The Pre-Mortem Test

The Pre-Mortem test is a valuable tool for mitigating the risk of failures, particularly in complex and high-stakes activities like backcountry touring in avalanche terrain. The core of the Pre-Mortem test is imagining the worst-case scenario—a complete and utter failure—and then working backward to identify all the potential factors that could have contributed to that outcome.

This process helps teams and individuals avoid failures in several ways:

●It encourages proactive thinking. By explicitly imagining a failure, the Pre-Mortem test forces participants to think critically about potential risks and hazards that they might otherwise overlook. This shift from a focus on success to a focus on failure helps uncover blind spots and vulnerabilities in planning and decision-making.

●It fosters open communication and collaboration. The structured format of the Pre-Mortem test creates a safe space for individuals to share their concerns and insights without fear of judgment. This collaborative brainstorming process generates a more comprehensive list of potential failure points than any one person could identify on their own.

●It promotes early identification and mitigation of risks. By identifying potential failure points early in the planning process, teams can develop strategies to avoid or minimize those risks. This proactive approach to risk management increases the likelihood of success and reduces the potential for negative consequences.

●It helps teams learn from past experiences. The Pre-Mortem test can also be used to review past events, both successes and failures. This reflective practice helps teams identify patterns in their decision-making and develop strategies to improve their performance in the future.

The sources emphasize that the Pre-Mortem test should not just focus on the possibility of an avalanche incident, but also on the potential consequences of a burial. This includes preparing for the challenges of a rescue and the possibility of serious injuries that require extended care in a remote environment.

The Pre-Mortem test is a powerful tool for promoting a culture of safety and proactivity. By regularly practicing this exercise, backcountry travelers can develop a more critical and nuanced understanding of risk and improve their ability to make sound decisions in avalanche terrain.

This content is adapted from Armbruster, S. , Moran. J.W., and Shirley, J. (2014). “Pre-Mortem Analysis” on http://www.phf.org/resourcestools/Documents/Pre_Mortem_Analysis.pdf for the context of avalanche experiences. The original text from the article is presented in regular font. 

My adapted notes are in italics.

Step 1 - Preparation: Convene the project team and assure that participants are comfortable and have several sheets of paper.

Your tour group. Are they a regular collection of regular  individuals? What skills and experiences do they have? 

Step 2 - Imagine a Fiasco: The facilitator starts by claiming to look into a crystal ball to see the outcome of the proposed plan, and then says: "Oh, no, oh, it's a failure! Not just any failure, but a complete, total, embarrassing disaster. It is so bad; no one is talking to each other! Things have gone as wrong as they can go! But this cheap crystal ball keeps buffering and won’t reveal the reason(s) for the failure. The question of the hour is "What could have caused this?"

What could be the worse thing to happen? We often lead to death, but in reality, a death means a body recovery, which does not necessitate haste. On the other end, in avalanche education, we often forget to highlight the myriad outcomes once someone is unburied. In many instances, the adventure is just beginning as we face a broken femur or spinal injury or internal rupture to vital organs and must care for a person with limited resources. The Pre-Mortem can not be about predicting likelihood of avalanche incidents; it must prepare for the worst consequence. Avalanche safety can not rest in the process of prediction of possibility. It must begin with plans for worst imagined consequences.

Step 3 - Generate Reasons for Failure: Ask each person write down all the reasons they think the failure occurred, giving them just three minutes of quiet time to generate a full list. Klein explains that this is where the differing intuitions of the team members come out. "Each has a unique set of experiences, scars, and mental models they bring. The collective knowledge in the room is far greater than that of any one person." Klein has found that this activity helps the group share experiences and calibrates their understanding of the difficulties.

Ask your touring partners about factors they can predict that would potentially expose them to undue hazards and risk. This is as simple an exercise as it seems: what do you think could go wrong? Why would those things go wrong? Of course, novices are limited by their lack of experience; however, the vicarious experience (through film, articles, etc.) can provide as ample a source of reference as personal experiences. We encourage novices (and experts) to consistently review accident reports and trip accounts that highlight accidents and near misses.

Step 4 - Consolidate the Lists and Pick the Absolute Game Changers: Each person shares one item on their list. A facilitator records them on a whiteboard or flipchart paper. After each person has shared one item, continue to go around the room, sharing one item each time, until everyone has exhausted their lists. By the end of this step, the list should include everyone's concerns.

Klein explains that this process liberates people who might otherwise be afraid of looking like they’re not a team player. "Now, everybody is being asked to think about failure. So instead of looking like a bad teammate, you’re pulling in the same direction as everyone else."

• Focus on show-stoppers. (Absolute Game Changers)

• Pick problems likely to happen.

• Discard problems you have no control over. 

From https://www.riskology.co/pre-mortem-technique/

Step 5 - Revisit the Plan and Create Solutions: Address the two or three items of greatest concern, and then schedule another meeting to generate ideas for avoiding or minimizing the other problems. If the project has a charter[4], these prioritized areas of concern can be listed in the "Assumptions, Constraints, and Risks" section, along with the planned strategies to mitigate the risks.

Consider at which points on a tour it is effective to make decisions. There are clear divisions to a tour that are aptly suited for specific information analysis and decision making. At the most, do not consider a decision made at the beginning of the day to be written in stone. Consider it to be written in soap. Easily wiped away and rewritten.

Step 6 - Periodically Review the List! Take the list out every 3–4 months to re-sensitize your team to problems that may be emerging.

Too often we do not reflect on experiences unless immediately. As well, experiences with unintended outcomes are often easier to analyze  than those where outcomes are as expected. What processes do you instill to utilize your experiences as learning opportunities?