DZ 4M I THE FRIDAY, JULY 25, 1986 The Basecamp Program The following is a complete text a! the report from the Basecamp Inquiry Committee to the Board of Thuiees of Oregon Episcopal School. July 22, 1986 Oregon Episcopal School of Trustees FROM: Basecamp Inquiry Committee SUBJECT: Review of die 0.E.S. Base camp Program ?Board Introduction ?This report is our response to the first charge given to our committee as per your letter of June 6, 1986. Our findings here are based on several con- siderations: a) A review of written materials speci?cally pertaining to the program. including 0.E.S. marketing brochures, 0.E.S. Self-Evaluation and the PNAIS Evaluation (both done in 1978), a document entitled Base- canip Overview," which appears to have been prepared during June of 1986, a proposal for annual Basecamp staff training, and a ?rough draft" of a Basecamp Staff Handbook; b) Conclusions drawn from the major investigative efforts of our com- mittee on the 0.E.S. accident on Mount Hood in May. 1986. (See the attach- ment which lists the individuals and written materials consulted for this work); c) Discussions among ourselves while at 0.E.S. as well as follow-up discussions via telephone and meet- ings; d) Our collective knowledge of edu- cation and adventure activities We will address each subject area included in the first part of your charge to us. We have added some categories as well. It is important to state at the outset that none of our findings are based on having seen the Basecamp Program in operation. We will recommend that step as a part of restructuring the program. Bas?camp Program Philosophy A. The description of the Basecamp Program found in the school marketing literature and the more detailed docu- ment entitled Basecamp Overview" very clearly outlines the philosophical goals of the program. We believe that the philosophy so described is compati- ble with the educational goals of the school. In fact. it more sharply de?nes the school and gives it an identity which sets it apart in an education- ally healthy manner from schools which do not use outdoor adventure components to achieve the same raults. B. Because the Basecamp Program is a requirement and because it makes use of activities not normally found in typical academic and extra?curricular setting, we believe that another goal should be added to the five specific ones stated: To learn to operate safely in wilderness settings. This goal assumes yet another, which is to gain skills in wilderness acu'vitles. The for? mer needs to be explicit, while the lat- ter could be included in goal number four, which is, ?To gain an apprecia- tion of the wilderness.? We recognize the fact that the coordinator of the Basecamp Program, Sam Dibbins, ac- knowledged safety as a primary con- cern, stating it explicitly in his propos- al for a staff training program. It only remains to be included similarly in all Basecamp literature, and in corre- spondence to students and their par- ents/guardians. C. The school must be certain that the specific Basecamp Programs for each class are compatible with the phi- losophy of the program. Since the phi- losophy stresses cooperation over com- petition, and involvement over exclu- sion, care must be taken to create pro grams in which all students and facul- ty can participate safely. The maxi- mum physical requirements for the worst possible situations must be ascertained, and should be no greater than the weakest participant can accomplish. If there are to be options within the program to the usual activi- ties, then they must be communicated clearly. (This comment is in speci?c response to the current whom com- munity service alternative to the Mount Hood climb. which, as several stated to us, is not really an option.) Operating Procedures and Policies A. According to the Operating Poli- cy which is part of the ABasecam Overview" document, the chain of command for the program begins with the Board of Trustees as they are recponsidle, ultimately. for all school here on Thursday 3 bodies found here Vladnesday i "sa- These are the investigation panel's key ?ndings on the decisions made during the fatal May 1986 Mount Hood climb. Analysis Of the climb but did not expect it to worsen as soon as it did. 3 It was not unreasonable for the climbers to start out under the weather conditions at the time.- around." THE PREPARATIONS THE GUIB during good weat tern general practices unacceptable. related matters. In our discussions with two trustees, however, we found that there was no formal structure for providing hoard oversight of Base- camp. We recommend that the 0.E.S. Board create a Safety Committee from among its membership to provide closer oversight of the structure and substance of the program. This com- mittee, which should include the head- master, should meet on a regular basis with the coordinator of the Basecamp to review policies and procedures and to be brought up to date on pertinent matters. Another function of this com- mittee is to conduct periodic internal and external safety reviews of the Basecamp Program in much the same manner as the 1978 Self Evaluar tion and PNAIS Evaluation took place for all the school?s other programs. Integral to this commitment is that the board must continue to maintain ade- quate funding for the program. B. The current structure names the head of the Upper Division as the indi- vidual to whom the coordinator reports. Currently, all paper work regarding the program goes through the head of the Upper Division. In terms of day to day operations, the program is handled by the coordinator, as one of his assigned duties In our attempt to pull together written materials on the program and from our interviews, it became apparent that coordinating the Basecamp Program has been a catch-up matter for the past several years, especially since the expansion of the student body. We rec- ommend that a full-time coordinator be hired, in view of the current size, nature, and complexity of the program. In conjunction with this, we further recommend that the Basecamp Pro- gram be suspended until such time as this person is hired AND the other rec- ommendations found in this report are addressed. C. Regarding the ?chain of com- man in general, we recommend that clear descriptions of the responsibili- ties of each person in that chain be written. Each role should have clear but sep- arate tasks of oversight D. We recommend that among the ?rst tasks of the Basecamp coordina- tor. the following materials should be completed. 