Unlearned lessons in Nebraska

When we report on serious accidents or fatalities on wildfires, we always try to obtain a copy of the official investigation report from the jurisdiction involved. But for the incidents on federal land at least, and on other lands in most of the western states, the responsible organizations almost always make the report available freely and conveniently, usually on the internet.

The primary reason to distribute accident reports as widely as possible is to reduce the chance of similar accidents. We call these “lessons learned”. There are entire organizations and web sites devoted to this concept, such as the Wildland Fire Lessons Learned Center, the U.S. Army’s Center for Army Lessons Learned, and the Department of Homeland Security’s Lessons Learned Information Sharing site. We put together the document titled Infamous Wildland Fires Around the World, which is a partial list, by date of the year, of some of the more famous, or infamous, multiple fatality wildland fires around the world over the last 150 years. We hope that firefighters will remember these accidents and the lessons learned from them.

But it is much more likely that mistakes made on fires in Nebraska will be repeated.

When we searched for an official report about the triple fatality on the April 28, 2011 prescribed fire near Trenton, Nebraska, we came up with nothing. We linked to a pretty good newspaper report, and asked if our readers were aware of an official report on the incident. One them told us that there was a multi-step process that involved many exchanges via snail mail to get a copy of a fire accident report in Nebraska. And it usually takes about a month, they said.

We called Jim Heine, the Assistant Fire Marshal in Nebraska and asked him how to obtain a copy of a report. He said it was a “simple one-step process”. But it turns out that there are five six steps.

  1. Complete an application form to request the report. The form can be downloaded from the Fire Marshal’s web site, printed, and completed by hand.
  2. Send it to the Fire Marshal’s office by fax or by snail mail.
  3. The agency’s legal counsel reviews the request. If it is approved….
  4. The Fire Marshal’s office sends you an invoice.
  5. You send the Fire Marshal’s office the payment for the report (a typical fee is $3.50).
  6. The Fire Marshal’s office snail mails you the report.

We asked Mr. Heine why the reports were not available on the internet. He said “If you had a family member who died on a fire would you want the report to be public?”

We have heard of many family members who had loved ones that died on a fire who are vehement that the circumstances and lessons learned become public. They would like to prevent other families from losing a loved one and going through the same pain and suffering. Two recent examples that come to mind are the CR 337 fire in Texas last year and the Carson Helicopter crash in 2008 on the Iron Complex fire near Weaverville, California.

Lynette Hamm’s son, Caleb Hamm, passed away on the CR 337 fire in Texas last July. When told about Nebraska’s policy on accident reports, she said:

I can only surmise Mr. Heine has never lost a loved one before. If so, I believe he would want to get to the bottom of it, however it happened, and have those findings available for future training. If the firefighting community really wants to learn from past mistakes/accidents, wouldn’t we want those reports to be made available to everyone in the hopes of preventing another occurrence? I would think so.

Nina Charlson’s son, Scott Charlson, died along with eight other firefighters and air crew members in a helicopter crash on the Iron Complex (or Iron 44) fire in 2008. Ms. Charlson has been very active in following up on the investigations of the accident. When she and family members of other firefighters attended a National Transportation Safety Board forum in November, she released a statement that included the following:

…We cannot bring our loved ones back but if we can stand up for safety changes for future passengers – that is what we want to do.

When told about Nebraska’s policy, she replied in part:

I think it is reasonable that if the victims families did not want to have details made public (maybe their firefighter made a stupid mistake) they could request it – but still firefighters should have the information for future safety measures.

The purpose for any future actions of the Iron 44 families part is definitely for the purpose of safety.

 

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Followup: three fatalities on 2011 prescribed fire in Nebraska

Casey, one of the people who commented on our article about the most significant stories of 2011, pointed out to us that in addition to the one person that was killed April 28 on the prescribed fire near Trenton in southwest Nebraska, two others also died weeks and months later. Theresa Schnoor, 46, passed away at the scene, but Robert Seybold, 40, died May 18, 2011, and 37-year-old Anthony Meguire died at a burn center in Lincoln, Nebraska September 18, 2011. The three of them along with five others were conducting the prescribed fire on privately owned land.

May they all rest in peace.

Casey also pointed out to us an article written by David Hendee of the Omaha World-Herald that summarizes an investigation of the incident conducted by the Nebraska Fire Marshal’s office. The article is quite disturbing to read. Not because of any gore or graphic details, but because it points out many factors that might have resulted in a more favorable outcome if they had been handled differently. The issues included planning, organization, briefing, fire departments that were asked but did not assist, equipment, personal protective equipment, alcohol, and weather and how it related to the prescription.

