Report released on the entrapment of firefighter and two civilians on Kincade Fire

The three people shared one fire shelter as the fire burned around them

The California Department of Forestry and Fire Protection, CAL FIRE, has released a Green Sheet, or preliminary report, on the October 25, 2019 entrapment of one firefighter and two civilians. It occurred on the Kincade fire northeast of Geyserville, California about 43 hours after the fire started.

In mid-afternoon a Division Supervisor was scouting his division and searching for firefighters who he had been told were not wearing their Nomex wildland fire jackets. He turned his SUV off Pine Flat Road onto Circle 8 Lane, an unpaved road that reaches a dead end 1.5 air miles from Pine Flat Road.

map Kincade Fire entrapment deployment
3-D map showing the approximate location of the entrapment of three people on the Kincade Fire, October 25, 2019.

Later, seeing that the fire intensity had increased and crossed the road behind him, he realized that he was in imminent danger and decided to ride it out near an old cabin. A dozer operator had already cleared a line around the structure as as well as a line from the road downhill to the drainage.

Below is an excerpt from the Green Sheet as well as more maps, photos, and a video. The Division Supervisor is identified as “DIVS1”.

Continue reading “Report released on the entrapment of firefighter and two civilians on Kincade Fire”

Firefighter injured last month passes away in hospital

Christian Johnson, 55, was severely burned on the Spring Coulee Fire in Washington

Christian Johnson
Christian Johnson, Assistant Chief of the Okanogan Volunteer Fire Department.

A firefighter who received second and third degree burns over 60 percent of his body September 1, 2019 while battling the Spring Coulee Fire in Okanogan County, Washington passed away yesterday, October 2, 2019. Christian Dean Johnson, 55, of Okanogan was surrounded by his wife Pam, family, and friends at Harborview Medical Center.

From the GoFundMe page that was created September 3:

Christian has served his country as a sergeant in the Us Army, and was deployed with the Washington State National Guard from November 2003-May 2005 in Baghdad. He retired after 22 years of service and has volunteered for the Okanogan Fire Department for 20 years.

Christian is a selfless man, who is always willing to help those in need, and never ask for anything in return. We are now asking for your help to make this long journey a little easier for him and his family. Any amount of donations are greatly appreciated and will go towards helping his wife (Pam Johnson) with travel, housing, food, etc.

Our sincere condolences go out to Mr. Christian’s family and friends. May he rest in peace.

Oklahoma firefighter suffered severe burns after becoming entrapped

The firefighter was operating a UTV when it became disabled

Oklahoma Map EntrapmentOn September 12, 2019 an Oklahoma firefighter operating a UTV became entrapped during the initial attack of a wildfire in the southeast part of the state 24 miles northeast of Antlers.   The Oklahoma Forestry Services released the following preliminary information about the incident.


“On September 12, 2019 during initial attack efforts on the Jack Creek Fire, an Oklahoma Forestry Services firefighter from the Southeast Area / Antlers District was involved in an entrapment and subsequent burnover while scouting control line opportunities. The fire was burning in steep, rugged terrain dominated by dense pine forest with occasional hardwood glades. The firefighter was operating a UTV scouting logging roads for access and suppression opportunities when the UTV became disabled. The firefighters escape route was compromised when fire behavior increased due to the fire making an uphill run in the flashy understory fuels and crown fire in the canopy fuels. The firefighter did not deploy his fire shelter.

“The dispatch office requested an ambulance at the time of the incident while Oklahoma Forestry Services and local fire department personnel located the firefighter. The firefighter was transported to ground ambulance then transferred to air ambulance taking the firefighter to a burn center. The firefighter remains at the burn center and is being treated for second and third degree burns on >30% of his body with the most intense burns to his face and hands.

“An Incident Review Team has been assembled.”


Thanks and a tip of the hat go out to Matt. Typos or errors, report them HERE.

Firefighter seriously injured on wildfire in Okanogan County, Washington

video Spring Coulee Fire Okanogan County, Washington
The Spring Coulee Fire in Okanogan County, Washington, September 1, 2019. Screenshot from video by Okanogan County Emergency Management.