1) A refinement of the written goals and objectives for the programs in each grade, with particular attention to evaluating the programs in the light of varying levels of students? abilities from?year to year. 2) Completion of the Basecamp Staff Handbook, which should include at a minimum a) program goals and policies; b) safety procedures for the program and each activity; c) emergen- The Rev. Thomas Goman had the necessary skills and training to lead the group on a climb 0 Training for the students met or exceeded 0 Equipment was adequate for fair to moderate weather but not for the conditions that day. 0 The ratio of climbers to leaders was 0 The group was alivare of the weather forecast. unaweptable" back at this roup'.? cy procedures; d) guidelines for each activitym 3) An accident data analysis sys- tem: 4) A system for evaluating and doc- umenting activities, each year's pro- grams, staff performance and training criteria; 5) A training system for staff that provides regular updating of common practices and procedures for this type of programming; 6) A written procedure for deter? mining the competency of all leaders in the program. Instructional Staff Training, Qualifications From our review of written materi- als and discussions with some faculty and Basecarnp staff, we found that identifying Basecamp instructors has been largely a matter of faculty mem- bers stepping forward because they have had the interest and the skills to match the program. The process has been informal, and has moved forward, as with many programs in place for a long time, on its own momentum. The ?eld staff we reviewed on paper and through interviews appeared to be competent for the program, but lack- ing in experience for managing worst- case situations. Again we would emphasize that safety in the program must be the ?rst consideration. A. Our ?rst recommendation is that speci?c job descriptions be written for staff at each instructional level. This should include a list of minimum oom- petencies needed in a worst?case sce- nario. B. We recommend that if 0.E.S. hires outside staff for the program, a written description of the role should be part of that process. C. There should be periodic review and training sessions for all Basccainp instructors. We noted that these had been held in the past and that more training is scheduled for this year. But we also saw in some of the internal correspondence that this need has been perceived for quite some time, and that ?nding the time and, until recently, the funding, have been identified as prob- lems. D. Faculty who serve as Basecamp instructors have been pressed to ful?ll all their obligations to the school. The program appears to have been regard- ed as part of an extra-curricular activi? ty, and part academic requirement, creating the possibility for the over- loading of schedules. We noted that plans were in place to work Two hours into the climb the group arrived at, Siloox Hut about an hour behind schedule. The decision to continue to climb was ?not 9 Atme'benchbelow Hoqsbackafteraghthours title night. At Palmer Lift. ?ve hours into the climb. ?Se ious The decision to build a snow cave after 16 hours consideration should have be?ngiv?n to turning point. The onward course of action would have been to descend with theentire load of Fr. Goman, for example, and we recommend that adjustment (of) teaching and extra-curricular loads be carefully considered for faculty engaged in the Ba?ecamp Program. E. Instructional staff need to be evaluated on a regular basis. We rec- ommend that this be an explicit proc- ess which results in periodic written evaluations. Students? Screening. and Preparations We do not lmow what percentage of the students at 0.E.S. are there because of the Basecamp Program, but because Basecamp is prominently dis- played in the school literature and because it is a requirement for the upper classes, we can begin by reiter- ating what we said in the section on philosophy: The activities must be compatible with program philosophy, and therefore, realistic options must exist within it to accommodate stu- dents? physical differences. A. It should not be necessary to screen students out of the program, but rather, to screen them for appropriate options within the program. Apparent- ly, the current system is one of careful- ly determining each student?s physical abilities and special medical neetk and then attending to those as they arise. The only adjustment in the program is to allow students not to complete an element. For example, turning back on Mount Hood is a common event. the goal being for each student to go ?a step beyond" his/her perceived limits much as athletic programs are structured to encourage students to push their limits. We recommend instead that screening both students AND the activities should be done in order to insure that all members of a given group can accomplish the task set forth. (For major elements, there fore, related but alternative tasks for different levels are probably appropri- ate. For example, Silcox Hut could be a goal for a group of students. B. Students need to be prepared mentally and physically for the various program elements. While there is a training program. we found that not all students or their parents felt that the preparations have been adequate. In the past few years, the problem seems to have increased due to a larger student population and staff members? schedules being stretched beyond their capacity. All required program ele- ments should be Within the students' grasp just as the academic program ?The human and environmental conditions clearly indicated that this was the time to tum 0 At Hogsback: ?The group should unquestionably have turned back? 0 The decision to warm Patrick McGinness after ascending for 12 hoursis accepted practice. but under the circumstances, it would have been better to continue down immediately or dig in for was acceptable only given the circumstances But the value of the cave was significantly diminished by the loss of equipment, other . members not helping to dig the move. and no _'pr?otocol established for its maintenance The Oregonian/STEVE NEHL Gremlin is. The history of 10th grade attempts on Mount Hood over the past 10 years suggests that many who have made the attempt had no chance of attaining the summit. We would recommend that only those students who have a ransom able chance of success or who have a real desire to try should be allowed to attempt an activity such as this. Peer pressure at this age and in the compeiu?ve school environment of 0.E.S. an easily lead students into sit~ nations for which they are not ready. It must be kept in mind that one of the underlying causes of accidents in out- door pursuits is the desire to please other people peers and authority ?gures included. communications It appears that better communica- tions between the school and home regarding the program should be developed. This problem came sharply into focus on the Mount Hood climb this year. Parents had received no information regarding the climb, as they had in years prior to the past two. and there was no meeting set up to dis- cuss the climb or the Basecamp Pro? gram. Both are recommended, even if only a few parents attend an informa- tion meeting (as apparently had been the use). The full nature of the pro- gram, and especially elements like a climb of Mount Hood, should be com- municated to parents, including a clear statement of the potential risks and a description of the methods for mini- mizing hazards. Accompanying this communication should be a written release to be signed by parents/guard- ians. We believe strongly that parents have a parallel responsibility to inform themselves as well, but the school has the initial responsibility for disseminat- ing information. Though the Basecamp Program has been an integral part of the school for well over a decade, each year there are students who are new to the school, and who therefore need to be provided with information on the Basecamp Program. This year, there were three students on the Mount Hood climb who were new to the school this academic year. Some par- ents indicated to us that they did not feel they had adequate information on the program as a. whole or the climb in. particular. Our general recommenda- tion in this area, then, is to develop a communication system which will keep students and their parents, as well as the trustees and staff of the school, more fully informed of the details of the Basecamp Program. General Conclusions The Basecamp Program at the Ore-g; goo Episcopal School is a educational adjunct. Precedents for such an endeavor exist in schools: throughout the country and abroad.? The response to the program by stu-.. dents. parents. and school staff, as welt, as the community, has been very tive, for the most part. Until the time of the accident on Mount Hood, the; program had an excellent safety rec?fi ord In recognition of the growth of meg; prorani plans were well under way?: to provide further training for staf?