The U.S. Forest Service has released their Serious Accident Investigation Report on the fatality of Ann Veseth, which occurred on the Steep Corner Fire 56 miles northeast of Orofino, Idaho August 12, 2012. The fire was on private property and was being managed by the Clearwater‐Potlatch Timber Protective Association (CPTPA). Ms. Veseth, in her second season working as a firefighter for the USFS, was killed when she was struck by a falling 150-foot tall fire-weakened green cedar tree. The tree fell on its own and was 13 inches in diameter where it struck her.
The report is unusual in at least two respects. It is written in the present tense, such as this:
Lee, the ENGB, works behind the E‐31 crew using a hoselay pumping water from the creek to secure fireline and watching for hazard trees.
In addition, there is a very nicely written one-page biography of the 20-year old firefighter which includes two photos.
The USFS report came out a few days after OSHA issued a citation to the organization managing the fire, the Clearwater-Potlatch Timber Protective Association (CPTPA). The citation comes with a “Notification of Penalty”, fines totaling $14,000. OSHA also issued a Notice of Unsafe or Unhealthful Working Conditions to the U.S. Forest Service, but without a monetary penalty. Wildfire Today summarized the OSHA actions on February 12.
Here is an excerpt from the just-released USFS report:
“Analysis and Conclusion
The cause of this accident was that a green cedar tree, weakened by fire, fell and struck a firefighter in the head. It fell with a force far greater than the design limits of any hardhat could withstand. This tragedy resulted from the chance alignment of certain conditions: an emergency response to control a wildland fire, which required the presence of firefighters in an area where fire‐weakened trees could fall on their own with little or no warning. The SAI team concluded that the convergence of these events – in a very specific way and with very specific timing – resulted in a fatal accident. Slight differences in any number of factors could have led to drastically different results.
Firefighters faced the same choice on this fire as they do on almost every fire: engage the fire and expose firefighters to a certain set of risks in order to control the fire, or don’t engage the fire and don’t control it, knowing that such a decision often poses a wider range of risks to firefighters and the public. Firefighters made the same basic risk decision on the Steep Corner Fire as they do routinely on most fires: to engage the fire and attempt to control it, knowing that firefighters would be exposed to hazards during suppression efforts.
On the day of the accident, after the implementation of safety mitigation measures, the firefighting professionals involved in the Steep Corner Fire reasoned the risks of engaging and suppressing the fire to be acceptable. After considerable review of the incident, including the leadership, qualifications, interagency cooperation, fuels, weather, incident management organization, and local policies, the SAI Team concluded that the judgments and decisions of the firefighters involved in the Steep Corner Fire were appropriate. Firefighters all performed within the leaders’ intent and scope of duty, as defined by their respective organizations. The team did not find any reckless actions or violations of policy or protocol.
On August 11, the day before the fatal accident, two Forest Service resources decided to limit their acceptance of risk on the Steep Corner Fire. Both the IHC and the E‐31 crew identified necessary safety mitigations. The IHC chose not to engage. The E‐31 crew disengaged and indicated they would not return to the fire until mitigation measures were implemented.
C‐PTPA took these events seriously and subsequently addressed the recommended mitigation measures. Personnel became the “adapters” that allowed C‐PTPA and the Forest Service, two organizations with very different natural resource management mandates, to functiontogether. Mitigation measures included ordering more firefighting resources, adding line overhead and a radio repeater, and using contract fallers to fell hazard trees ahead of those digging fireline. The morning of August 12, the E‐31 crew decided to re‐engage when it became clear C‐PTPA was addressing their safety concerns. The IHC was already reassigned to anotherfire and did not return. In general, firefighters expressed their impressions that Saturday was a bad day but Sunday (before the accident) was much better, in terms of organization of the fire and mitigation of the hazards.”
(end of excerpt)
The 38-page report only has two recommendations. One is to introduce the LCES (Lookouts, Communications, Escape Routes, Safety Zones) concept into the National Wildfire Coordinating Group’s curriculum for use in disciplines other than fire management. The other is: “Occupational Safety and Health Office should develop a methodology for effectively teaching non‐fire workers the concepts related to hazard tree identification, scouting an area, and determining escape routes and safety zones for overhead hazards”.
Several things about the incident and the report are troubling, but one item in the report stood out (emphasis added):
This tragedy resulted from the chance alignment of certain conditions: an emergency response to control a wildland fire, which required the presence of firefighters in an area where fire‐weakened trees could fall on their own with little or no warning.
Perhaps it is just an unfortunate choice of words chosen by the primary author which somehow was missed by the large number of people who probably reviewed the report before it was released. Giving them the benefit of the doubt, maybe they didn’t really mean to imply that firefighters are REQUIRED to perform an action on a fire simply because the fire is uncontrolled, even “where fire‐weakened trees could fall on their own with little or no warning”.
Someone might say that trees could fall during suppression action on most timber fires. Right. However on this fire, the large number of falling trees was identified the previous day, when a Hotshot crew refused to be assigned to the fire because of falling trees and many other unmitigated hazards, saying in a SAFENET report filed three days later that they “had huge concerns about the number of snags burning”. An engine crew left the fire for similar reasons that afternoon, but returned the next day after being assured that the hazards had been mitigated.
Firefighters are not REQUIRED to perform a task on a fire if there are known extraordinary hazards that cannot mitigated. We are talking about trees, grass, brush, or houses…. that will all grow back. Firefighters can’t.
Maybe it is just an unfortunate choice of words.