Dozens of people became sick at the Redrock and Trailer 1 fires 25 miles north of Reno, Nevada around July 19. Tests on some of them revealed that they had been infected with the Norovirus. The Medical Unit Leaders, Chris Graves and Diana Ludwig (trainee) prepared a lessons learned document, which is now on our Documents page, titled “Redrock-Trailer fires: Norovirus Lessons Learned”.
The Alaska Division of Forestry has issued a Factual Report about the accident on July 9th in which Todd Wanner of the Idaho City Hot Shots received burns while working around a portable pump. The full report is on our Documents page, but here are some excerpts:
At approximately 1857 hours (ADST) on July 9th, 2009 while supporting a water pumping operation, a member of the Idaho City IHC was burned while working on the Logging Slash Fire in interior Alaska. The Idaho City IHC Crew Member was assigned the operation of a Mark 3 pump to support a water pumping function utilizing a folda-tank and Mark 3 pump. During a routine check of the fuel supply the crew member opened the Jerry can (fuel tank); flammable liquid and vapors spewed from the container and were ignited. The resulting flash fire burned the crew member. Investigation reveals the jerry can, during set-up of the pump, was placed in close proximity to the Mark 3 exhaust (muffler). During the interval that the pump was running the exhaust did impinge upon the jerry can preheating the gasoline. Upon opening the bung of the jerry can; volatile gasoline vapors and liquid escaped and were ignited by the muffler/hot components of the Mark 3 pump. Portable fire extinguishers were used to extinguish the fuel can, pump and other burning objects that had been ignited by the flash fire.
A designated medivac helicopter from an adjacent fire was dispatched while medical personnel on scene began treatment of the injured crew member and prepared him for transport. The injured crew member was rapidly transported to a Fairbanks hospital and after an evaluation by physicians, was then transferred to a Seattle burn center. The crew member spent several days in the intensive care unit of the burn center where his condition rapidly improved and was released from the hospital on 07/22/2009. He continues to convalesce and is expected to make a full recovery.
Causal Factors and Findings
Placement of the jerry can in close proximity to Mark 3 muffler and in an angled alignment with the exhaust.
Size/shape of fuel containment dyke may have been a contributing factor in the placement of the jerry can next to the muffler. The investigation team recommends additional research regarding whether the fuel containment dyke does readily lend itself to safe and practical set-up / operation while adhering to containment standards.
Briefing IC-IHC received regarding very strict spill prevention and reporting may have been interpreted to include all incidents.
Educate all wildland suppression agencies and organizations of the Burn Injury Criteria that is present in Chapter 7 of the 2009 Interagency Standards for Fire and Fire Aviation Operations.
Update NWCG S-211 course to include more information regarding the proper use of spill containment devices and importance of keeping the jerry can away from muffler side of pumps
Place a label near fuel line port of jerry can stating “Do Not Place Can Near Exhaust”
All training should emphasize the proper use of PPE including eye and hand protection during all fueling operations
All training should address the utilization of Crew Resource Management during any emergency
All wildland fire suppression organizations/agencies should develop a “Safety Gram” to emphasize the dangers of placing fuel containers too close to mufflers or other sources of ignition
Tom Harbour, the Director of Fire and Aviation Management for the U.S. Forest Service, sent a memo dated yesterday to the Regional Foresters. It covers some changes that will be made in the contracting and management of helicopters used on fires.
Usually initiatives like this are the result of a specific incident or accident. The federal fire agencies are more likely to enhance safety after fatalities occur rather than being proactive to prevent them. Of course the memo does not identify what precipitated these changes, but one has to wonder if the accident on August 8 last year that involved the Type 1 helicopter and the deaths of 9 firefighters on a fire in northern California had anything to do with it. As far as we know those accident reports, USFS and NTSB, have not been made public.
Date: July 7, 2009
To: Regional Foresters
This memo is to inform you of the operational safety enhancements in the Aviation program for 2009. The key actions are in progress and listed below:
Multiple contract changes are being made to the national helicopter contracts.
Aircraft will be weighed with FS maintenance inspectors present to verify weight submitted with contract bid.
More stringent standards for seating and restraint systems.
Contract scope now contains active safety management requirements.
A copy of the performance charts submitted for bid will be onboard each helicopter to allow the helicopter manager to verify the correct performance charts are being used.
Increased number of vendor training pilots will be allowed to accompany less experienced pilots during incident operations to provide tactical training and increased oversight.
Contract compliance inspection teams will be dispatched during field operations.The Department of the Interior Aviation Management Directorate is a partner in this initiative and will enhance capability and the number of teams that can be deployed.