Reason swiss cheeze model

This multiple fatality incident could be an example of the “swiss cheese” model developed by James Reason. A single error or unsafe act may not result in an accident, but multiple unsafe acts may align, like holes in layers of swiss cheese, to produce an unfortunate outcome.

We were not able to find a copy of the original Fire Marshal’s investigation report over the weekend, but if anyone has access to it, please let us know.

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UPDATE: January 10, 2012:

We found out more about Nebraska’s policy which makes it difficult to learn lessons from accidents on fires.

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Thanks go out to Casey

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California inmate dies while training with CAL FIRE

On Wednesday an inmate that was training with CAL FIRE died. Our condolences go out to the family, friends, and coworkers.

Here is an excerpt from a news release by the California Department of Corrections and Rehabilitation:

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THURSDAY, JANUARY 5, 2012

Inmate Firefighter Dies of Presumed Natural Causes

SAN LUIS OBISPO – A California Department of Corrections and Rehabilitation (CDCR) inmate firefighter assigned to Cuesta Fire Camp at the California Men’s Colony died of presumed natural causes Wednesday afternoon during a training exercise with the California Department of Forestry and Fire Prevention (CAL FIRE).

The inmate, Crisanto Leo Lionell, 54, was participating in a training exercise at the California National Guard’s Camp San Luis when he lost consciousness. Emergency personnel transported him to a local hospital where he was pronounced dead at approximately 4:45 p.m.

Lionell was received by CDCR on February 10, 2010, to serve an 11-year sentence for transportation and possession for sale of controlled substances in Tulare County.

CDCR and CAL FIRE will conduct a review of the incident.

CDCR currently operates 44 adult and two Division of Juvenile Justice Conservation Camps in California. CDCR jointly manages 39 adult and juvenile camps with CAL FIRE and five adult camps with the Los Angeles County Fire Department. Nearly 4,000 offenders participate in the Conservation Camp Program (CCP), which has approximately 200 fire crews.

Since 1946, the CCP has provided the State’s cooperative agencies with an able-bodied, trained workforce for fire suppression and other emergencies, such as floods and earthquakes.

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Six Chilean firefighters killed in wildfire

UPDATE January 6, 2012:

The body of the seventh firefighter killed while trying to contain a blaze on the property of the Mininco Forestry company was recovered early Friday.

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Six firefighters working on a wildfire in Chile were killed on Thursday when they were entrapped and overrun by flames. Local governor Miguel Mellado was quoted as saying, “the fire suddenly surrounded them because of the wind, they drew closer together, one against another, and saw the fire pass above them”.

During the incident, the group of ten firefighters working for a forestry company were entrapped while they were suppressing the wildfire in a forest near Carahue in Araucania. Six of them were killed, two were badly burned and evacuated by helicopter, one escaped, and one is listed as missing.

Authorities suspect that since multiple fires started almost simultaneously in the regions of Biobio, Maule and Araucania, that the fires were ignited by arsonists.

Our sincere condolences to the family, friends, and coworkers of these firefighters.

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Followup on New Zealand firefighting helicopter crash – 2 fatalities

There is now confirmation that the crash of the firefighting helicopter in New Zealand that Wildfire Today covered yesterday resulted in two fatalities. Initially it was known that the helicopter crashed Wednesday night into the ocean off shore from a vegetation fire, but the official status of the pilot and passenger was “missing” until divers could access the wreckage in seven to ten meters of water a few hundred meters off shore.

Below is an update, courtesy of FirefighterCloseCalls.com:

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We regret to advise you that 2 Firefighers died this morning when a helicopter operating at a wildland fire that destroyed homes in New Zealand’s North Island. The helicopter went missing late last night off the Karikari Peninsula, at the northern end of the North Island, and the wreckage was found early today. Rescue divers reached the wreckage and confirmed the two-man crew, a commercial helicopter pilot and a conservation department ranger, died in the crash. The helicopter was carrying out a reconnaissance flight over the fire when it crashed. The 2 Firefighters faced very heavy fire and smoke conditions. Pilot John de Ridder, along with Department of Conservation Ranger William Macrae, were sent to help evacuate trapped residents on the Karikari Peninsula. The Squirrel helicopter went down not far from the fire while making a reconnaissance flight over the fire which burned two homes in Matai Bay.

De Ridder, a seasoned pilot in these conditions, was a director for Salt Air, a charter company. Chief executive Grant Harnish said that de Ridder was one of the Far North’s most experienced and respected helicopter pilots. They were fighting the fire when he was requested by command to divert to pick civilians up from the beach and get them away from approaching fire and out of harm’s way. The pilot removed the monsoon bucket and then began the new task.

