During one of the clinics that was run as part of the 2022 Remarkables Ice and Mixed Festival (RIMF), an equalised three-piece ice anchor failed when loaded. A clinic participant, Bia Boucinhas, fell from the top of a ~25 m climb to the base of the route and slid ~20 m down the snow slope, sustaining serious injuries.
This report outlines the events surrounding the accident, and the review of both the anchor failure itself and other factors that contributed to the accident. We are sharing this report at the request of the participant involved.
We would like to thank Bia who was injured as she has been instrumental in our debrief and review of this incident. We also want to acknowledge the courage required by her in revisiting a traumatic accident during our debrief process and requesting ECC to publicly share learnings for the benefit of the community.
Obviously, this is also a distressing scenario for any volunteer or participant on a course, and we are also very grateful to the volunteer instructors who were present during the accident and involved in this review.
Recommendations and Learnings
Organisational factors that contributed to the incident
At our internal debrief, we identified the following organisational shortcomings that contributed to the anchor failure:
- Last minute and informal communication with instructors including an informal and distracting setting for the instructor briefing, and lack of structure to the briefing. This also resulted in a failure to formally induct all new instructors. However, it is noted that the lead instructor on the RIMF Chicks and Picks course was an experienced instructor having taught at several ECC RIMF events.
- Unclear separation of tasks between RIMF volunteers – this resulted in unreasonable division of responsibility between members of the ECC RIMF organising committee. It is important to ensure that sufficient attention can be paid to instruction course oversight free from other event administration tasks.
- Good weather and packed evenings leading to time constraints in the evenings, causing slimmed down safety briefings and discussion of conditions on the mountain.
- No formal instructor briefings in each clinic both as part of the instructor briefing, and before, during, and after the operation of each clinic.
Review of the anchor failure
The anchor that failed was a three-piece ice anchor with the primary arms being an equalised double v-thread. It was situated on an eastern facing aspect over a thin (less than 1 m thick) flow of waterfall ice flowing over gray/dark bedrock. The ice flow had been subjected to several days of only slightly sub-zero temperatures in the week before the incident including several clear days where it was exposed to extended periods of direct sunlight. The day of the anchor failure was clear (direct sun exposure) and only slightly below freezing (-2 to 0 degrees at Lake Alta). The anchor was installed by a clinic instructor, who had considerable ice climbing experience both in Canada and in New Zealand. The anchor was in place for only about 1.5 hours from around 11.00 am. The anchor failure was caused by direct exposure to intense solar radiation in only slightly sub-zero temperatures. This may have been compounded by the dark-coloured rock behind the flow being warmed through the thin ice by the solar input and contributing to the melting of the ice from behind.
The climbing public may be aware that Alta Ice has a standard double bolt rock anchor installed on a slab ~10 m beyond the top of the main ice flow. This anchor is suitable for abseiling, but is considered to be unsuitable as a top-rope anchor by the RIMF clinic organisers. Depending on the season, the anchor is located ~50+ m above a suitable belay stance, and is typically buried and difficult to locate even by those familiar with its location. No attempt was made to locate or use this anchor during the 2022 clinic, following normal RIMF clinic practice. This practice is normal because much shorter (~20 m) ice climbs are preferred for instruction (primarily to mitigate risk of falling ice dislodged by climbers), and because there is only one set of bolts but multiple anchors are needed. Shorter climbs mean that (practically inevitable) ice fall has less potential to cause injury, and also allows greater rotation of climbers. However, these shorter climbs also require multiple ice anchors (at intermediate height on the main ice flow) to be established by the clinic instructors prior to ice climbing instruction.
Key points
- While a double v-thread or three piece ice anchor is an industry accepted anchor solution in sub-zero conditions, it is not appropriate in all conditions. Extended use without resetting the anchor is not appropriate in waterfall ice that is exposed to solar input.
- New Zealand is mid-latitude making our solar radiation more intense in winter than other higher latitude countries. This means acceptable practices relating to solar input in high latitude countries may not be applicable here.
- For example, whereas v-thread anchors placed in shady areas in Canada may last weeks or months, an equalised double v-thread has in this case failed within less than 1.5 hours.
