Report released for engine burnovers and entrapment on North Pass Fire

E-2 after the burnover
E-2 after the burnover. Photo from the report.

A Facilitated Learning Analysis has been released for the engine burnovers and entrapments that occurred on the North Pass Fire on the Mendocino National Forest in northern California, August 25, 2012.

You can read the entire report (large 3.8MB file), but here is a very brief summary. On August 18,2012, five Type 3 Engines from municipal fire departments in southern California were working as a Type 3 Engine Strike Team with the assignment that day of securing a dozer line. Due to dense vegetation along the dozer line, and a lack of information about their situation, they were surprised when a spot fire caused by a burning tree resulted in a fire that overran their position.

E-2 at the burnover site, before the incident and before turning around
E-2 at the burnover site, before the accident and before turning around. Photo from the report.

The crew from E-2 dismounted to assist with the spot fire, leaving the engine operator to button it up, disconnect hoses, and move it to assist with the spot fire at another location along the dozer line. The fire approached the engine before the operator was able to relocate the engine. He decided to run down the dozer line to escape, telling a hand crew after he reached safety, “F*** my engine burned up…. F*** my engine burned up!” Hand-crew members responded, “It’s fine, it’s fine. You’re alive so it’s fine.”

A second engine was also burned over, according to the report:

At the same time fire is engulfing E-2, E-5 finds their egress cut off by the flames now lying over the dozer line. E-5 was then forced to withdraw to a safe area. Capt. E-5 notifies ST-1C STEN they are remaining at their current location and requests permission to fire out the area around them. ST-1C STEN tells them, “Do what you need to do.” The crew of E-5 pre-treats the area around them using Class A foam, depleting their water supply. E-5 then deploys thermal curtains, and they seek shelter in the apparatus as the fire burns around them.

After the burnovers the strike team was sent to a USFS work station. The Strike Team Leader reported to a Ground Support Unit Leader who escorted them to the Incident Base. After receiving medical evaluations, all personnel were cleared by the Medical Unit and received no injuries.

Below are excerpts from the lessons learned, as shared by the facilitated learning analysis participants:

  • “Try to think more three-dimensionally. I really didn’t see/perceive the layout of the road, the green, or the fire. It would of helped to realize the danger there.”
  • “Maybe a picture from the air.”
  • ”I wish I’d known I had a qualified faller. Don’t know that I would of used them.” [to cut down the tree throwing out burning embers that caused the spot fire.]
  • “Had I perceived the danger, I wish I’d thought twice about the assignment for E-2.”
  • “I will definitely request more 800 MHz radios.”
  • From the Division Supervisor: “It would have been more appropriate to recognize that their (ST-1C) specialties were in other areas of firefighting and take the time to give them a more thorough briefing on the assignment rather than handing them off to be briefed by ST-2C STEN.”
  • “Walking through it afterward, E-2 was in perfect alignment with the draw, but of course you couldn’t see with all of the vegetation.”
  • From Capt. E-1: “Should of used a faller to drop the problem tree in the first place. Use the professionals.”
  • And from the same Capt: “There are all these other resources that we don’t normally deal with, like fallers, inmate crews and dozers. We had resources we could have used, but I just didn’t have the experience to think to ask for them.”

Excerpts of observations from the FLA team members:

  • The participants believe the division was large and complex. Geographically the division stretched over 5 to 7 miles of line.
  • The participants felt complexity and scope of the division complicated communications over the assigned tactical channel. Early on in the shift it was identified that communications were difficult. To mitigate it, ST-1C began using their 800 MHz for intra-crew communications. One difficulty was that not everyone had both radios. Some had the 800 MHz, and some had a VHF radio, but not everyone had both. Every member should have the same type of communication capability.
  • FLA team members and participants acknowledged that utilizing an unassigned tactical frequency on an incident is against several policies & guidelines.

USFS releases report on Steep Corner Fire fatality

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.

Ann Veseth
Ann Veseth. Photo from the report.

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”.

