Dangers That Can Cause or Lead To…
South Boston’s Elisa Santry went on her Outward Bound trip, as the company’s own ads say, to test her limits. She wound up lying face down and bloody on a rocky canyon floor. A year later, her family is still struggling to make sense of what happened, and that quest is raising a big question: Just how safe is the gold standard in wilderness adventure?
Elisa Santry had been crying, which was not like her—she was a Southie kid, after all.
She hadn’t eaten much, either, just some trail mix and maybe a cracker. And it was hot. Unbelievably hot. The mercury bubbled toward 110 degrees, and the sun reflecting off the canyon walls in southeastern Utah’s red rock country made it feel like being trapped in a furnace. Still, she trudged on.
For the past 16 days, Elisa had hiked through mountains, backpacked through desert, and rappelled off cliffs; she’d also spent two days on a “solo,” testing her survival skills alone in the wilderness. So far, it had been a typical Outward Bound experience, at turns exhausting and electrifying. But today, Sunday, July 16, 2006, was not typical. The itinerary had called for an early morning hike down Lockhart Canyon to the Colorado River, followed by a multiday whitewater rafting trip. However, a girl in Elisa’s seven-member patrol had hurt her ankle while rappelling the day before, and the group’s 26-year-old instructor, Rob, had set out that evening to ready the rafts. His younger colleague, Alex, stayed behind to coordinate with an evac unit in Moab by satellite phone. Her hands full, she made sure the other six kids—Elisa, a girl named Karly, and four boys—had maps and whistles and, shortly after noon, sent them off to travel the eight miles alone.
The group followed a well-marked dirt road, taking a break in a spit of shade around 2 o’clock. That’s when Outward Bound’s Southwest program director, Mike DeHoff, passed them on his way to assist with the evacuation. Outward Bound says he asked the teens if they were okay. They all said yes. But Elisa was not okay. She told a patrolmate she felt like she was going to pass out, and took a nap while the others rested.
At 4:30 p.m., after trekking for another three miles, the group broke again. By this time, Karly (who, according to Elisa’s letters, sucked her thumb and could not tie her own shoelaces) was moving much slower than the rest. The boys were keen to keep going, and set off to walk the remaining 1¼ miles to the river, leaving the girls behind—a clear breach of Outward Bound’s protocol that says a patrol must stick together. A protocol that, Elisa wrote in her letters, the boys had already been chewed out for breaking once before.
Sometime after 5 o’clock, says Outward Bound, Elisa hiked ahead of Karly. At about 5:30, Alex, trailing the group after the evacuation, caught up with Karly and walked her down the dirt road to a gate. They passed through the gate and some dense tamarisk brush to meet up with the boys on the riverbank. It was 6 p.m. Elisa Santry was missing.
When Elisa Santry thumbed through Outward Bound’s 80-page brochure in early 2006, the 16-year-old saw scenes that were far removed from anything she’d ever experienced. “Find the edges of your limits and go beyond,” screamed the big blue text hovering over snapshots of teens crashing through frenzied whitewater and scaling frozen peaks. “Find out how far you can go.”
Elisa was hardly an adrenaline junkie. A quiet girl with a shy smile, slender build, and long, straight brown hair, she was a rarity in her hard-luck Southie family. Her mother was stuck at home caring both for Elisa’s elderly father, who was fading fast into the clutches of Alzheimer’s, and for her two young grandchildren, the kids of one of Elisa’s three older half-brothers. Two of those brothers lived in Massachusetts; the other, Michael, was far away in California.
An honor student who had just aced her MCAS tests at Roxbury’s John O’Bryant School of Mathematics and Science, Elisa hadn’t missed a single day of class—or a single episode of American Idol—since sixth grade, even while working part time as a cashier at Sullivan’s on Castle Island and helping care for her father. She had dreams of becoming a pediatrician or a singer, and spent her free time scribbling in a journal and working out algebra equations.
