Investigation report released for Black Forest Fire

Origin of the Black Forest Fire

Origin of the Black Forest Fire

The El Paso County Sheriff’s Office has released a summary report on the investigation of the Black Forest Fire which started June 11, 2013 near Colorado Springs, Colorado. The fire killed two people and burned 489 houses and 14,280 acres, resulting in $420 million in insured losses.

The investigators eliminated natural causes, such as lightning. That left human-related ignitions.

Below are excerpts from the report:

…Given the known devastation of the fire at that point, an Investigation Team was formed consisting of recognized experts in the area of Wildland fire investigation from agencies including the USDA Forest Service, the Aurora Fire Department, the US Bureau of Alcohol, Tobacco, Firearms and Explosives (ATFE), the 4th Judicial District Attorney’s Office and others. This team was assisted by surveyors from the El Paso County Public Services Department.

The only clearly established fact was that no natural causes existed and thus the fire was human caused. A potential cause associated with the metal particles can not be ruled out, or positively identified. A potential cause associated with an intentional ignition is not supported by the evidence or circumstances, but can not be completely ruled out. The origin of the fire is in an area that is not readily accessible from a roadway, allowing an easy escape, as is typical in intentionally set Wildland fires. There was no evidence of any other miscellaneous cause such as blasting, fireworks, welding, target shooting, etc.

Upon the completion of the investigation, the entire case was reviewed by the Sheriff’s Office Investigations Division and the District Attorney’s Office to determine if any additional leads remained. It was the determination of the El Paso County Sheriff’s Office and the District Attorney’s Office that there was not sufficient evidence to warrant criminal prosecution at this time. None of the investigation or forensic examination supported any one possibility to the extent needed to pursue criminal charges. Additionally, no additional recommended follow-up work could be identified at this time.

Three other reports have previously been released about the Black Forest Fire:

  1. Report on how the fire was managed on the first day, issued by the Black Forest Fire District Board on February 19, 2014. The complete report can no longer be found on the District’s web site.
  2. A 2,000 page, 345 megabyte report, released March 14, 2014, commissioned by the Black Forest Fire District which evaluated how the fire was managed, including the performance of Fire Chief Bob Harvey during the first hours of the fire. Sheriff Terry Maketa had been extremely critical of the Chief in numerous interviews with the media. The complete report can no longer be found on the District’s web site.
  3. After Action Report, by the El Paso County Sheriff’s Office, May 15, 2014. We preserved this report on the Wildfire Today web site.

 

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Report released on engine burnover in Idaho

Richfield fire, engine burnoverAn investigation report has been released for an engine that was destroyed by a wildland fire near Richfield, Idaho on July 16, 2014.

During the initial attack phase on the Bureau of Land Management Fire, a Type 4 engine from the Richfield, Idaho Rural Fire Department responded. The two people on the engine attempted to make a frontal attack on the head of the fire.

The engine got stuck, or high-centered, on a rock and could not be moved. The two people on the engine, a city employee and a “part-time” volunteer, in an attempt to protect the truck from the approaching fire used two small booster hoses, one-half inch in diameter with a flow rate of 10 gallons per minute. They had to abandon the engine as the fire got closer, and it was destroyed. There were no injuries to the personnel.

Below is an excerpt from the report. “ENG3″ is the apparatus that was destroyed by the fire:

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“…ENG3 proceeded south on the two track toward the head of the fire with FF2 riding on the top of the engine. The engine left the two track road and drove off-road toward a lava blister trying to access the active fire perimeter. Near the base of thelava blister, ENG3 struck a rock cluster high centering the rear axle of the vehicle and rendering ENG3 immobile. FF1 utilized four-wheel drive in an attempt to dislodge the vehicle, but sandy conditions caused ENG3’s side tires to sink. The rear axle of the apparatus pivoted on the rear differential, listing the vehicle to its right side. The driver’s rear tire was raised off the ground by 8-12 inches.

WT1 operator, FMO, and AFMO hiked west from the highway over the lava blister and observed ENG3 high centered on a rock in unburned fuel north of the active fire perimeter. The AFMO notified the IC at approximately 1215 of the immobilized engine. ENG3 crew deployed booster hose off both sides of the truck. FF2 worked from the right hose reel in front of the truck and south about 50 feet up the lava blister into sparser fuels. FF1 stayed near the front of the truck wetting a heavier pocket of unburned grass and brush.