A firefighter suffered serious burns September 1, 2019 while working on a 142-acre fire near Spring Coulee Road in Okanogan County, Washington.

The information below is from Okanogan County Emergency Management, September 3:


Christian Johnson, Assistant Chief of the Okanogan Volunteer Fire Department, has suffered serious injuries while on the Spring Coulee Fire. He has second and third degree burns over 60% of his body.

Christian is currently in a medically-induced coma at Harborview Medical Center in Seattle. They are trying to stabilize him so they can proceed with skin graft surgery. He will be looking at a minimum of 2-3 months in the ICU.

Christian has served his country as a sergeant in the Army, and was deployed with the Washington State National Guard from November 2003- May 2005 in Baghdad. He retired after 22 years of service and has volunteered for the Okanogan Fire Department for 20 years.

Christian is a selfless man, who is always willing to help those in need, and never asks for anything in return. We are now asking for your help to make this long journey a little easier for him and his family. Any amount of donations are greatly appreciated and will go towards helping the family with travel, housing, food, etc.

If anyone would like to make a donation, they may use the GO FUND ME account or make a donation to: Christian Johnson Donation Account at North Cascades Bank, PO Box 672, Okanogan WA 98840.

Christian Johnson
Christian Johnson, Assistant Chief of the Okanogan Volunteer Fire Department. Go Fund Me.

Below: Video of the Spring Coulee Fire in Okanogan County, Washington, September 1, 2019. Okanogan County Emergency Management.

Thanks and a tip of the hat go out to Tom. Typos or errors, report them HERE.

21 issues frequently identified in firefighter entrapment reports

Can lessons actually be learned?

Horse Park Fire
The Horse Park Fire in Colorado, May 31, 2018. Screenshot from the Hotchkiss Fire District video.

The 43-page facilitated learning analysis about the entrapment on the Mendocino Complex of Fires was well-researched and skillfully written. Six firefighters received burns and other injuries when they had to escape from the fire by running through unburned vegetation.

The intent of the analysis and hundreds of others like it is for firefighters to gain knowledge from the dozens of identified lessons learned that were meticulously documented, hoping that they will not be repeated by those who read the report.

That sounds very straight forward and simple.

But will reading about something that occurred on a fire months or years ago and hundreds or thousands of miles away actually influence someone’s behavior, performance, or decision making ability? Intuitively, we may say, “Yes. Of course. Learning about something that went wrong on an incident will keep us from making similar bad decisions later.”

A comment left by Paul regarding the article about the facilitated learning analysis was interesting:

Nothing “new” in the “Lessons Learned”. After decades in the fire service, makes me wonder if Lessons can be really be learned (and applied) at an organizational level. Seems they are constantly learned at the personal level.

Paul makes a good point. Those of us who have read numerous after action reports have seen almost all of the identified lessons many times before. Below are 21 issues mentioned in the Mendocino Complex report that were identified on the August 19, 2018 incident-within-an-incident.

  1. Interpersonal communications
  2. Communications system (radios & repeaters)
  3. Organizational structure
  4. Inadequate briefings
  5. Span of control way out of whack
  6. Inadequate knowledge about the real-time location of the fire
  7. Crew resource management
  8. See something say something
  9. Play the what-if game
  10. Turn down assignment
  11. Interagency rivalry
  12. Inadequate lookout ability due to terrain
  13. Metro firefighters and those from a different fuel type thrown into a complex wildfire situation
  14. Escape routes
  15. Safety zones
  16. Not knowing the real-time location of firefighting resources
  17. Holy Grail of Wildland Firefighting
  18. Burn victims not being sent to a burn center
  19. Very long travel times to fireline assignments
  20. Personnel shortages on Incident Management Teams and Unable To Fill resource orders on fires affecting tactics and safety
  21. Failure to declare an Incident-Within-An-Incident

Will identifying these issues still another time in a well-written document help prevent them from recurring? We have always assumed it will. But if so, why do the well-intentioned reports continue to list many of the same items?