- Adding new double-bolt rock anchors mid-height on Alta Ice has been considered, but suitable locations have not been identified that will enable ice climbing but that will not simply be buried by snow / ice during normal conditions. Shorter ice climbs on natural ice anchors remain the preferred instruction approach compared to longer climbs using the rock anchor.
Incident Summary
The ‘Chicks ‘n’ Picks’ clinic was made up of six participants, two volunteer instructors (one lead), plus a volunteer photographer. At the Festival Instructor Briefing, a group decision was made to take the Chicks N Picks clinic ice climbing at Alta Ice.
One ~25 m and one ~20 m high top-rope anchors were set up around 11.00 am for the ‘Chicks N Pics’ clinic. Falling ice was observed during the clinic, and last climbs were announced at 12.20 pm as a result of the continued falling ice.
The anchor failed on static loading when Bia was about to get lowered from the top of the climb on a top rope set up. The three piece ice anchor that failed consisted of two structural arms (equalised v threads) and a third arm attached to an old thread (around a visibly rotten ice pillar), which had failed prior to weighing the anchor. The participant had raised concerns at the failure of the old thread, but was reassured that the third arm was old and not a structural part of the anchor, and was instructed to quickly be lowered due to falling ice. Upon loading, two ‘zips’ were heard, then Bia fell from the top of the anchors to the base of the ice (~25 m) before sliding (~20 m) on sloped snow. Bia suffered a head injury, shoulder and hip injuries, and bruising.
First aid was administered at the scene by a festival volunteer photographer who is also a medical doctor. An emergency response was initiated via an inReach, however the attending doctor was able to satisfactorily clear for C-spine injuries so the patient was able to walk down to Lake Alta, where Remarkables Ski Patrol provided pickup with a skidoo.
Implementation of Recommendations
An incident review was conducted, which engaged the affected participant, clinic instructors, the photographer/doctor, and key personnel from the Expedition Climbers Club. As a result, a series of recommendations were issued to learn from the incident and lessen the likelihood of similar issues in future.
Although by no means exhaustive, we summarise and share a few of the key recommendations and ways in which they have since been implemented by the ECC at the subsequent 2023 Remarkables Ice & Mixed Festival:
- Recommendation: Create separation in tasks between the RIMF coordination (pre-festival planning and operations) and RIMF safety management to ensure safety management at the RIMF is formalised, unified and implemented (both pre-festival and during the festival).
Implementation: At the 2023 Festival, a separate room was booked for clinic volunteer instructor safety briefings, which were held every evening, including a detailed formal review at the start of the Festival. The RIMF Safety Management Plan was updated prior to the 2023 event and copies provided to all the lead instructors to take with them on the mountain. Furthermore, key personnel from the ECC met or engaged with representatives from the Police, Search & Rescue, Remarkables Ski Patrol and NZ Ski to ensure a comprehensive and cohesive approach to safety management at the 2023 Festival.
- Recommendation: Ensure the person overseeing the instructor briefings and evening safety evaluations is not instructing so that they have time to concentrate on preparation.
Implementation: At the 2023 Festival, the person managing instructors and safety briefings was not instructing, and remained in town and contactable throughout the duration of the Festival, acting as a single point of contact for any incidents, should they arise. They also facilitated a check-out and check-in system to monitor where each clinic was and when they returned.
- Recommendation: Arrange sufficient experienced ‘on-call’ instructors who can assist at short notice if required, without sacrificing or affecting our safety culture.
Implementation: At the 2023 Festival, a number of experienced volunteer instructors were kept on standby in the event of a call-up at the last minute across any of the clinics. In addition, these and other key personnel engaged with various safety and rescue services (as above) in the lead up to the Festival, and were contactable throughout the Festival in the event of any unexpected developments.
- More simply, the ECC no longer uses Alta Ice as a clinic venue on sunny forecasts. We consider that the risk of icefall and / or anchor failure at this location cannot be managed acceptably in an instruction context.
Further details of the accident, along with a summary of recommendations can be found here.