She was so impressive that her teachers nominated her for Summer Search, a national program for gifted high school students from poor families. It was there, in the organization’s local offices on Amory Street in Jamaica Plain, that Elisa came across the Outward Bound brochure. She penned an essay about wanting to overcome her shyness, and was one of 57 local kids to win a Summer Search scholarship to Outward Bound that summer. The $3,400 award paid all expenses for the 22-day “Southwest Mountaineering, Rafting, and Canyoneering” adventure, a trip that would take her far from the streets of her neighborhood to a remote region of Utah that had once been the largest uncharted area in the United States.
But her mother, Elisa Woods, was nervous. She’d always been overprotective of her namesake, ever since the two of them nearly died during a difficult early labor. Woods was wary of Outward Bound’s lengthy liability waiver, which read, in part: “I acknowledge that participating in an OB program involves inherent risks…hazards, and dangers…that can cause or lead to death, injury…I understand that OB cannot assure my (or my child’s) safety or eliminate all of these risks.” Risks, the release said, that included unpredictable or harsh weather; being separated from leaders or from other participants for considerable periods; and potential misjudgment by Outward Bound instructors.
Elisa, however, was determined to go. She was a kid; Outward Bound was cool. In the end, her Summer Search mentor helped put Woods’s mind at ease. This was the gold standard in kids’ adventure trips—the program was perfectly safe. There would be plenty of supervision at all times, Woods says the mentor told her. And, after all, no one had ever died on Outward Bound.
Of course, that wasn’t quite true. Since Outward Bound staged its first U.S. excursion in 1962, some 24 people have lost their lives on its trips. The fatalities—cardiac arrests, mountaineering falls, drowning, hypothermia—have not been widely publicized, and the company has never been held liable for a death by a judge and jury. But a former Outward Bound employee argues those numbers are misleading. “There are so many near misses you don’t even hear about,” the ex-staffer says. Like the case of the 14-year-old boy who, just 48 hours before Elisa’s disappearance, was hit by a falling rock dislodged by an instructor on an Outward Bound excursion in Colorado. His lower leg was amputated two weeks later.
When Elisa’s group discovered she was missing last July 16, they shouted her name for nearly an hour. There was no answer, but no immediate panic, either. People had been lost on Outward Bound before. Lost, and then found. There was no need to call for help—which was hours away, at best—not until her instructors conducted an initial search. And course director Casey Montandon was already in the area for another patrol. He hiked back into Lockhart Canyon, tracking footprints and looking for clues, while the instructors, after two of the boys said they had seen Elisa near the gate, focused on the tamarisk thicket.
Twilight ended at 9:12 p.m. with still no sign of Elisa. Using headlamps to guide them, the entire patrol kicked through the brush for another hour, performing walking-line searches at 15-foot intervals. Montandon then asked the boys if they were sure they had seen Elisa at the gate. They weren’t.
At 11:05 p.m., five hours after Elisa went missing and nearly 11 after she had last been with an instructor, her body was found 1,000 feet off the dirt road they had traveled, in an open canyon on a sloping side trail. With her backpack still on, Elisa had fallen to her knees, doubled over, and landed face first on hot gravel. According to Outward Bound, Alex turned Elisa’s body over and made an effort to resuscitate her. But she knew Elisa was dead. Rigor mortis had already set in.
The phone rang at 4:51 a.m. on July 17 in the Woodses’ dilapidated second-floor O Street apartment. Elisa’s mother picked up. As soon as she heard Outward Bound Wilderness president Mickey Freeman’s voice, she knew why he was calling. “Please don’t tell me she’s dead,” she cried, hysterical.
Woods dialed her son Michael, a 31-year-old MIT grad now working in San Francisco as an engineer. He threw hiking clothes and photos of Elisa into a suitcase and caught an afternoon flight to Salt Lake City, where he met up with his mother. They waited a full day to see Elisa’s body at the local mortuary, and when they did, on Tuesday afternoon, they were shocked. Elisa’s face was bruised; blood rimmed her nostrils. Michael says the medical examiner told him the most likely cause of his sister’s death was heat stroke, which, he said, can come with very noticeable warning signs—signs like red-hot skin, headache, dizziness, nausea, and disorientation.
