IMPROPER DECISION–FAILURE TO TURN BACK, FATIGUE, EXPOSURE, HYPOTHERMIA, INADEQUATE EQUIPMENT, WEATHER, FAILURE TO FOLLOW ROUTE

Oregon, Mount Hood

Early on the morning of May 12,1986, a party of 20 from the Oregon Episcopal School left Timberline Lodge at the base of Mount Hood for a summit attempt. The climb was part of the O.E.S.’s Basecamp Program, a four year adventure component which is an integral part of the school’s curriculum. The group was led by Fr. Thomas Goman (44). He was assisted by Ralph Summers (31), who had been hired as a Technical Consultant/ Assistant Instructor by Fr. Goman.

Twelve sophomore students formed the nucleus of the group. In addition to the leaders, they were joined by one parent, a faculty member, three upper class students who had received additional skills training, and Dee Dzudniak, an Outward Bound instructor who had been asked to join the group so that she would become familiar with the route and the program. (She might have become an Assistant Instructor on a later attempt.)

The weather two days prior to the climb had been unsettled, and there had been new snowfall. Rain and more snow were predicted. The leaders had heard the forecast on the radio and in the sign out area at Timberline. They were aware that a storm was predicted.

The group left Timberline about 0230, with students leading and breaking trail through calf-deep snow. Within 45 minutes, one student and her mother turned back. The rest continued on, reaching the Silcox Hut at 0500, an hour behind schedule. Here, two more students turned back, and soon thereafter, another student was escorted down by one of the upper class students.

After a rest at the top of the Palmer Lift at 0800, during which time more students discussed returning, the group pressed on in windy, cold, but seemingly stable weather. At a “bench” below the hogsback (2850) meters), Summers reported still being able to see both the summit and Timberline Lodge.

Shortly after leaving the hogsback, Dzudniak turned back due to a recurrence of snow blindness. The weather was changing, and various members were experiencing difficulty. Goman and Summers discussed turning back, but Summers reported that the leader wanted to make one more effort upward. Continuing on, the group was apparently spread out, and the weather had deteriorated even more. Summers, who was in the lead, came back and suggested that they turn back at once, which they did.

Difficulties began immediately on the descent. In whiteout conditions, many were in need of help. Patrick McGinness (15) was hypothermic, and efforts were made torewarm him. Conditions were extreme after this, with the wind estimated at 40 knots and visibility down to three meters or less. The trail was lost because of this and some confusion regarding the compass setting. Faculty member Marion Horwell (41) and Goman were exhibiting signs of hypothermia. Summers halted the group in a steep and crevassed area about 1900 and began digging a snow cave with his shovel, the only one they had. The cave was about the size of a six person dome tent when completed. There was not enough room for everyone inside at the same time. Throughout the night, attempts were made to widen the cave opening, and on a rotating basis, people would go outside for air. There was no equipment brought inside the cave, and during the night, the shovel was lost.

By morning the storm had abated, and two hours after daylight, Summers decided to descend for help, convinced that “we had lost the ability to take care of ourselves.” Molly Schula (17) volunteered to go with him. Fr. Goman was in a declining state of hypothermia by this time.

Simply stated, events for the next two days in and out of the cave involved a prolonged and valiant attempt on the part of the students to maintain the cave. When the rescue teams finally found the group, only Brinton Clark (16) and Giles Thompson (16) were alive. The others, nine in all, had succumbed to the extreme conditions. (Source: Condensed from a 22-page investigative report submitted to the Oregon Episcopal School by John E. Williamson, Chair of the Inquiry Committee, whose other members were Cameron Bangs, M.D., Andrew Harvard, Peter Lev, and Bruce Shaw)

Analysis

The overall training which the students had received for this climb for the most part met or exceeded general guiding practices, as well as the specific Mount Hood protocols developed by recognized local guiding groups. In our estimation, preparations were adequate for a fair to moderate weather ascent at this time of year.

Given the actual weather conditions at 0230 on May 12 and the preparations 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. But it should also be noted that other parties indicated that they did not start out that morning 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 summiting were less than good. Some climbing parties turned back on the two days prior to this because of the conditions. There were also some who indicated that the forecast was enough for them to cancel plans for a climb.

There were critical decision points as the ascent progressed. First, at the Silcox Hut, where the group had been for more than two hours. We find that continuing on from this point was acceptable, given the ease of route finding and the proximity of Timberline Lodge. But at the Palmer Lift, we conclude that serious consideration should have been given to turning back. The prudent course of action would have been to descend with the entire group.

The human and environmental conditions clearly indicated that the bench below the hogsback 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.

Decisions up to this point were consistent with previous climbs which the leader had attempted. The decision not to turn back was inconsistent with Fr. Goman’s long record with the Basecamp Program. We can only speculate that there was the strong possibility that fatigue and the cold were affecting him adversely at a much earlier state than others in the group had become aware.

Once the descent began, the group should have continued down immediately, foregoing the rewarming process until out of the life-threatening environment. First aid procedures cost the group an hour, and thereby further deterioration of others. Losing the route on the way down resulted in the need to dig in, which was acceptable only because of the circumstances of the moment. The cave location, only a few hundred meters laterally from the top of Palmer Lift, is an indication of how desperate conditions were. The value of the cave was significantly diminished by the loss of the shovel and the unavailability of the stove and other materials buried under the tarp outside.

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 understanding of where educational decisions must become secondary to safe mountaineering practices. In addition to our specific conclusions, we offer the following general observations:

Fr. Tom Goman had the skills and training to lead Grade I ascents and had proven his ability to do so successfully—in terms of both mountain safety and achieving desired educational results. In 18 attempts over the previous ten years, he had turned back two out of three times. On May 12,1986, the conditions on Mount Hood changed the level of difficulty of the climb at least one Grade. While this happened predictably, it also happened with much greater speed than anticipated, and this, combined with Fr. Goman’s uncharacteristic decision to continue ascending, the various condition of individuals in the group, and the kind of equipment available, led to tragic results.

Ralph Summers has the skills and training to lead Grade I ascents. His role as Technical Consultant/Assistant Leader on the O.E.S. Mount Hood climb did not put him in the primary decision making role until circumstances became dire, overwhelming all concerned.

The Schedule. One of the primary 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-curricular activities, was stressful in itself.

Leadership Roles. In our opinion, if an individual is hired or assigned the role of “Technical Consultant” or “Assistant Leader,” then the authority to make decisions in the particular areas assigned to that role must be given. Further, the areas assigned must be clearly defined. Co-leading and 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. (Source: Condensed from a 22-page investigative report submitted to the Oregon Episcopal School by John E. Williamson, Chair of the Inquiry Committee, whose other members were Cameron Bangs, M.D., Andrew Harvard, Peter Lev, and Bruce Shaw)