-?i' and to restructure the overall manage-3?" ment in order to keep up with the changes. We have identified those areas which need to be addressed specifically? if 0.E.S. is to continue with the pro?. gram, and we hope that the school will make these changes and modifications? rather than to discontinue having this unique and potentially positive offer-- ing for its students. Recommendations 1. There should be a moratorium? declared on the Basecamp Program until a) a full-time director of the Base: camp Program has been hired AND by. the specific recommendations we have-z put forth throughout this report havei . been ful?lled 2. 0. ES should communicate with.? the Association for Experiential Educa?n' tion, whose membership includes; schools. Programs, and individuals: engaged in experiential endeavors such?. as the outdoor/adventure activities, offered in the Basecamp Program. burr. thermore. the Basecamp Program: should make use of the A.E.E. publicity;- tion ?Common Practices in Adventure". Programming" as a guide when. addressing the recommendations we have set forth. 2 As soon as the Basecamp Pro~ gram is ready to function, the external. 7 review process begun with our com-r: mittee's work should continue with an look at both the structural and field; aspects. Respectfully Submitted. John E. (Jed) Williamson Chair Cameron Bangs, MD. Andrew Harvard Peter Lev Bruce Shaw July 22, 1986 The Mount Hoodji accident Following is the inquiry commit: tee's report on the Mount Hood acci- dent itself. Board: T0: Oregon Episcopal School of Trustees FROM: Base Camp Inquiry Committee SUBJECT: Analysis of the Mount Hood Accident May 1986 introduction The following report stems from; the second charge given to our com-3. mittee as per your letter of June 1986. Our ?ndings are based on several; considerations: a) Personal interviews with OILS . parents, students. staff, and boar members (see Appendix b) Personal interviews with outside} resources, including a local meteorologj gist and Weather adviser to Mount . Hood, Portland Bureau of Parks and; Recreation personnel, Mazamas perr?, sonnel, Timberline Mountain Guides, Outward Bound personnel, Portland. Mountain Rescue, and the 304th (see Appendix c) A review of written materials; which includes personal statements written by surviving climbing ment-u bers, 0.E.S. Basecamp policies and}. guidelines, 0.E.S. internal correspond?g ence pertaining to the sophomore pro- gram, Mazamas and Portland Bureau. of Parks and Recreation guidelines: ?Guide to Oregon? 5 Mountains? Nicholas Dodge, newspaper articles, . and both the Clackamas County Sher iff?s Department and Seattle Mountain Rescue Council reports on the accident (see Appendix f, d) Discussions among ourselves dur ing our 011- -site review held from Jun 1&22, 1986, as well as follow- -up con- versations; e) Site visitation to Mount Hood by:V a: Peter Lev on June 20 to ascend the: South Side route and to descend to the" site of the emergency snow cave; . . f) Site visitation to the 0.E.S. equip-1,, ment room by Jed Williamson on Jungd . 396 g) Our collective experience and knowledge of mountaineering, educaD; tion, adventure programs, and hypogg thermia, especially with regard to mat? Page 03. -, it] IHE OREGONIAN, JULY 25, 1986 - Decision not to turn back inconsistent with past ters of leadership and maintain safety. Our conclusions cannot change the results of this terrible accident, howev- er, they should be of interest to others In the interest of preventing mgedia of this magnitude in the future. we encourage you to share this report. This report will praent summary descriptions of each signi?cant event surrounding the accident, followed by our discussion and observations. Our general and recommenda? tions will be found in the final section. Circumstances Preceding the Climb Description Prior to the first 1986 attempt on Mount Hood by the 0.8.5. sophomores, preparations had included a) a day of technical training in how to travel over snow terrain, use of ice axes and climbing ropes. basic first aid, and familiarization with clothing and equipment; b) a conditioning hike: and c) classroom meetings to discus phi- losophy, goals. and any pertinent details regarding the climb. All the sophomores were required to attend these sessions, before participating in the attempt on Mount Hood. (Makeup sessions were scheduled for those who missed any.) Medical forms and Emergency Authorization forms were completed by each student. In addition, Fr. Goman. the Grade 10 Basecamp leader, made written notations of individual student problems as recorded on the medical forms and'as observed during the conditioning hike. An equipment list and a description of the equipment was given to each student. The equip ment and clothing of each was checked prior to the conditioning hike, and immediately prior to departing 0.12.5. for the Mount Hood climb. Each stu- dent unpacked his or her pack to enable an A.C.T. to check for required items. Six people did not have their packs checked but were checked ver- hally. Before leaving the school on the evening of the climb, according to Molly Schula, a 12th grade A.C.T. member, each student was given two caribiners, a seat harness or webbing, a prussik sling, and a breakfast and lunch. At Timberline Lodge. each stu- dent was given an ice ax and helmet. Group equipment for the climb included one frame pack, one sleeping bag,?one lZ-foot by 14-foot coated nylon tarp with grommets and tie strings, one mountain stove, three climbing ropes, about 50 wands, a few flukes and one picket (anchors for fix? ing lines above Hogsback), and two first aid kits. Fr. Goman and Ralph Summers carried Silva Ranger and Explorer compasses, and Summers car- ried a Rama: mountain shovel. Fr. Goman was designated by Sam Dibbins, the director of the entire Basecamp Program, as the leader of the Sophomore Basecamp Program, which included the climb of Mount Hood. With the approval of Mr. Dib~ bins, Fr. Goman had hired Ralph Sum~ mers to help instruct on the technical training day and to be a ?technical consultant" on the Mount Hood climb. Summers had been one of the leaders the previous year, when Paci?c Crest Outward Bound staff ran the technical aspects of the sophomore program. He was also chosen because it was believed that he had the appropriate communications skills for working with this age group. Summers? speci?c responm?bilitiee, as he understood them, were to be a consultant in the technical areas of emergency medicine and tech- nical climbing, and to be of general assistance to Fr. Goman in the leader- ship of the climb They had discussed the nature of both their leadership roles in early March. Fr. Goman?s responsibilities as leader included set- ting the tone, working with individual students, and determining when to send students down or to let them turn around. He had the overall responsibili- ty for determining whether the climb would be a go or nogo. Once on the mountain, it would also he Fr. Goman?s responsibility to make the decision as to whether to condone or turn back. Ralph Summers proposed bringing Dee Zdum?ak, a Paci?c Crest Outward Bound instructor, on the climb in order to familiarize her with the program. It was hoped that she could assist Fr. Goman on the fourth attempt for 1986, as Summers had a prior commitment for that time period. Fr. Goman agreed to this arrangement Advanced Climbing Team members upper class students who had received additional skills training and had been selected by a panel of judges from the school were desig- nated to be of assistance, primarily to escort individuals who could not con- tinue back to the parking lot. The were not viewed by the school, Fr. Gordan. or our committee to have had leader status. The actual ratio of leaders (those who assumed responsibility for the safety and conduct of the climb -- Fr. Goman and Ralph Summers) to ?cli- el?its" (those whose safety was to a large degree dependent upon the guid- ance and decision making of the lead- ers all the students and the inex? perienced adults) was thus one to 8.5. 