ENG1 left the west flank and drove to the location of ENG3 to help remove ENG3 from the rock. ENG1 determined that an attempt to dislodge ENG3 would be unsuccessful. ENG1 then drove southwest and established an anchor point at the lava blister, approximately 200 yards from ENG3. ENG1 resumed mobile attack working back towards the disabled engine.

Between 1220 and 1225, wind direction changed from west to south. Fire behavior increasedand the fire made a rapid run toward the disabled engine. The FMO and AFMO made verbal contact with the two individuals on ENG3. The FMO and FF1 retreated to a safety zone in the black on top of the lava blister approximately 25 yards east of the disabled engine. The AFMO urged FF2, still by ENG3, to immediately retreat toward him into the safety zone. FF2 delayed until he felt excessive heat from the fire, closed the nozzle, and retreated to the safety zone.

At 1227, ENG3 was engulfed by the fire and completely destroyed…”

Richfield fire, engine burnover

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USFS to use new serious accident review system

(Updated on August 9, 2014 to include a link to details about the new USFS policy, and on August 11 to correct information about the distribution of the version of the report prepared for “organizational leadership”.)

The U.S. Forest Service has created a new review process for serious incidents involving a fatality or three or more hospitalizations, called the Coordinated Response Protocol (CRP). According to the agency:

The CRP is a process now being used to ensure we learn everything possible from serious incidents so we can prevent recurrence while reducing the painful effects on those closest to the incident or accident by coordinating the investigations and reviews that are required when fatalities have occurred. The CRP uses pre-trained and designated response teams. This provides a basis for coordination and communication before any team is dispatched to an incident. This new process minimizes traumatic impacts on witnesses, coworkers and others close to the tragedy while improving our ability to gather information and learn. The CRP replaces the Serious Accident Investigation with a new process called the Learning Review. The Learning Review is designed to create learning products for multiple audiences.

A new Interagency Serious Accident Investigation Guide was used for the first report on the Yarnell Hill Fire on which 19 members of the Granite Mountain Hotshots were killed. The process prohibited causes, conclusions, and observations from being included in the public report; they were reserved for a second version of the report that would be for internal agency use only.

That process was a total failure and set a new low bar for learning opportunities following serious accidents. The USFS prohibited their employees that had specific knowledge about the fire from being interviewed.

The new protocol just introduced by the USFS also specifies that two reports be produced; one for the public and another for organizational leadership.

Ivan Pupulidy called us to say that he was the author of the new protocol. Presently he is the Acting Program Manager for Human Factors Risk Management Research Development and Application for the USFS’ Rocky Mountain Research Station. In September he will be the Director of the USFS’ new Office of Learning. Mr. Pupulidy said the agency no longer subscribes to the one-year old Interagency guide and explained that under the new system both versions of the reports will be published on the Wildland Fire Lessons Learned Center website. When asked if the causes, conclusions, and observations would be included in the reports, he said they “will not include traditional nonsense”.

Mr. Pupulidy said the information will be broken up into two reports, rather than just having one, because a single document became “lengthy and troublesome”.

Our view:

Some firefighters would argue that causes, conclusions, and observations are not “nonsense”, but are some of the more important and useful features of an accident report, and that banning them reduces the opportunities for learning and preventing similar accidents. Having subject matter experts review an accident and provide information about how and why it happened can be crucial information for those in the early stages of their career.

Any effective accident review must collect all of the information, and without censoring or overtly protecting agency officials, distribute findings that can reduce the chance of a future similar accident. As we found out, anything short of that is a waste of time and money. More than 50 people worked on the Yarnell Hill report, and could not pull it off. It sounds simple, but to get a politically sensitive agency to carry it out, apparently is very, very difficult.

In addition, innocent bystanders and witnesses with information about the accident must be protected from civil lawsuits and criminal charges.

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The USFS’ description of the new policy: Coordinated Response Protocol Paper

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Report released on USFS engine rollover in Wyoming

Engine 492, front

The U.S. Forest Service has released a report on the August 8, 2013 rollover of Engine 492 southwest of Newcastle, Wyoming. In August we provided some information from the 72-hour report.

