hall became a legend in the world of commercial expeditions. Within three years of Ball’s death, Hall could boast of having guided thirty-nine clients to the top of Mount Everest. No other company or guide could come close to such a score.
Hall was highly valued by customers for his extraordinary attention to detail and precise planning, as well as his obsession with safety, which came from a genuine humility in the face of the mountains. He was a strong leader type, imposing strict rules of behavior on his teams. The combination of these factors meant that there was enormous interest in expeditions run by Adventure Consultants, who charged much more than their competitors did. For the 1996 expedition, Hall recruited eight customers, including Jon Krakauer, a very talented rock climber and a contributor to Outside magazine. His role, therefore, was a double one, as the publicity generated by the article about his experience would increase the likelihood of the company’s getting even more customers the following year.
At the same time, a team led by the American Scott Fischer, owner of Mountain Madness, arrived at base camp. Fischer was six years older than Hall but came across as much younger at heart. His approach to organization was much more relaxed, and he didn’t set out much in the way of rules or defined procedures. This approach had worked on earlier sporting expeditions, ultimately giving Fischer the first US ascent of Lhotse (27, 940 feet) and helping him to conquer Everest and K2 (28,250), considered the toughest eight-thousander. On both Everest and K2, Fischer climbed without oxygen. Like Hall, he had attracted eight people to join his party for this particular expedition, including his own media presence, Sandy Hill Pittman. Pittman was a New York socialite who was breaking new communications ground by blogging about her attempt to complete the Seven Summits (to climb the highest peak on each of the continents), a feat that required a great deal of equipment in addition to her climbing gear. Everest was the last one on her list.
In the case of both teams, a vital role was played by the professional guides who were hired to help the amateurs throughout the entire climb. Hall’s team included Andy Harris and Mike Groom, while Fischer’s team had the excellent Kazakh climber Anatoli Boukreev (who was against using supplemental oxygen on ascents) and Neal Beidleman. Both expeditions also included several Sherpas, led by a sirdar named Ang Dorje, who climbed with Hall. Another sirdar, Lopsang Jangbu, accompanied Fischer. The Sherpas were there not only to carry heavy equipment and food to the higher camps, but also to prepare the fixed ropes securing the especially dangerous sections of climbing. Throughout April, the Sherpas prepared the camps, and the clients of both companies acclimatized themselves to the increased physical demands of higher altitudes. Lopsang took up the heavy electronic equipment that Pittman needed to relay the course of the expedition live on NBC’s website.
It’s worth mentioning that in May 1996, Hall’s and Fischer’s expeditions were not the only ones on Everest. There was also a poorly prepared team from Taiwan, led by Makalu Gau; a South African team, led by the controversial Ian Woodall; 5 Todd Burleson’s commercial expedition; and an IMAX team that included David Breashears
and that was planning to film a documentary about the realities of climbing the highest peak on Earth. This meant that there were dozens of people on the South slopes of the mountain all at the same time, and the majority of them had little experience of climbing at such an altitude. Taking this into consideration, Hall and Fischer decided to join forces and lead their clients together, so as not to get in each other’s way during the most critical stages of the climb.
After analyzing the weather data from previous years, as well as the current forecasts, the leaders decided that May 10 would be the best time to push for the summit. The combined teams set off on May 5 from a base camp at 17,600 feet, crossed the dangerous Khumbu Icefall, and reached Camp I, at an altitude of 20,000 feet. On May 6, they attempted to reach Camp II, during which one of the Mountain Madness customers, Dale Kruse, began to feel sick and was taken back to base camp by Fischer, who rejoined the remaining climbers at Camp II the following day. During the following two days, the teams pressed on higher, and by May 9 they had reached the fourth and last camp, just beneath the South Col at almost 26,000 feet. From that camp, the climbers would set off on the final assault. So far, though, the weather conditions had been very difficult, with winds of up to 60 mph, which persuaded the IMAX team, among others, to descend to base camp and wait it out.