5? The weather for the two days prior to the climb was unsettled and there had been new snowfall. On Sunday, May 11, Fr. Goman heard a weather l. report. At lea: two sets of parents had also procured a weather forecast and. asrainandsnow werepredictedhad called Fr. Goman regarding it and the plans for the climb. Mr. and Mrs. Header and Mr. and Mrs. O'Leary told us that they were informed by Fr. Goman that the group would probably only be out for a few hours and would probably be back by 1:00 or 200 pm. (See Appendix On the morning of the climb, Sum- mers and Zduniak were in the parking lot at Timberline Lodge when the 0.2.3. students, Fr. Guinea, Mrs. Spray, and Marion Horwell arrived at about 0230 hours. Summers had heard the weather forecast on his FM radio, and was aware that a storm was pre- dicted for Monday. The weather radio in the climbing sign~out but was on. In previous years. Fr. Goman wrote to the USPS (US. Forest Service) at Mount Hood regarding the plans for the climbs. He asked for the appropri- ate forms and permits, and the response he got was an instruction to fill out a ?Climbing and Backcountry Travel Register? form at Timberline prior to each departure and upon return. Since this instruction had been consistent over the years, Fr. Goman filled out a Climbing and Backcouutry Travel Register form and left it in the box. as he had done in the past. (See Appendix C.) Everyone made clothing changes and other necessary adjustments, and departure from the parking lot occurred about 0300 hours. Observations The overall training which the stu~ dents had received for this climb for the most part met or exceeded general guiding practices, as well as the specif? ic Mount Hood protocols developed by recognized local guiding groups. In our estimation, preparations were ade? quote for a fair to moderate weather ascent at this time of year. We will comment on speci?c items where some questions arise. especially given the existing snow conditions and the potential for the projected severe storm front moving in. 1. Boots. In our opinion, the flexi- ble, lightweight leather hiking boots, with rough leather out, which some studenm were permitted to wear were inadequate for the conditions prevail- ing and forecasted for the time. Such footwear may be adequate in fair weather and for hard summer snow conditions, assuming crampons will not be worn. 2. Gaiters. In fresh, deep snow con- ditons, such as those prevailing and forecasted, coated nylon or goretex gaitors (Spats which cover lower legs, ankles, and boot tops) provide protec? tion from snow-water entering boot tops, keeping socks and feet drier. This item should have been required for all. 3. Face Mask or Balaclava. This item provides protection in wind and storm conditions and should have been a requirement. 4. Crampous. We understand that the two leaders and the had crampons, and that the reason studeus did not have them was because the leaders agreed that persons untrained in the use of crampons might stand more chance of injuring than of help- ing themselves. We further understand that the plan for securing the route where crampons might be needed was to put in fixed lines, anchored with flukes or pickets. The leaders then would cut steps, and students would use prussik slings on the ?xed lines. While in our opinion this method would work if conditions were hard- packed snow, we must also note that local protocol requires that crampons be carried by all. If the climbing ropes were not to he used as fixed lines. then students would be roped up and moving contin- uously, with a leader for each rope. This method would be acceptable if there were no more than two students per rope. as it is unlikely that a leader could self?arrest more than that. Bemuse of the ratio of leaders to cli- ents on the climb, this method would not have been possible. We would also note that both methods are time con- suming and therefore add to the com- plexity of the climb. 5. Ensolite Pads. Either one full length pad for each sleeping bag aar- ried or individual pads big enough to sit on should have been included in the group equipment. 6. Sleeping Bags. There should be a ratio of one bag for every three or four people in each group. 7. Bivonac Sacks. There should be one of those for every six to eight peo? ple. both for accommodating sick/injured people and severe weath- er. 8. Shovels. There should be a mini- mum of two shovels in each group. There should be a ratio of one shovel for every six to eight people. 9. Map. The leaders should carry a topographic map of the mountain. Compass bearings and landmarks should be reviewed on the map. 10. Altimeter. While not all guided groups we talked with carry this item. we recommend it for Mount Hood becausea)itisabarometerandb)in whiteout conditions, knowing one?s elevation is an aid to navigation. In this particular situation, it could have greatly aided the rescue operation to know the elevation of the snow cave Leaders should be familiar with rele- vant deviations and landmarks on the rail ute. 11. Radios and Pieps (radio bea- cons). Neither of these are standard items on ascents of the South Side of and accident investigations. . ANDREW HARVARD ascent of Mount Everest. DR. CAMERON BANGS Treatment." BRUCE SHAW- 355. The investigators Irile ?ve?member panel that investigated the climb included: JOHN EDWARD WILUAISON Williamson is from Hanover, N.H., and is chair- American Alpine Club. chairman of the club's safe- ty committee and editor of the alpine club's annual report. ?Accidents in North American Mountain- eering." Williamson has led climbs by college stu- dents and has conducted numerous safety reviews A senior attorney from Brooklyn, N.Y., Harvard is with the Federal Reserve Bank in New York and is formerly of Washington state. He has 20 years of mountaineering experience with 12 major expe- ditions, including one as coleader of a suwessful A mountaineer and skier from Oregon City, Bangs has participated in several international expeditions but is best known as an expert in the treatment of hypothermia. He has been involved in ?eld treatment in 55 rescues. He is co?author of the book ?Hypothermia. Frostbite and Other Cold Injuries; Prevention, Recognition and Pre-hospital Shaw is from San Rafael, Calif. The headmaster of Marin Academy, a private school in San Rafael, he has been active in the school?s outdoor educa- tion program, which includes snow camping, river rafting and kayaking. He has taught English and 7 social studies and previously was head of the upper school at Shady Hills School in Cambridge, Lev is from Draper, Utah, and Moose, Wyo. He