Below is an excerpt from the summary — you can read the entire report HERE.

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“On Thursday, August 8, 2013 Medicine Bow-Routt National Forest and Thunder Basin National Grasslands Engine 492, a 2013 KME Type 4 engine was involved in a rollover accident along Wyoming State Highway 450. The accident occurred around noon, as Engine 492 was responding to the Osage Fire, in mutual aid assistance to Weston County, Wyoming. The accident occurred near mile marker 40, or approximately 10 miles east of the Thunder Basin Work Center.

The engine left the highway, veered slightly to the right side of the road hitting a paved apron to a side gate, with the driver seeking to decelerate and regain control of the engine. The engine returned to the road, with the engine brakes being heavily applied, then redirected back to the highway, which resulted in crossing the center line and going to the opposite road edge. Engine 492 rolled over a few times before coming to rest on its wheels (up-right).

At the time of the accident all three members of Engine 492 were wearing their seatbelts. Use of seatbelts and the integrity of the engine cab are likely the principal reasons for the survivability of this accident. All three crew members were hurt in the accident and the Type 4 engine was a total loss. Two of the crew members were transported by ambulance to Newcastle, Wyoming and the third member was transported by ambulance to the high school practice field in Wright, Wyoming where he was transferred to, and then transported by helicopter to the hospital in Casper, Wyoming. The two crewmembers that were transported to Newcastle, Wyoming were released later the same day. However, the injuries sustained by the third member resulted in a longer stay in Casper and release from the hospital on Saturday, August 10th…”

Engine 492, left side Engine 492, wide

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Report released on escaped prescribed fire at Devils Tower

 

Devils Tower escaped prescribed fire

Map, showing the approximate location of the planned prescribed fire at Devils Tower (300 acres in white) and the 56 acres (in red) that escaped beyond the planned perimeter. Image from Google Earth. Perimeters by Wildfire Today. (click to enlarge)

Yesterday after Wildfire Today made inquiries about reports that may have been completed regarding the escaped prescribed fire on May 8, 2013 at Devils Tower National Monument in Wyoming, the National Park Service released the official review of the incident.

The NPS ignited the 300-acre unit on May 7, 2013. Several spot fires occurred outside the planned perimeter that were contained the first day. But during mopup at 12:50 p.m. on May 8 fire became established again at one of the spot fire locations on the southwest side of the project. At that time the cooperating U.S. Forest Service resources present the day before had been released. Some of the remaining firefighters were concentrating on the previous day’s spot fires at another location, but most of the firefighters were attending an After Action Review of a non-injury tipover of a Utility Task Vehicle (UTV) that occurred the day before. The 56 acres burning outside the burn unit were mostly stopped at the Monument boundary, but a few acres crossed over onto private land leased by Wyoming state Senator Ogden Driskill, but no structures were damaged.

Devils Tower Rx fire, May 8, 2013

Devils Tower Rx fire, May 7, 2013. NPS photo.

In the interest of full disclosure, Devils Tower was one of the seven National Parks for which I was the Area Fire Management Officer, from 1998 until 2003.

The review pointed out several times that one of the primary issues related to the escape was that in computing the fine dead fuel moisture, it was assumed that the fire would be shaded by the smoke column. However, some of the area was not shaded, and for two hours each day on May 7 and 8, at those locations the fine dead fuel moisture dropped below the 4 to 10 percent allowed in the prescription, down to 3 percent.

Other than how the weather affected the fuel moisture, the review barely mentioned the weather conditions and the forecast. Two spot weather forecasts were issued before the escape — one at 7:57 a.m. MDT on May 7 and another at 9:29 a.m. on May 8, the day of the escape. For May 8, both forecasts predicted fairly strong northeast winds, of 7 to 15 mph and 8 to 14 mph.

The Remote Automatic Weather Station at Devils Tower is very close to the location of the prescribed fire, in a low-lying area partially sheltered by trees from winds from all directions (see map above). Northwest, north, and northeast winds are additionally partially blocked by higher ground and the Devils Tower itself. Below are the weather observations from the weather station between 17:23 on May 7 through 17:23 on May 8. They show mild sustained wind speeds, with gusts around mid-day to late afternoon on May 8 of 13 to 22 mph. If the weather station was in a more exposed location the recorded speeds would have been higher.