What the hell were they doing hiking in 110-degree heat? Michael seethed. He had a lot of unanswered questions. He composed a list of 27 and read them off to John Read, the president and CEO of Outward Bound USA, who had arrived in Salt Lake that day. Michael asked Read to take him to the site of Elisa’s death. Later that night, the two men flew to Moab; the next morning at dawn, they boarded an aluminum riverboat on the Colorado River with two Outward Bound vice presidents of safety. Also on board was Mike DeHoff, the last adult to see Elisa alive.
Michael and the Outward Bound brass followed the group’s footsteps in reverse—up from the river, through the thicket and gate, along the open desert trail. Michael was stunned by how well marked the dirt road was. An experienced hiker, he had trouble understanding why a clear-headed person would veer off the road, as Elisa had done, turning left before the gate onto a gravel-strewn side trail.
Michael peppered the execs with more questions. Why didn’t the kids have walkie-talkies on such a hard-core trip? Would the instructors have heard Elisa’s whistle if she had blown it? Why weren’t they using the buddy system? Originally, Michael says, Read had told him Outward Bound would conduct an internal inquiry into Elisa’s death and also invite outside investigators to review the incident. But out in the desert, when Michael asked to see the findings of both, he says, Read clarified that he would not pursue an external probe. (According to Freeman, Outward Bound is now undergoing an external review.) Dissatisfied with Read’s answers, Michael began to wonder if the company might be more concerned with how his sister’s death would affect enrollment, more interested in damage control, than in finding out why she had died.
In the 46 years since its founding, Outward Bound USA has enjoyed explosive growth, evolving into a multimillion-dollar nonprofit conglomerate. In that time, the company has leveraged its brand to tap new markets like corporate training, school reform, and delinquent youth. It’s also greatly expanded the offerings of its wilderness division, which today has 500 expeditions in 14 U.S. states. But while the wilderness division remains Outward Bound’s core, its revenue has been in decline for more than a decade. Indeed, between 1991 and 2005, enrollment plummeted by half.
In response, in 2002 Outward Bound hired John Read, a Harvard M.B.A. and former head of a private equity fund, to turn things around. His answer to the company’s financial woes was a series of business mergers. By 2005 he had merged seven of the 10 regional Outward Bound schools into a single nonprofit with a single management structure and fiduciary board. The transformation, Read wrote in a press release, would allow Outward Bound to better serve more students. The plan seemed to be working for the bottom line. By the next summer—the summer of Elisa’s trip—enrollment was up 13 percent.
But if the numbers looked good, the programs themselves were mired in problems, according to the former Outward Bound employee. “Outward Bound started chasing revenue in the body of students. The more students you get, the more money you get, but you have to put those students in the field and you have to have instructors,” the ex-staffer says. (Four other former Outward Bound employees interviewed for this article said the average age of the company’s instructors has dropped by several years in the past decade.) “A 23-year-old doesn’t have experience, so he needs to be trained,” continues the former employee. “And they are not being trained adequately.” Freeman strongly disagrees. “We have the best training in the industry,” he insists. “Every instructor has to have a minimal level of first aid and a minimal level of wilderness skills.”
All the former employees I spoke with say that the Outward Bound of today is very different from the pre-merger Outward Bound. For instance, in 1998, a 22-year-old woman on a Pacific Crest Outward Bound School (PCOBS) mountaineering trip in Washington state slid off a snowy cliff, tumbling to her death. As a result, the PCOBS adjusted its training curriculum, creating a program so rigorous and effective, says a former staff member, it was presented at a national wilderness-risk management seminar. Outward Bound began to integrate the PCOBS program companywide, but by 2006, according to an ex–field staffer, it had been dismantled, and “there was no single person whose full-time job was training anymore. That happened to be the same season where we had some terrible accidents in the field. Perhaps that’s a coincidence, but not having a safety quality training director because it didn’t pass through budget cuts is an example of a culture that doesn’t put training first.” Freeman says Outward Bound has two executives responsible for safety and training; the ex-staffer remains unconvinced.