is part?owner of the Exum School of Mountaineering and Guide Service in Jackson Wyo., and one of the principals of the American Avalanche Institute. A guide in the Teton Range for 25 years, Lev IS an avalanche expert and meteorologist who has advised the U. Forest Service about avalanche hazards. The Winn Mount Hood in this season. Pieps are normally worn when traveling in ava- lanche terrain. For this climb, radios and/or Pieps would be a precaution exceeding the normal practices. While in retrospect it appears obvious that if each student had been wearing a Pieps, finding the cave location could have been greatly facilitated, in our opinion we do not believe that they should have been a required item, based on the fact that the climbing party should not have been out in the conditions it encountered. l2. Compasses. Each leader had a compass, which is appropriate. The compass should be accessible. We note that Mr. Summers' compass was in his pack and was not used. 13. Watches. Each leader should wear a watch or have it accessible. Keeping track of the time during a cloudy day, a storm, and the night can only be done with a lime piece. 14. Special Use Permit. The prima- ry purpose of this permit is to collect user fees, not to assess or control the qualification of climbers or leaders. This regulation is enforced variably throughout the mum, and we do not consider it relevant to the particulars of this accident. 13. Ratio of Leaders to Students. Given that by de?nition each person designated as a leader must be capable of taking on all the responsibilities anticipated during the climb, the ratio on this climb was one leader to 8.5 cli- ents, since the do not have suff- cient experience to meet such stand- ards. In our opinion, a ratio of one to four is appropriate for this kind of climb. In any event, we consider a ratio of more than one to six to be unacceptable. On this climb. a greater ratio of leaders to climbers could greatly have increased the chances of a safe descent. 14. Parent/Student/Staff Under- standings and Expectan'ons. We under- stand that at least some parents and students had been told by Fr. Goman that the group would only be out for a few hours. making only a token effort before returning, in view of the weath- er forecast. 0n the other hand, Ralph Summers and other students under- stood that the group would be attempt- ing to reach the summit unless weather or human conditions actually dictated a descent. The net result of the inmnsis- tent expectations was that what had been apparently intended as a means of reassuring concerned parents in fact served the opposite purpose, in both the short and long run. This apparent lapse in communication probably exa- cerbated by the fact that for the past two years a letter describing the Grade 10 Basecamp Program was not sent out to parents as it had been from 1977- 83. 15. Weather Report. The weather report. which both leaders had received forecast a several?day storm. From the weather maps available at the time and from conversations with Mr. Charles Feris, the local meteorologist who advises Mount Hood, we conclude that because of the nature of the cyclonic storm, the forecast was highly reliable, and it was for a pattern for which forecasts are generally known to be reliable. The only variable was the pre- cise arrival time of the main front, bringing the most severe aspect of the storm. A variation of plus or minus six hours is a reasonable expectation. (See Appendix B.) 16. Decision to Leave the Parking Lot. Given the actual weather condi- tions at 0230 on May 12 and the prepa- rations for the climb, we conclude that leaving the parking lot was not an unreasonable decision. It was at this point, however, that the group should have been briefed as to the conditions and the overall plan, including a clear understanding of the basis on which a decision to turn back Would be made. Some of the local climbers and guides told?us that they would have begun the climb under these or worse conditions. It should also be noted here that other parties indicated that they did not start out that mornng either because they did not have enough clients or because they did not want to make a long drive to and from the mountain if the chances for sum- mitiug were less than good. It is note- worthy that climbiug parties turned back on the two days prior to this because of the conditions. There were also some who indicated that the fore- cast was enough for them to cancel plans for a climb. The Climb Description What follows is a summary of the principal events of the climb as pieced together from talking with some of those who returned early in the attempt, and with Giles Thompson. Briutou Clark, Molly Schula, and Ralph Summers, as well as from the written statements made of Ralph Summers and Molly Schulz. The group left the parking lot around 0300, with Molly Schula (an ACT member) setting the pace in front and Susan McClave (also an ACT mem- ber) in the rear. Fr. Goman, Ralph Summers, and Dec Zduniak caught up with the group shortly after they had continued on from their first rest stop. Dee Zduniak stated that she talked with Fr. Goman during the ascent of this ?rst section because she wanted to learn more about the program and spe- ci?cally about the role of the technical assistant or assistant leader. She asked Fr. Goman whether the person in that role had any decision-making author- ity, and he told her that he was ulti- mately responsible for the decision making but that he would certainly consider the advice of the technical consultant. Students continued to lead, break- ing trail through calf deep snow. Progress was slow. Summers went up and down the line making contact with the students. The weather was windy, cold, and, according to Molly Schula, the stars could not be seen, but the . lights of Timberline Lodge could be. Within the ?rst 45 minutes to an hour, Hillary Spray, who is a diabetic, was not feeling well, so she and her mother turned back to the lodge, which took them ~15 minutes to an hour to reach. Theeaimatedtimeofarrivalatthe Silcox Hut was 0500 hours - about an hour behind schedule according to Fr. Goman, who was the only member with a watch on. (Summers? watch was in his pack.) Everyone was encouraged to eat and drink. After a 15-minute rest, the group started again, with three students sharing the lead. The progress of the group contin- ued to be very slow. Two more stu- dents, Courtney Botsman and Lorca Fitschen, turned back, and a while later, Mick Garrett (an ACT member) escorted John Whitson down. Accord- ing to Molly Schula, the group became divided before reaching the top of the Palmer lift, primarily because faculty member Marion Horwell was moving very slowly and complaining of dizzi~ nesc. (Ms. Harwell was an adult facul- ty member, but an inexperienced climber. and was not considered to have any leadership responsibilities on the climb.) Fr. Goman asked her if she wanted to go down. but she decided to go on a little further. his plan being for Schula to escort her down when she became too tired to go on. The group reached the top of Palmer Lift around 0800 hours. having taken several breaks. The weather was still windy (estimated at 15-20 by Summers) and cold, and there were two layers of clouds. During the 20 minute break here, Summers told us? that some students considered turning back, but after discussion with the leaders. they decided to go on. Every- one was encouraged to eat and drink. One student was feeling nauseous at this point. The climb continued. Above the lift