William Macrae, 54, was in the passenger seat when the helicopter crashed and was a long serving and highly respected ranger who has worked the job for 16 years. Macrae’s brother, also a DOC ranger, was busy operating at the fire when his brother crashed. His wife is the receptionist at the Kaitaia office. The fire, believed to have been deliberately set, started late Wednesday, forcing some residents in the remote area to wade into the ocean to escape the fire. Our sincere condolences to all affected.

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2 Pilots dead in separate wildfire aviation accidents in Spain

The International Association of Wildland Fire is reporting the deaths of two pilots in separate wildfire aviation accidents in Spain. One was a single engine air tanker that crashed on October 2, and the other was a mid-air collision of two helicopters on September 30. There was one fatality in each incident.

It has been a very bad year in Spain for wildfire aviation fatalities. Six firefighters died March 16 in the crash of a helicopter, and three died on September 19 in another helicopter accident.

Here is the information reported by the IAWF about the two most recent fatalities:

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INCIDENT #1

  • Name: Iñigo Zubiaga Padadogorriaga
  • Rank: Pilot
  • Age: 54
  • Gender: Male
  • Status: Contractor to the Airborne Firefighting Service of the Galician Regional Government (INFOCAM) (INFOGA)
  • Years of Service: Very experienced pilot and had flown the last four fire seasons in Galicia (Galice) Spain. He was a master of the Aeroclub of Biscay, and wrote a very popular manual for obtaining a private pilot’s license.
  • Date of Incident: 2 October 2011
  • Time of Incident: approximately 1715 hours local time
  • Date of Death: 2 October 2011
  • Company: Martínez Ridao Company
  • Fire Department: Airborne Firefighting Service of the Galician Regional Government (INFOCAM)
  • Incident Description: Pilot Zubiaga, was helping to extinguish a large fire in the Serra da Meda, Galicia near the town of Arcucelos (Laza). The plane he was piloting, an Air Tractor AT802, crashed for reasons still unknown but the pilot had time to radio his base that something was wrong with the aircraft. Nearby observers saw the “aircraft was on a strange maneuver before plunging to the ground.” Firefighters from Verín started an immediate search and when they found the aircraft the Zubiaga was not inside. He died of unknown causes and was found about 150 meters from the crashed aircraft in an area of rough terrain. His body was discovered about 1900 hours local time and was taken to the Hospital Complex of Ourense. An autopsy was to be performed to determine cause of death. The Regional Ministry of Rural Affairs announced an inquiry would take place concerning the incident.
  • Incident Location: Autonomous Community of Galicia, Ourense-Xunta de Galicia province, in Serrra da Meda, between Laza and Verín to 42.008999,-7.482033. Galicia (Galice) is in northwest Spain and is bordered by Portugal to the south, the Atlantic Ocean to the west and the Bay of Biscay to the north.
INCIDENT #2
  • Name: Leo Jenssen (from Denmark)
  • Rank: Pilot
  • Age: unknown
  • Gender: Male
  • Status: Contractor to the Airborne Firefighting Service of Castilla La Mancha Regional Government (Incendios Forestales Castilla La Mancha, INFOCAM)
  • Years of Service: More than 10700 flight hours and eight fire seasons in Spain
  • Date of Incident: 30 September 2011
  • Time of Incident: 1340 hours local time
  • Date of Death: 30 September 2011
  • Company: Grupo INAER
  • Company Address: Oficinas Centrales (INAER Helicópteros), Aeródromo de Mutxamel, Partida La Almaina, 92, 03110 Mutxamel, Alicante, SPAIN
  • Fire Department: Airborne Firefighting Service of the Castilla La Mancha Regional Government (Incendios Forestales Castilla La Mancha, INFOCAM)
  • Helicopter Contractor: Grupo INAER
  • Incident Description: Two helicopter Bell B212′s touched and crashed during aerial maneuvering to refill with water at the Bienservida reservoir. Pilot Jennsen (flying helicopter MSN 30775, CC-CIS) was the only one of the two pilots who died during the incident. The other pilot, Manuel Fuertes, with 13 years’ experience, (flying helicopter EC-GIC), survived with minor injuries and burns but walked away from the crash and was taken to the hospital in Ciudad Real. Pilot Jennsen was unconscious and with a pulse when extracted from the water and CPR was administered. Pilot Jennsen was pronounced dead at the hospital and reportedly died from drowning. He was working for INAER, for the Castilla La Mancha fire agency. The fire reported at 1245 hours local time was extinguished at only 6 ha. The Accident Investigation Commission and Civil Aviation Incidents (CIAIAC) of the Ministry of Development is responsible for the investigation. The helicopter had last undergone and passed a review on 22 September. At this time the cause of the accident is unknown.
  • Incident Location: Area known as Los Castellares in the Alcaraz Sierra, Autonomous Community of Castilla-La Mancha, Albacete province, at the Bienservida reservoir, 38.519429,-2.61137. Spain.
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