The day Elisa died, Lieutenant Monte Dalton of Utah’s San Juan County Sheriff’s Department was called out to Lockhart Canyon. Though he lives in Monticello, just 60 miles away, it took him two hours to drive the rocky, rugged roads to reach her body. When he arrived, at daybreak, everyone save Casey Montandon had left the scene; Outward Bound later moved the others by raft to Moab and put them up in a hotel. Dalton didn’t see a need to call in any of his 10 deputies, who together are in charge of an area the size of New Jersey. And as the local medical examiner’s representative, he had to get Elisa’s body to Salt Lake for an autopsy. He slipped her corpse into a body bag, laid it into the bed of his pickup, and headed north. No further investigation seemed warranted.
In the 1980s, Utah developed specific health and safety standards for some youth wilderness programs: A child’s backpack can’t weigh more than 20 percent of his or her body weight (Elisa’s weighed up to 60-plus pounds, about 60 percent of her 105-pound weight); hiking is prohibited in temperatures above 90 degrees (it was well over 100 degrees on July 16); and each youth group must be supervised by a minimum of two staff members at all times (Elisa was unsupervised for at least five hours). But the regulations only apply to therapy programs that kids attend involuntarily. Outward Bound’s program is voluntary, which means that, aside from light monitoring by the Association for Experiential Education (AEE), a small nonprofit with vague safety guidelines, it’s also unregulated, free to set—or break—its own rules, which are less than stringent: It allows unsupervised travel, relies on the judgment of its instructors regarding hazardous temperatures, and has no pack weight limits. And according to Henry Wood, an AEE director, Outward Bound has recently chosen not to renew its accreditation.
Ken Stettler, the head of licensing in Utah’s Department of Human Services, argues Outward Bound’s weak guidelines and lack of oversight are dangerous. “I think there need to be basic safety regulations, some basic standards, no question about it,” he says. Stettler used to think Outward Bound had a stellar reputation, but now, he says, “it’s gotten so big that they don’t have the controls that they used to have. It’s become a business.”
In Elisa’s case, under Utah law, the only things Outward Bound could be charged with violating are the state’s recklessness and negligence statutes, Class A misdemeanors that carry a small fine. Michael Woods wants to make sure the company faces at least that meager punishment. “What I’m requesting is not so unreasonable, when my sister is dead,” he says. Michael called Dalton and persuaded him to look further into the case; Dalton agreed to put a sheriff on it and talk to County Attorney Craig Halls.
Eight months after Elisa’s death, Halls said he had not seen any kind of report on the investigation. Dalton himself says Outward Bound had “clammed up” and was stonewalling his sheriff, but following an inquiry from Boston magazine, it agreed to have a company representative meet with him. (According to Dalton, Outward Bound had previously volunteered to hand over its internal report and the names of the other students, but has yet to do so. Outward Bound’s Mickey Freeman says he only recently received the sheriff’s department’s official request.)
For his part, Stettler has little faith in the local PD. “Law enforcement just dropped the ball,” he says. “They allowed the rest of the group to leave [the state] without even interviewing them. Now, they’re just covering up their own ineptness.” Legally, the sheriffs could subpoena information from Outward Bound, or turn to the state Attorney General’s Office for help. But they haven’t, yet. Dalton isn’t in a hurry to move things along. “I think it’s tragic, but like I told Michael, nobody went out and forced Elisa to go on this thing,” he says. “For a misdemeanor, we have two years to file. So it’s not like we have to do it right immediately anyway.”
Sitting in a cavernous conference room overlooking downtown Boston, surrounded by lawyers, Elisa Woods looks like a broken woman. It’s January 16, 2007, the six-month anniversary of her daughter’s death. Dressed in a worn red sweater and jeans, she keeps her eyes locked on a fixed point on the dark wood table in front of her as she describes her youngest child. “She was following in Michael’s footsteps,” Woods says. “She was smart; she had a lot going for her.”
Michael first contacted attorney Richard “Rocky” Grossack in August, after he realized he wouldn’t get the answers he wanted from Outward Bound. But Rocky, a friend of Elisa’s uncle—and the kind of personal-injury lawyer who takes referrals from those commercials that blanket midday TV—knew early on that the case was way too big for him alone. “I don’t really litigate,” he says. “I do a high-volume business; I’m what they call a rainmaker.” So the Woodses also enlisted high-profile Boston attorneys Tim Kelleher and Pat Jones, the same lawyers who won the family of Victoria Snelgrove $5.1 million after she was killed in an incident on Lansdowne Street during the 2004 Red Sox American League pennant celebration.