Susan McClave and Fr. Goman took turns breaking trail and carrying the frame pack with group equipment. Wands were placed about every 200 feet. A ?bench" below the Hogsback around the 9,300foot level was reached at about 1100 hours, according to Summers. He also stated that the weather ?remained stable,? with more low clouds in the valley, but less wind and ?relatively warm? temperatures. He reported that they could still see Timberline Lodge and that they could see the summit. Shortly after leaving this place, within a half hour, Dee Zduniak turned back because of begin ning snow blindness, apparently a recurring injury from the previous winter. At about this time, the weather was beginning to change. Clouds were lowering and eclipsiug the summit. Summers and McClave were now in front, making steps in the soft, deep snow. The group was moving slowly, with Marion Horwell in the rear being assisted by Fr. Goman. By the time they had travelled through the area known as the Devil?s Kitchen and were at the Hogsback where it meem Crater Rock, the visibility was down to 50 feet, and it was getting colder. Various members of the group were having dif? ?culty. Fr. Goman and Ralph Summers discussed turning back. Summers reported that Fr. Goman wanted to make just one more effort upwards. Summers said that he deferred to Fr. Goman?s leadership of the group on this issue, but. that it was understood they would only go a short distance further. Continuing on from the Hogsback, the group was apparently spread out, and the weather deteriorated even more. They left their packs at the Hogsback. Summers was in the lead, but moving more quickly than the stu- dents, he soon lost contact with the group. He went back to them, and then told Fr. Goman they should turn back. which they did. It is at this point that Summers said be mentally became the leader, but did not discuss this with Fr. Goman. At this time, about 1400 or 1500 hours, they had been ascending for at least 11 hours, including breaks. Observations Climbing Guide to Oregon? 5 Mountains" by Nicholas Dodge, Mount Hood is described as a mountain whose ?register probably records more entries than any other major peak that must he climbed on foot.? In good? weather and good conditions, it can be a comparatively easy uphill bike. It has been successfully ascended by many inexperienced people, including several physically impaired individuals. The fact that Mount Hood has been climbed by people from age 5 to 75, and by tens of thousands over the past century must be viewed, however, with an understanding of is having one of the highest accident rates of any mountain in the Lower 48 states. In bad weather or poor conditions, Mount Hood can be a serious mountain environment requiring the skill and experience for survival. The primary route, South Side, is rated in the guide book, under the National Climbing Classification Sys- tem (NCCS), as 1-1. (The top of this scale is The Roman numeral indicates overall dif?culty, takes into consideration the required commit? ment and the objective dangers involved. The Arabic numerals indicate individual pitch dif?culty of the hard- est free (ropes and pickets, etc.. not used for direct aid just for protec- tion in case of a fall) climbed pitch or move. While a Grade I climb is consid- ered to have the least overall dif?culty, thisdoes not mean it is without objec- tive dangers such as bad weather, rockfall or route finding problems. (Fr of comparison with the South Side Route, we note that' Ore? gon, the most dif?cult overall snow tr climbs, according to Dodge?s book are the Eliot Headwall on Mount Hood and the East Arrete on Mount Jefferson These are Grade 111's. and involve the use of protection, and exposure to rockfall, with estimated ascent times between nine and 14 hours.) The South Side of Mount Hood requires protec- tion (either fnred ropes or belays) only above the Hogsback, though most peo- ple climb that section unprotected when conditions are good. The esti- mated climbing time up on South Side is from four to 10 hours. The general orderliness of the ascent to the Hogsback by the Grade ll) Basecamp group, while different from typical guided climbs in which one of the leaders sets the pace and keeps everyone together, was not unusual for a group of this type. It appears likely that, over the 10 years during which the climb of Mount Hood has been attempted by Fr. Goman and about 350 sophomores, the range of abilities and the levels of enthusiasm of this year's group were no less than those of previous years. We were told by students, parents and faculty that this particular group was notably above the norm in terms of ability and enthusiasm. We were also told by Sam Dibbins that on two out of every three attempts Fr. Goman had made with 0.12.5. he has turned back because of human variables and/or environmental conditions. His decision not to turn back sooner on May 12, in fact, seems out of character. (See further discus- sion of this in following pages.) Local protocols (Mamas. Timber- line Guides, Pacific Crest Outward Bound, and Portland Bureau of Parks and Recreation) put the recommended turn around time at 1100 to 1200 hours, with the latest being 1300 to 1400, assuming reasonable weather and a group which is moving at an appropriate pace. An alternative proto? col for turning back is based on the total number of hours ascending; that is, if a group has been going up for 10 hours and is still short of the summit by half an hour or more, turning back is strongly recommended. We will discuss the critical decision points as the ascent progressed. l. Silcox Hut. At this point, the group had been out for two or more hours. They had been moving slowly through calf deep snow. The combina? tion of wind and temperature made everyone feel the cold. They were, by i the estimate of the leader an hour, behind schedule. We find that continu- . ing on from this point was an accept- able decision, given the ease of the route finding and the proximity of Timberline Lodge and the ability of the group to quickly descend to the lodge from any point between Silcox Hut and the top of the Palmer Lift. . 2. Palmer Lift. By this time, six1 people had turned back. At least two -: people Marion Horwell and Alison, Litzenberger were not feeling well. One or two others were also consider- ing turning back. The time was about 0800 hours, and the weather was about the same as when they had started. Given the time of day, the weather, and the deteriorating condition of the: group, we conclude that at this point,_ serious consideration should have been .A given to turning back. The prudent; course of action would have been to descend with the entire group. 3. The Bench (below Hogsback),. about 9,300 feet. Another person had} turned back below this point, and the. group was moving very slowly. They arrived here about 1100 hours, having dropped further behind schedule. The. weather, while appearing to be stable. had begun to change. The warming 7 trend which was felt was an indicator- of the leading edge at the front. The human and environmental con-V di?ons clearly indicated that this was the time to turn around. Progress. beyond this point exposed the group to the risk that they would be unable to- descend safely if the weather or their condition worsened. 