An opinion

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.

NPS releases report on Lassen National Park’s Reading Fire

Reading Fire
Reading Fire. Photo by Lassen National Park.

The National Park Service has released a report about last summer’s Reading Fire in Lassen Volcanic National Park in California which, after being monitored for two weeks and burning 95 acres, grew to 28,079 acres, escaping the park boundaries. The fire started from a lightning strike on July 23, 2012 and was contained on August 22. For the first two weeks it was managed under a “Wildland Fire for Resource Benefit” strategy.

Reading Fire, final perimeter
Final perimeter (in red) of the Reading Fire. The green line is the boundary of Lassen Volcanic National Park.

The expectation was that they could stop the fire when it reached the Lassen National Park Highway, about a mile north of the point of origin. On August 6 when the fire was 140 acres the Type 4 Incident Commander transitioned to a Type 3 IC. Later in the day the fire ran for about a mile and a half, blowing right across the 2-lane highway. Then a Type 2 Incident Managment Team was ordered, which eventually transitioned to a Type 1 IMTeam on August 13. When the fire was contained it had burned 11,071 acres of US Forest Service land outside the park boundaries and 75 acres privately owned, for a total of 28,079 acres. By August 23 the National Park Service had spent $15,875,495 observing, managing, and later suppressing the fire.

As we have stated before, managing a fire with your hands tied by utilizing little to no aggressive suppression action, is extremely difficult, requiring an extraordinary amount of skill, knowledge, expertise, experience, and luck. Especially if the fire starts in mid-July, leaving 6 to 12 weeks of weather ahead that is conducive to rapid fire spread. Few people can do this. It is impossible to predict accurately how weather will affect a fire more than 10 days ahead.

Here are some some excerpts from the 53-page report:
Continue reading “NPS releases report on Lassen National Park’s Reading Fire”

Another report about Lower North Fork Fire offers recommendations

Lower North Fork Fire
Lower North Fork Fire. Photo provided by Jefferson County Sheriff’s Office

A special commission created by the Colorado General Assembly to investigate the Lower North Fork fire has released their report. The fire originated from an escaped prescribed fire southwest of Denver on March 26, 2012. It burned 4,140 acres and killed three local residents at their homes. The report offers a number of recommendations but did not place blame.

This is the second report about the fire. The first, released in April, 2012, was conducted by Colorado’s Department of Natural Resources. That 152-page report (a very large 11.8 MB file) only addressed the management of the prescribed fire, and did not cover the suppression of the wildfire, the three fatalities, or the controversial evacuation procedures during the wildfire.

The charter of the commission  which produced the second report was to investigate the following:

  • causes of the wildfire;
  • the impact of the wildfire on the affected community;
  • the loss of life and financial devastation incurred by the community;
  • the loss of confidence by the community in the response to the emergency by
  • governmental bodies at all levels; and
  • measures to prevent the occurrence of a similar tragedy

Their recommendations were on the following topics:

  1. Coordination among fire districts
  2. Raising the liability cap
  3. Wildland-urban interface and local land use egulations
  4. Funding for the federal FLAME Act (which is not fully funded by Congress)
  5. 911 capabilities
  6. A consistent revenue source for wildfire suppression
  7. Air emission permits
  8. Funding for the SWIFT Program

The Commission also recommends that four bills be introduced in the Colorado General Assembly:

  • Prescribed Burn Program in the Division of Fire Prevention and Control
  • Wildfire Matters Review Committee
  • Extend Wildfire Mitigation Financial Incentives
  • All-hazards Resource Mobilization and Reimbursement

You can read the entire report HERE.

 

Thanks go out to Gary

Local Colorado newspaper investigates management of Waldo Canyon Fire

Waldo Canyon Fire, June 26, 2012
Waldo Canyon Fire, June 26, 2012, the day hundreds of homes burned in Colorado Springs. Credit: Keystoneridin

The Colorado Springs Independent conducted an exhaustive study into the management of the Waldo Canyon Fire, which in June, 2012 killed two people, destroyed 346 homes, and burned 18,247 acres — with some of those acres and most of the homes being within the city limits of Colorado Springs. The results of their investigation, published in a lengthy article on December 12, are extremely interesting. More about that later.