The three lawyers are pursuing a civil suit against Outward Bound—in which Elisa’s family could win compensatory and punitive damages—and they are hovering over Woods, making sure she doesn’t say anything to harm the case. In order to win damages that could run into the multimillions, they’ll need to prove either that the indemnity release is unenforceable, or that the organization was guilty of gross negligence, a more aggravated form of negligence not covered by the document. The release states that while Woods cannot “make a claim against OB as a result of any loss, injury, damage, or death suffered by…my child,” she would be able to pursue a claim that fell under that category.
Sending the kids out alone in extreme temperatures during the middle of the day with heavy packs might be an example of gross negligence, but the lawyers aren’t eager to publicly outline their case (which as of press time they were still preparing, and had not yet formally filed). Others, however, are not as reserved. “Elisa Santry died not because she was alone in the desert, not because those boys hiked ahead,” says the former Outward Bound employee. “She died because the instructors were out in a situation they were not prepared to handle.” Stettler shares that opinion: “There’s no question,” he says, that this was a case of negligence.
It’s a charge Outward Bound itself vehemently denies. “Do I think Outward Bound was negligent? Absolutely not,” Freeman says. In the past 25 years, the company has put thousands of kids through the Utah desert, he says, and none of them have died. Everything done that day, he insists, was in keeping with Outward Bound’s standard safety protocols. In fact, after completing its internal investigation of that day’s events, the company says it won’t change its operating procedures. (As a matter of policy, Outward Bound does not release investigation findings or operating procedures.) Elisa’s death was simply the result of “a perfect storm of random events,” Freeman says. The medical examiner’s opinion aside, Freeman even disputes that Elisa died of heat stroke. “I think there was possibly some physical or other issue at play,” he speculates. “It begs the question, she was kind of a thin person, was there something else going on…. Could there have been something in Elisa’s chemistry that threw her over the edge?
“We are, hands down, the leader in risk management. We set the bar,” he adds. “Of course, there’s always a chance that something will happen, the one-in-a-million situation when something goes wrong.” In fact, the actual odds of something going wrong—of dying alone in a desert or having your lower leg sawed off—are much higher than that number. But when parents sign Outward Bound release forms, how consciously are they making that calculation? Are they making informed decisions, or, like Woods, are they placing undue faith in Outward Bound’s vaunted reputation? A reputation, the former Outward Bound employee says, the company no longer deserves.
“The organization that was once great has lost its moral compass,” the former staffer says. “I might be viewed as a disgruntled employee, but that doesn’t change the weight of what I have to say: The root cause of Elisa’s death is that the leadership of Outward Bound didn’t do its job—they just don’t get the concept of risk management and safety in the wilderness environment.”
On July 23, 2006, the day before she had been due to make the 2,500-mile trip back home to regale her family with tales of her life-changing experience, Elisa Santry lay dead at the J. F. O’Brien and Sons Funeral Home in South Boston, her body displayed in an open casket surrounded by pink and white flowers.
Her mother and brother stood by the coffin for hours as a long line of relatives and friends offered condolences. They both were exhausted. Woods had been up all night gluing pictures of Elisa to a white poster-board memorial. Michael hadn’t slept much, either. He was poring through Elisa’s letters and journal from Outward Bound, memorizing the names of the kids on her trip. He still had more questions than answers, and was hoping a patrolmate might show up to pay respects.
None did. But among the mourners that day was a girl named Tam. She came up to Michael and introduced herself; he recognized the name. “Did you go to school with Elisa?” he asked. “I have something for you.” He pulled out a handful of unmailed letters Elisa had written to Tam and several other girls while she was in Utah. They huddled together and read the notes, laughing and crying.
Later, Michael ran over to the fax machine at the funeral home and made copies. He didn’t want to let go of the originals yet. He’s still searching for some hint, some sign, hidden somewhere in a 16-year-old’s scrawled words, that might explain why she was left alone to die.
Source URL: http://www.bostonmagazine.com/2007/04/dangers-that-can-cause-or-lead-to/