As helicopters are activated for early use, compliance teams will be dispatched to conduct spot inspections and weight verification.
Performance planning charts for all contract helicopters will be available via the web to allow helicopter managers to ensure the accuracy of load calculation allowable payloads.
Continue to utilize more Exclusive Use (EU) helicopters and minimize use of Call-When-Needed aircraft.EU helicopter managers are generally better trained and more experienced and provide safer and more efficient operations.
Independent contractors will be hired to develop an Operational Risk Management (ORM) risk/benefit analysis process.
A formal risk assessment of Type I helicopter passenger transport has been completed by a professional aviation safety consultant. Assessments of Type 2 and 3 operations are planned.
Formal program reviews for the seven national Type 2 helicopters will be completed this season.
These items are critical for the continued safety and success of our aviation program and are underway. If you have any questions please contact Karyn Wood, Assistant Director for Operations.
The evolution of the “13 Situations that Shout Watch Out” and the “18 Watch Out Situations”.
From a paper by Jennifer A. Ziegler, PhD., Department of Communication, Valparaiso University:
Although it is still a mystery about precisely when, where, or how the original 13 Situations that Shout ‘Watch Out’ were developed, there is good reason to believe that they originated in the late 1960s, and most likely after 1967. Officially, there were 13 “Situations that Shout ‘Watch Out’” in effect through the summer of 1987.
Then, five items were added to the list when NWCG developed the “Standards for Survival” course later that year (1987). At that time, the name was also changed to 18 “Watch Out Situations,” and the sentence structure of each item was altered from the subjective “You are…” to a more objective description of each situation.
1987 was also the year the Fire Orders were reordered, and the Standards for Survival course and subsequent trend analyses of the Watch Out Situations emphasized how the two lists were supposed to work together. Although the Fire Orders were reordered (again) in 2003, the list of Watch Out Situations has remained unchanged since 1987.
“Basic 32” wildland fire training
In 1972, when I was on the El Cariso Hot Shots near Elsinore, California, the crew, led by Superintendent Ron Campbell, saw the need for standardized basic training for wildland firefighters. At the time, there was nothing, just collections of papers, research, and some books. Some people had written some lesson plans, but there was no widely available, organized training curriculum that could be used to take someone off the street and put them through a structured multi-day course in wildland fire suppression.
In what is now seen as a remarkable accomplishment, the crew created a 32-hour course, complete with lesson plans, a slide-tape program, tests, and a student workbook, to fill this need. Over the next several years, dozens of copies of the program were made and distributed, mostly around the Cleveland National Forest and other areas in southern California. Later it was converted to video tape which made it a lot easier to put on the training, and the popularity spread even further.
Tom Sadowski and I took most of the photos, the slides, that were used in the program. Recently I converted over 800 of my slides, prints, and negatives to digital form, including some copies I had of some of the original slides that I took that were in what became known as the “Basic 32” training.
13 Watch Out Situations from the 1970s
The photo at the top of this post is from that “Basic 32” program, and was one of the 13 images of what was then the “13 Situations That Shout Watch Out”.
I will post the other 12
From March 19 through 30 I will post the other 12 of the color images from the “13 Situations”, one each day.
Here are the 18 Watch Out Situations as they are today.
1. Fire not scouted and sized up.
2. In country not seen in daylight.
3. Safety zones and escape routes not identified.
4. Unfamiliar with weather and local factors influencing fire behavior.
5. Uninformed on strategy, tactics, and hazards.
6. Instructions and assignments not clear.
7. No communication link with crewmembers/supervisors.
8. Constructing line without safe anchor point.
9. Building fireline downhill with fire below.
10. Attempting frontal assault on fire.
11. Unburned fuel between you and the fire.
12. Cannot see main fire, not in contact with anyone who can.
13. On a hillside where rolling material can ignite fuel below.
14. Weather is getting hotter and drier.
15. Wind increases and/or changes direction.
16. Getting frequent spot fires across line.
17. Terrain and fuels make escape to safety zones difficult.
18. Taking a nap near the fire line.
Dr. Ziegler will be presenting a follow up poster at the 10th Wildland Fire Safety Summit in Phoenix, April 27-30, regarding the origin of the original 13 Situations, called “Help Uncover the Mystery of the Original 13 Situations That Shout Watch Out”. One aspect of the Situations that has captured her interest is that they were originally intended to be operational tactics and not safety guidelines.
A question she will be asking at the Safety Summit will be “What is the 19th Watch Out Situation?”