The Wildfire Lessons Learned Center has posted the Accident Investigation Report, the Fire Behavior Analysis, and the Time Line for the Panther Fire on which Dan Packer was entrapped and died on July 26, 2009 in Northern California.
Briefly, Mr. Packer, a Division Supervisor (DIVS), was scouting the fire with another Division Supervisor DIVS the day before their incoming Type 1 Incident Management Team was scheduled to assume command of the fire. When the fire behavior increased as predicted, the other fireline personnel withdrew to safety zones, but the two DIVSs did not. As the fire overtook their position, one of them escaped downhill through very thick vegetation, but Mr. Packer deployed his new generation fire shelter. However, the intense heat of the fire and its residence time exceeded the capability of the fire shelter.
Here are the recommendations from the report:
1. Submit the task of evaluation of the Safety Management System (SMS) to the National Safety Council and to Research and Development with respect to the following:
a. Forest Service Wide implementation of SMS
b. Just Culture
c. Inclusion of standard HF analysis in all accident investigations
d. Establishment of Doctrine (Leader‟s Intent) in Forest Service Manual Systems
e. System Safety
f. Organizational Risk Management
(Findings 1, 3, 5, 6, 7, 9)
2. Solicit Forest Managers to develop a safety briefing procedure for newly arriving personnel that personalizes the safety briefings used in high risk operations. Establish a working group to assess the current forms of communication of safety information transmitted through briefings. This group should produce guidance to reflect actual conditions facing the firefighters on the line and prepare them for the hazards unique to the specific conditions that crews are likely to encounter. The briefings should address safety considerations and procedures unique to the assignment, based on thorough risk assessment.
(Findings 2, 7, 8, 9)
3. Develop a policy to fully evaluate and, if indicated, develop a system which standardizes communication of safety critical information and Crew or Team Resource Management for ground firefighters. If indicated, include this language and CRM training for personnel engaged in high risk operations.
High Reliability Organizations know that odd things can occur and want their people to be on the lookout for these odd or unusual things instead of assuming that they don’t matter or are not important. They train their people to look for anomalies and recognize decoys and most importantly to decouple systems when problems are discovered and then empower employees to act. This was absent as evidenced by the assumptive behavior observed on this fire and common to many fire and aviation accident investigations. Recent investigations have identified this as the “Need for upward voice”. An example of a successful briefing used the phrase, “Let me know if you see anything Dumb, Different or Dangerous.”
(Findings 3, 7, 9, 10)