4. Hogsback. At this point. we con- clude that the group should unques- tionably have turned back. Fr. Goman?s decisions to continue to the. Hogsback and beyond were unsafe mountain praclicm. ?rst, the visibility was only 50 feet at the time of the decision to turn back, and the slope leading to the crest of the Hogsback required a steep right angling traverse of some 200 feet (this is where the ?rst steep terrain is encountered on the route.) Second, the group did not have the collective skills, additional leaders, and appropriate additional equipment to manage the environmental condi- tions they were encountering. The grade of the climb had changed and most of the climbers were cold fati-V gued from their efforts up to this point At this point we must consider the crucial question: Why wasn?t the deci- sion to turn back made? Decisions up to this point were consistent with pre- vious climbs. The decision not to turn back was inconsistent with Fr. Goman's long record of safe climbs and conservative operations within the Basecamp Program. Clearly the rea? soning on which be based his decision- can never be known. It appears to us that Fr. Goman was ?rst and foremost an educator, and second, a person who: loved the outdoors and the mountains in particular. It appears further that he_ saw the latter not from the point of view of an expedition climber or a mountain guide, but rather, from his: chosen vocations priest and educa- tor. The mountaru was yet another classroom for him, another place where he could help others learn more See TEXT, Page D4.- is; I THE OREGONIAN, FRIDAY, JULY 25. 1986 Primary leadership role shifted when descent began next. from Page as. about themselves and grow. 0n the day of his last climb. he spent much of his time with Marion Harwell. whose need was great. His interaction with the rest of the group was primarily at the breaks and resting places. the nature of which. we gather was to encourage them. Deter mining his gen? eral frame of mind as he climbed that day would be highly specrdative. but as we discuss the descent. it will be seen mat there is the strong possibility that fatigue and the cold were affecting him adversely at a much earlier Stage than others in the group had become aware. ph Summers stated that he was still operating under the assumption that Fr. Goman was the leader. and Summers respected him both for hav- ing more experience on Mount Hood and for knowing the limits of the peo ple in the group. The-Descent Description Dif?culties began right away on the descent. The weather. which included whiteout conditions. and the people needing help drew heavily upon the energies of the two leaders. Patrick McGinness. who had not been feeling well since they had ?rst arrived on the Hogsback, was showing signs of Wm thermia. His temperature was taken with a hypothermia thermometer. At the flat area on the Hogsback, they found their packs. and efforts to rewarm McGinness were begun. About an hour later, around 1600 hours. Sum- mers and McClave started down with McGinness, who had been warmed in the sleeping bag and given warm drink. The others collected the gear and started after them. Giles Thomp- son carried Summers? pack, and Erin ton Clark carried her own and some one else?s pack. Fr. Goman was carry~ ing two packs also. as well as ropes. The going was difficult. The steps made on the way up were blown in. Molly Schula was leading the group behind until finding Summers and McClave, who were moving slowly with McGinness. They now faced the additional prob? lem of route finding. Fr. Goman was giving directions from the rear, shout- ing, ?Go left, go left." He had his com- pam out. Summers asked for the com? pass to be passed forward so the per? son in front could use it. At this point, they had found two of the wands which had been placed on the ascent. He reported that the compass was set at 160 degrees. He stated he assumed that this was to avoid heading into Zig lag Canyon. which could happen in whiteout conditions. As Summers was holding on to McGinne?. the compels was given to McClave. The conditions of travel were by now extreme and severe. with winds of 40 and gusts much higher. visi- bility at 10 feet or less, and deep snow. The group found no more wands beyond the place where the exchange took place. The wands were on the 180 degree course. Continuing on, they came to a crevassed area and steeper terrain. (Summers told committee member Lev that he thought they were in the southeast facing head of Zig Zag Canyon and that he was confused as to their location.) Schula remembers that just before this area. Fr. Goman had fallen over and couldn't get up without assistance. Summers stated that he halted the group in this steep area and asked Goman the time. which was reported at 1900 hours. He said he decided that given the environmental conditions. the lateness of the hour, not knowing their location, Patrick McGinness? and some of the others? physical conditions, the best plan would be to dig in. Molly Schula said that she recalled that Fr. Goman said they had better dig in. Summers used his shovel, and with some assistance from Fr. Goman, be dug the snow cave, estimated by Sum- mers to be six feet by eight feet by four feet high. The rest of the group was huddled under the tarp. with McGinness in the sleeping bag, while the shelter was being constructed. Between one and two hours later. Summers said he felt it was becoming critical to get people inside. as expo sure was now a serious factor. He asked everyone to get warm clothing and ?everything they wanted" from their packs, as it was decided that there would be no room in the cave for them. He got a space blanket for the floor from Molly Schula. The cave was very cramped. and the entrance was on steep terrain. McGinness took a fall down the bill from the entrance when he got out of the sleeping bag. He was guided back up by Summers? shouts and flashlight. Both Fr. Goman and Ralph Summers manifested hypother- mic behavior by the time they got into the cave. Fr. Goman was described by Molly Schula as ?violently shivering and couldn?t talk.? Staying warm, keeping the circulation going. and get- ting enough air to breathe were of con- cern to all throughout the night. There were no packs in the cave and there- fore no extra clothing other than what people had already brought in and no food, water, or stove to melt snow for water. During the night, the cave entrance got filled considerably and changed in configuration from horizontal to an upward angle. As the snow accumulated outside, attempts were made to widen the opening. On a rotating basis, people also would go outside feet first for air. Fr. Goman spent a lot of time outside dur- ing the night, and when he finally came in. he was again very cold. There was not enough room in the cave for the entire group to be inside all at once. Even with two or three people outside, the people inside would be piled on top of each other. In order to make any major position changes. people would have to go outside. Because of the cramped conditions. both air and blood circulation were compromised. Sometime during the night, the shovel went over the edge. Some peo- ple lost a hat. a mitten. a boot, etc. in the cave and did not find them. The storm had not abated by morning. In fact. it had become worse. About two hours after daylight. Summers decided to try to descend to get help. He stated that by this time. ?We had lost the ability to take care of ourselves; I felt I needed to let them (the people he knew would be down below) know of our situation." He stated that he was aware that Fr. Goman was in very poor condition. and was unable to respond to Summers' decision. He said he attempted to dig out his pack. but didn?t have the strength to do so. There was no sign of where the tarp