In a perfect world an important lesson to be learned would be described once in a report. It would then become global knowledge in the firefighting world and the issue would never again have to show up in an after action review.

If these documents and formal classroom training is what Paul refers to as the “organizational level”, does he have a point that the most frequent way firefighters learn is from personal experience?

How do we increase the effectiveness of lessons learned reports?

Is there a different, or innovative method that could transplant these lessons into the personal mental “slide shows” that experienced firefighters consult and refer to when they are faced with a tough decision in the field?

Without doubt, someone will say all we have to do is abide by the 10 Standard Firefighting Orders and 18 Watch Out Situations. The Orders have been around for 62 years. Someone else just saying “follow them” will not magically make it happen. That has been said millions of times in the last six decades and still, between 1990 and 2015, an average of 17 wildland firefighters were killed each year. Continuing to do the same thing while expecting different results is not realistic.

Lessons learned after the entrapment on Mendocino Complex of Fires

Six firefighters received burns and other injuries when they had to escape from the fire by running through unburned vegetation

fire wildfires crew carrier damaged burned injuries
Crew carrier that was damaged during burnout operations on the Mendocino Complex of Fires August 19, 2018. Photo from the report.

A facilitated learning analysis (FLA) with dozens of valuable lessons learned was just released about an incident where six firefighters were entrapped on a wildfire and had to run to safety through unburned vegetation. The incident within an incident occurred August 19, 2018 on the Mendocino Complex of Fires east of Ukiah, California. Six firefighters received burns and other injuries when the fire crossed a dozer line in multiple locations during burnout operations and cut them off from their planned egress. Some of the firefighters refused treatment, while others were transported to hospitals where they were treated and released.

You can download the entire report here: (large 7MB file).

One thing to keep in mind when you read the lessons learned is that the organizational structure on the fire, which ultimately burned more than 459,000 acres, was very unusual. Two complete Type 1 incident management teams were ordered for the fire due to its enormous size. Normally when there are two teams on a very large fire they divide it into two geographical zones, with each team assuming responsibility for one. Logistically, in this case, there were not enough logistical resources available to support two large incident command posts, so everyone worked out of one base. The two teams were merged into one, which produced duplicates in some overhead positions.

The report was very skillfully designed and written and could be a valuable resource for wildland firefighters.

Below we have a very brief summary from the report of the entrapment, and following that, all of the lessons learned attributed to the personnel who were on the fire, in their own words. We did not include another section from the report that contains analysis from the FLA team.


BRIEF SUMMARY FROM THE REPORT

During burnout operations, a sudden wind shift and explosive fire growth happened and personnel were cut off from their escape routes. Most of the firefighters were able to move back to their vehicles to exit the area. However, six individuals farther down the dozer line were forced to run in front of the advancing flame front, through unburned fuels to a nearby dirt road for approximately one mile before they were picked up and transported for treatment. Five Los Angeles Fire Department firefighters and one CAL FIRE firefighter were injured. Two unoccupied CAL FIRE emergency crew transports parked in the vicinity sustained damage from the fire when it jumped containment lines.


LESSONS LEARNED BY THE PARTICIPANTS

Interviews were conducted with key personnel involved in the entrapment on the Ranch Fire. At the conclusion of each interview, each person was asked what they learned for themselves from this event and what they believe the greater wildland fire community could learn. The following are the subsequent lessons the participants shared with the FLA Team that they believe could benefit others. When possible, these lessons were written in the words of those interviewed, though a few places lesson were edited for clarity. These lessons were broken into four categories: Aviation, Inter- Crew, Fireline, and Overhead.