On October 23, the City of Colorado Springs released what they called an “Initial After Action Report”, but in the document they admitted the AAR was not the final, comprehensive report on the fire, but was considered preliminary. An in-depth analysis, they said, would occur over the next several months to fully explore Colorado Spring’s management of the fire.

The report, as we wrote then, was unusual. It listed some strengths and recommendations, but omitted information about the issues that caused the recommendations. Therefore, it was not always clear WHY the recommendations were made, forcing an observer to read between the lines. This limited the opportunities for lessons learned and may not in all cases have the desired result of preventing mistakes. There was no indication that they consulted experts outside the city for unbiased opinions or recommendations.

In reviewing the recommendations in the ARR, it appeared that many of the issues would be mitigated with adequate training and experience in the Incident Command System.

After reading the article in yesterday’s Colorado Springs Independent, I am left stunned. Regarding the management of the fire within the city of Colorado Springs, I have never heard of a wildland fire with such a huge impact that was so utterly, catastrophically mismanaged.

The fire started Saturday, June 23, 2012. A Type 1 Incident Management Team, Great Basin Team 2, with Incident Commander Rich Harvey, assumed command Monday morning, June 25. Except, according to the article:

[Colorado Springs FD Fire Chief Rich] Brown said he specified in the city’s delegation of authority that the city, and no one else, would have control if the fire crossed into Colorado Springs.

The newspaper examined hundreds of documents including reports written by firefighters working on the fire. The article is astounding. If it is correct, and I have no reason to believe it is not, it exposes complete failures in pre-incident planning, qualification and training of fire department personnel, evacuation planning and execution, logistics, daily incident planning, strategy, and tactics. Apparently this large, modern city with an extensive, very vulnerable wildland-urban interface was completely unprepared to manage a large wildland fire or evacuations.

The article does not criticize firefighters. It points out the failures in preparedness and management of the fire by upper level officials, before, during, and after the incident. Some mid-level and upper level firefighters were forced into positions of great responsibility on the fire without having been provided the necessary training and experience. That was not their fault, it was just the way it was done in Colorado Springs.

You should read the article. It’s long, but worth it from a lessons learned perspective. The comments at the bottom of the article are interesting as well.

Here are a few excerpts from the article, copied and assembled into bullets:

  • When the fire swept into Mountain Shadows, the city had a mere four firefighting vehicles, or apparatus, assigned to that subdivision and all other land north to the Air Force Academy.
  • The evacuation plan had been drafted only that morning, and was enacted minutes before the first homes burned.
  • Local firefighters found themselves outgunned, and much of the help from other fire departments was nowhere close, because leaders sought those resources only after flames came into the city. Their chief staging area wasn’t set up and equipped until houses were ablaze, and they didn’t have a mobile command post until eight hours into Tuesday’s firefight [when most of the homes burned].
  • And, as readily admitted by city firefighters leading efforts on the ground that night, the fire could have charged further eastward for miles had it not been for the unanticipated arrival of U.S. Forest Service engines and their hot shot crews.
  • [A Colorado Springs FD Captain], a heavy rescue expert with no current wildland certification, was in charge of the city’s deployed resources on Tuesday [when most of the homes burned].
  • And because the department hadn’t made maps in advance for out-of-town engines, crew’s like Company Officer P.J. Langmaid’s were told to “split all our companies and place one member on each Denver Fire rig as a point of contact and communications/operations liaison.”
  • The next day, the city did sign its own delegation of authority — but apparently made it clear its fire personnel would remain separate from Harvey’s [Type 1 Incident Management] team, which arrived Sunday night. In a July 16 interview, [Colorado Springs FD Fire Chief Rich] Brown said he specified in the city’s delegation of authority that the city, and no one else, would have control if the fire crossed into Colorado Springs.
  • As adamant as the city was that its personnel operate independently during the fire, it is equally adamant that only its personnel examine the response. No third party has been engaged to review the city’s performance, which often is requested when a fire kills people.