had been. He felt the cold quickly, and decided to try to get someone else to go with him. He asked Giles Thompson. But Giles had been doing a lot of work to keep the entrance open. and was recovering from having been out in the weather. Molly Schula volunteered to go with him. They took one ice ax. leaving at least one other for those in the cave to work with. They took the compass as well, and proceeded to descend in con tinuing stormy weather. The events of the next two days at the cave and of the rescue itself are not a part of the charge of this committee as they do not pertain to decisions which led to and then influenced the accident. With Fr. Goman in a declin- ing state of hypothermia and Ralph Summers gone. the leadership of the group was no longer present. Howev- er, we feel compelled to observe that in the absence of leadership, the students exhibited a great deal of courage in continuing their efforts to'help each other to survive. The fact that three were caught outside the cave while on one of their turns and that two were found directly in the changed cave entrance where they had been strug- gling to keep it open exemplifies the students? spirit and drive under severe ly deteriorating conditions. Observations At the turnaround point, the environmental conditions and the levels of functioning in the group were increasingly on the decline. Protocols for me situations encountered became confused. and each action taken had as much chance of adding problems as of solving them. A basic factor which changed when the descent began is that the primary leadersz role shifted from Fr. Goman to Ralph Summers. though Ft. Goman was still in?uential in terms of the direction of travel. In light of this, we will look at the specif- ic decision points during the descent. l. Re?wanning Patrick McGinness. While the accepted practice is to re warm an individual with McGinness? under the circumstances it might have been better to a) condone down immediately. even if it meant dragging McGinness using a climbing rope; or b) to go to the next appropri- ate procedure digging in right there. The immediate goal in such a situation is to same everyone as quickly as pos- sible from the immediate life-threaten. ing hazard. even before performing first aid. The hazard was the weather. and the first aid cost the group an hour of time, and thereby. possibly the dete- rioration of others towards hypother- min. 2. Wands and Compam Course. Dur? ing the on-site descent of Mount Hood, one of our committee determined that because of the terrain, the group had to be descending on an azimuth of 180 degrees from the bottom of Crater Rock to the last wand found, which was between 9,300 and 9,400 feet. Whether the compass had been used for determining this direction is unknown. But from this point, the compass was used for direction, and its setting of 160 degrees and the constant going left even more than the bearing dictated were inaccurate, thereby put- ting them off-course. The correct azi- muth is 180 degrees, and between that and keeping Crater Rocks immediately to one's right on the descent either by visual contact or actually feeling the rock allows one to make a ?blind" or instrument descent. Not continuing the search for wands by using a climbing rope and having someone fan out on the end of it while another holds the other end at the last wand was a decision Summers said he made based on a) weather con~ ditions, b) the time it would take. and c) the ability to use the compass instead. Provided that the compass hearing was correct and the protocols used by local climbing guides for descending here were known, this would be an appropriate decision. 3. Digging In. The snow cave deci? sion is acceptable only because of the circumstances at the moment Other- wise. the protocol is to keep people moving down with as much energy and force as the leader(s) an muster. The value of the cave was signi?cantly diminished by a) the lem of equipment especially the shovel and Stove. because the former would have allowed them to work on the cave and with the latter they could have melted snow for water; b) other members of the group not participating in the dig- ging; and c) no continuing protocols for maintenance and discipline within the cave. 4. Leaving the Cave. Summers? deci? sion to leave the cave is one upon which we have drawn no conclusion. There were reasons to stay and reasons to go down. and given the dire circum? stances. both seem compelling. Staying could provide morale and perhaps bet- ter maintenance capability. It might have helped them remain more able to be rescued by being more visible and active. It might have been a reasonable expectation that rescue efforts were already under way. On the other hand. descending could insure that a rescue would begin. and that some help in locating the group might be given. General ConcIUsions Guiding young neophytes on climbs such as Mount Hood requires leaders with mountaineering skills which have been tested under extreme conditions. precise knowledge of the mountain and route being climbed, and a clear under- standing of where educational deci- sions must become secondary to safe mountaineering practices. In addition to our speci?c conclusions found in the text of this report, we offer the follow- ing general observations which pertain to the opening sentence. 0 Fr. Tom Goman had the skills and training to lead Grade I ascents and. over the years. had proven his ability to do so successfully in terms of both mountain safety and achieving daired educational results. On May 12, 1986, the conditions on Mount Hood changed the level of dif?culty of the climb at least one grade. While this happened predictably, it also happened with a much greater speed than antici- pated. and this. combined with Fr. Goman?s uncharacteristic decision to continue ascending. the various condi- tions of individuals in the group. and the kind of equipment available, led to tragic results. 0 Ralph Summers has the skills and training to lad Grade I ascentsf His role as technical consultant/assis? tant leader on the 0. ES. Mount Hood climb did not put him in the primary decision?making role until circum-_. stances became dire, overwhelming all concerned. 0 The Schedule. One of the pri? mary culprits in this accident was the - need to try to stick to a schedule. This was to be one of four ascents of the mountain by Grade 10 students, with no possibility of make-up dates because of the leader?s schedule and the school schedule. In addition. the leader's work schedule, which included academic. religious. and extra-curricu? tar activities, was stressful in itself. 1' 0 Leadership Roles. In our opin- ion. if an individual is hired or assigned the role of ?technical consultant" or . "assistant leader," then the authority to make decisions in the particular I areas assigned to that role must be given. further. the areas assigned must - be clearly defined. Co-leading and .3 assistant leading situations require the utmost care in this regard, as roles such as these may result in an unclear . understanding on the part of all as to where authority and responsibility rest. - Recommendations I. There should be at least a two~ year moratorium before attempts to climb Mount Hood. in- order that the rest of these recommen? dations can be effectedcontinue with the Basecamp Program. a full? time person" with quali?cations commensurate with the position should be hired to direct the 3operation. .0. E. S. should complete that mittee. 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