AVIATION

  • I’m not sure what lessons I learned could apply to the ground. It is not my job to second guess what folks are doing on the ground. My job is to support them and give them our perspective to help them to succeed. They use our input as another tool.
  • Let incoming aircraft know what type of response they are being requested. This is what it would sound like, “Declare an IWI and have them report to Mendo IP (initial point – aviation) for an IWI.”
  • We had an awareness of not taking risks that would incur potential damage or injuries or add more complexity. There is a balance when you are dealing with a life threatening situation that we didn’t make things worse, i.e. compromise ourselves in poor visibility. We ordered additional support to maintain span of control. We immediately ordered up additional support and didn’t try to tackle it ourselves. Didn’t want to be a liability.
  • Declare an IWI when injuries are discovered and follow IWI protocols so communication is clearer. Not declaring this an IWI created a lot of confusion because others did not understand the extent of the injuries or people involved.
  • I knew the voice on the ground so I did not provide decision points or trigger points. I just gave him the facts based upon what he was seeing. If it was someone else, I might have said no to the operation (in reference to when Dep. Branch II was asking about location of the fire for the burnout operation).

INTER-CREW

  • Everybody has a responsibility to run a risk management profile and use Crew Resource Management.
  • Ask questions when something does not make sense to you.
  • Ensure you and your resources are briefed thoroughly and information is flowing. People need to understand the assignment and have buy in.
  • Maintain transparent communication between resources and within your crew.
  • Speak your mind if something does not feel right. Make sure your voice is heard and understood when doing so. Validate subordinates concerns by passing them up the chain of command. If you are asked a question and don’t have an answer, re-evaluate.
  • Trust but verify. You will receive intel from other resources, but validate that information for yourself. Gather your situational awareness.
  • Rely on your experienced personnel within the group, no matter what position they hold.
  • Do not let urgency influence your actions.

FIRELINE

  • Remain vigilant and consider the worst-case scenario. Play the “What if?” in your mind.
  • Take the time to assess the situation and determine if it fits an IWI circumstance. ”I was mad at myself for not following the IWI in the 206.”
  • Good communications are critical. Validate the information you are given. Take time to scout the line. The best thing to do is ask questions for the things that are unknown and communicate with your people frequently.
  • Have the courage to turn down an assignment.
  • Vulnerability and approachability are key traits of a strong leader.
  • There was a perception that refusing an assignment could get you less desirable jobs or reassigned on the fire.
  • Rank adds to the confusion and tension around speaking up.
  • I think the dysfunction and disconnect between commanders intent and what was happening in division and branches was a contributing factor to the very rushed firing operation.
  • The CAL FIRE/Fed rivalry was evident on this fire and I believe it was a detriment to the operational tempo and production.
  • Help your supervisors and use humble inquiry to have a discussion about tactics. Do things make sense? What is the end state?
  • There was no good vantage point for the lookout. Our perception is that a lookout can see the fire but is maybe in a less than desirable location.
  • If you don’t get a good briefing, ask for it. Make sure to receive a thorough briefing from supervisors.
  • I think we need to encourage a culture of voicing concerns in a professional manner. Leadership needs to be approachable. I’ve been a metro firefighter for more than 30 years.
  • I’ve only been in wildland for 6 years, and I’m like born again after doing some structure protection just a few weeks before on another fire (burning out around six homes, we saved five of them). I really believe in that – this highly influenced my decision to accept the assignment. Huge mistake.
  • PPE. We have it for a reason. Wear it all appropriately, in particular shrouds and gloves.