Devils Tower weather, May 7 and 8, 2013

Devils Tower weather, May 7 and 8, 2013

The NPS committed four people to the facilitated learning analysis of the non-injury slow tip over of the UTV, and three to the review of the escaped prescribed fire.

UTV  at Devils Tower

Photo from the FLA for the UTV tip over, that presumably shows a UTV in the approximate location of the accident. NPS photo.

We initially covered the prescribed in 2013 fire HERE and HERE.

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Weather cited as primary issue in escaped prescribed fire near Hettinger, ND

Pautre Fire originA report issued by the U.S. Forest Service for a prescribed fire that escaped on the Dakota Prairie National Grasslands in northern South Dakota last year cited weather as being one of the primary factors in losing control of the fire.

The Pasture 3B prescribed fire was planned at 210 acres, but strong winds on April 3, 2013 caused by the predicted passage of a cold front pushed the fire across a mowed fire line into tall grass and ultimately burned 10,679 acres, (3,519 acres federal and 7,160 acres private). The wildfire, named Pautre Fire, was stopped at 11 p.m. that night.

On April 3, 2013 we wrote about the wildfire:

An article in The Rapid City Journal has more information about the impacts of the fire on the ranchers. Privately owned grazing, hay stacks, and miles of fencing were damaged or destroyed during the ranchers’ calving season. Here is an excerpt:

“Laurie Casper, 36, said the fire destroyed 95 percent of her family’s farmland, which is more than 1,000 acres.

‘We lost all of our calving pasture, we lost our summer grazing, we lost our fall grazing, we lost 100 percent of our alfalfa— which we cut for hay bales in order to feed the cattle this oncoming winter— all that’s completely gone,’ she said. ‘And there’s just just miles and miles of fences that are completely gone.’ “

The prescription in the project’s burn plan for the maximum wind speed at eye level was 15 mph and the maximum wind speed at the 20-foot level was 20 mph. One of the spot weather forecasts for the morning of the prescribed fire predicted the passage of the cold front, with winds shifting from the south at 5 to 11 mph in the morning, to northwest at 25 mph with gusts to 30 mph in the afternoon. The actual weather that day was very similar to the forecast.

About a month later, another prescribed fire not too far away, at Devils Tower National Memorial in western Wyoming, also escaped, due partially to strong winds. That report still has not been posted on the Wildland Fire Lessons Learned Center website. We were told today that was due to a glitch, and it will appear there very soon, possibly as early as today, February 4. (UPDATE, February 5, 2014: the National Park Service arranged to have the Devils Tower report posted late in the day on February 4. We wrote about it here.)

Pautre Fire. US Forest Service photo.

Pautre Fire. US Forest Service photo.

The report said firefighters concluded they would not do much different next time (page 12):

Firefighters did an excellent job of planning, organizing and executing this prescribed fire and adhering to the prescribed fire plan. Following the control of the escaped fire some firefighters had difficulty thinking of anything they would do differently next time. While it is true that we work in a dangerous environment with unexpected changes in weather, we strive to be a learning culture and continuously improve our ability to make decisions that evaluate risk and get work done on the ground.

Some of the issues listed by the Facilitated Learning Analysis team included:

  • Improved weather forecasts are needed.
  • Consider additional research on methods to predict effects of drought on fire behavior in grass fuel models.
  • The nearest remote automated weather station (RAWS) is more than 90 miles away.
  • The project was conducted at the critical edge of the prescription.
  • Consider gaming out worst case scenario “what ifs” during the planning process, and discuss with participants during the on-site briefing.
  • There were problems with radio communications [note from Bill: I don’t remember EVER seeing a report like this that did not cite radio communications as being an issue].

The commendations section included this:

The personnel involved in all levels of the Pasture 3B prescribed fire were motivated, worked well as a team, were adequately trained, and appropriately briefed. They had a keen awareness that this was the first burn of the year, and took numerous precautions to ensure successful completion of the prescribed fire.

We did not see any mention in the report of damaged fences, hay, or pastures.

Some ranchers in western North Dakota donated hay to the South Dakota ranchers who lost theirs in the escaped prescribed fire.

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