The map below shows the progression of the Waldo Canyon Fire. Colorado Springs is on the eastern edge below the blue box that says “July 1-6”.
Waldo Canyon Fire progression map

The Colorado Springs Independent, and the reporter, Pam Zubeck, deserve a great deal of praise for their investigation and the writing of this excellent article. Pulitzer Prize-worthy maybe?

Differences between military and Forest Service accident investigations

The accident report on the fatal crash of the military C-130 MAFFS air tanker which was released yesterday illustrated one very important difference between accident investigations conducted by the military and the U.S. Forest Service. A notice on page two of the report points out that the findings of military aviation accident investigations are regulated by law, 10 U.S.C. 2254(d), which states:

Use of Information in Civil Proceedings.—For purposes of any civil or criminal proceeding arising from an aircraft accident, any opinion of the accident investigators as to the cause of, or the factors contributing to, the accident set forth in the accident investigation report may not be considered as evidence in such proceeding, nor may such information be considered an admission of liability by the United States or by any person referred to in those conclusions or statements.

C-130 MAFFS crash, July 1, 2012
C-130 MAFFS air tanker crash, July 1, 2012. US Air Force photo

For fatal wildfire burnovers or entrapments of U.S. Forest Service employees, a law provides for just the opposite, thanks to a bill that was sponsored by Senator Maria Cantwell and U.S. Representative Doc Hastings, which became Public Law 107-203 in 2002:

In the case of each fatality of an officer or employee of the Forest Service that occurs due to wildfire entrapment or burnover, the Inspector General of the Department of Agriculture shall conduct an investigation of the fatality. The investigation shall not rely on, and shall be completely independent of, any investigation of the fatality that is conducted by the Forest Service.

The Cantwell-Hastings bill that was signed into law in 2002 was a knee-jerk reaction to the fatalities on the Thirtymile fire the previous year. The Department of Agriculture’s Inspector General’s office had no experience or training in the suppression or investigation of wildland fires. They are much more likely to be investigating violations at a chicken ranch than evaluating fire behavior and tactical decisions at a wildfire. The goal of the Inspector General investigation would be to determine if any crimes were committed, so that a firefighter could be charged and possibly sent to prison.

After the trainee wildland fire investigator for the OIG finished looking at the Thirtymile fire, on January 30, 2007 the crew boss of the four firefighters that died was charged with 11 felonies, including four counts of manslaughter. The charges were later reduced to two counts of making false statements to which the crew boss pleaded guilty on August 20, 2008. He was sentenced to three years of probation and 90 days of work release.

The criminal charges brought against the firefighter who may or may not have made some mistakes on the fire had a serious, chilling effect on wildland firefighters. Not only does it make them reluctant to speak to anyone about what happened on an accident, some even had second thoughts about their willingness to continue working in a professional they loved because potential criminal charges or convictions could ruin their lives and the livelihood of their families.

In addition, firefighters lawyering-up after an accident makes it difficult to discover the causes of an accident and to learn lessons which could save lives by preventing similar fatalities.

The four-fatality MAFFS accident was a complex chain of events involving many individuals and firefighting resources. But in spite of the complexity, the report was released to the public only four months after the accident, making it possible for lessons to be learned while reducing the chances of a similar accident taking more lives.

This short turnaround is unheard of in the wildland fire agencies in part due to the potential civil and criminal implications down the road.

This is literally a life and death issue — Senator Maria Cantwell’s and Representative Doc Hastings’ hastily conceived Public Law 107-203 must be repealed and replaced by one similar to 10 U.S.C. 2254(d), which serves the military very well. The Cantwell-Hastings law serves no useful purpose. Accidents are investigated, with or without the ridiculous law. It had unintended consequences and needs to be fixed.