OVERHEAD

  • Who can call for a “Roll Call” to ensure everyone is accounted for? Should it be done at the division or with the Team?
  • Command channel was never cleared. Weather was read over Command during the incident.
  • It was a difficult unified command. We typically go unified with an IC and maybe OPS, but not unified with two whole teams.
  • Trying to meld two Type 1 teams is not advantageous. There are too many voices and it muddies the water. That was happening on this incident. Having Deputy Branches was a side effect of blending two teams together. We had different operational mindsets and they weren’t communicating clearly enough. If we ever have two Type 1 teams again we need to address this more clearly.
  • Don’t get down into the weeds. This is very difficult when there is a Branch and a Deputy Branch. They need to stay up and out of weeds.
  • Don’t use deputy branches. I will fight tooth and nail not to have a Deputy Branch again. Next time I can isolate branches, make them smaller or broken apart.
  • Regardless of how good the plan is, timing is a critical element of the development of the plan. Sometimes we get wrapped up in the plan and fail to reassess the plan. When conditions changed, we needed to reevaluate.
  • I should have spoken up sooner. When I drove up, I should have voiced more that this was not a viable plan.
  • Put too much time in trying to salvage a line that was already lost.
  • I need to ask more questions to get a clearer picture.
  • Make sure everyone has a clear plan. The basics. LCES. Where are we going? Who is in charge? Leaders Intent, even if briefing has to be hasty.
  • Drop points are not safety zones. TRAs are not safety zones or deployment zones.
  • When you have two teams there can be difficulties like one team pushing for one thing and the other team pushing for another. You have to be more vocal. If we make deputy branches, they have to ride in the same vehicle. They cannot divide and conquer tasks because there is confusion about who is in charge.
  • We created a hybrid of the ICS system. The two ICs got along great. Below OPS is where it got muddled. Both teams had some failures when it came to how we were organized and communicated below us. Once we got feedback from the field, we cleaned up and it went better. There are definitely ways to make it work better.
  • I should have come up on Command and at least notified the medical unit there was an IWI. I should have forced myself to help Branch check those boxes. I’ve been thinking how I could have helped. “At all costs you have to address what you feel isn’t safe.”
  • I’m not blaming CAL FIRE or the Forest Service, I’m blaming human nature. We have to let go of what’s on your shoulder [referring to the organization/agency patches].
  • Talk to each other. We have qualifications for a reason. At the end of the day, we have to work together and realize there are good people out there in all agencies. Talk with people to determine their experience levels and comfort in different fuel types, conditions, etc. If someone is a qualified division, they are qualified. Base actions on the complexity of what the fire is going to do instead of I don’t know this guy or trust him so I’m going to just take this on myself.
  • It took too long for the FLA team to get here. Quite honestly, we were talking to you seven days later. Guys were barely at the hospital when I requested a team. Bring someone in to look at this objectively. I’m a little frustrated that it took a while to get here.
  • When we decided to meld the teams, we asked for Agency Administrators and Incident Commanders to get together and have a frank discussion behind closed doors. I believe that should happen more.
  • Letter of delegation is not real. You need closed-door discussions and talk about it. This settled things down a bit. It might be a best practice.
  • I believe that CAL FIRE and Forest Service are going to work together in the future. Anytime we are going to do that we need to work out HOW beforehand. Every time we have worked out something it’s been during a fire and that’s not the time to do that. We need to look at how both sides operate and drill down how it works and whose going to do what, before the fire bell rings. On the dirt, we fight fire, and it shouldn’t be that different on the teams.
  • For me personally, as Operations when I am in the field I try not to be overly involved in tactics so I don’t know all the details of what has already being looked at. If you get too involved you can get things messed up. I should have spoken up sooner. When I drove up I should have voiced more that this was not a viable plan. Looking back, we should have just fired out to protect people. I took for granted that was what was going on.
  • Branch was calm when the separation happened. He handled it well. It was textbook on how to help folks that are cut off and running. He asked for resources and kept his voice calm. Once the message was passed to all resources that we would shelter in place in the saddle we realized it was not the best place for a safety zone. People stayed calm, folks understood what they needed to do, and it allowed Branch to deal with separated folks.
  • Peer support is important. Having CISM there was awesome. They had a couple of therapy dogs. We now want to have a permanent CISM and dog on our team.
  • OPS leadership out there at the time helped people. They had their heads down on the mission and OPS being there may have helped them survive.
  • We recognized radiant burns can be misdiagnosed or dismissed as minor or superficial. Blisters and swelling can occur many hours later. The burns need to be looked at by a specialist and we had to convince the doctor to get referral to a specialist. We also had firefighters refusing treatment. One firefighter that went in had red ears the night before and the next day they looked like cauliflower. We need a universal protocol.