Andrew Palmer fatality report released

Andrew Palmer, NPS photo

The National Park Service has released the report about the accident in which an NPS firefighter, Andrew Palmer, died. Mr. Palmer was killed during a tree falling incident on the Eagle fire, part of the Iron Complex on the Shasta Trinity National Forest in northern California on July 25, 2008. He was a firefighter at Olympic National Park in Port Angeles, Washington.

Here is a link to the report.

Below is the complete executive summary from the factual report:

Early in the day on July 22, 2008, an engine from Olympic National Park received a resource order to report to the Iron Complex, on the Shasta-Trinity National Forest, near Junction City, California. The crew and line supervision at the park were so motivated to see the engine crew obtain an immediate assignment that the NPFMO accepted the resource order despite not being able to contact all crew members who were on their day off. NPFMO tried all day to contact the crew and eventually assembled and dispatched the crew at 2100. Despite a late start and a series of complications enroute to the fire, which included mechanical problems with their engine that lead to the separation of their crew and engine captain, the remaining crew members were encouraged to continue to pursue a line assignment as a falling team. Because Incident Management personnel were equally motivated to find a line assignment for the eager crew, the crew was ultimately given an assignment as a falling module that they were not qualified for and without qualified first or second line supervision. During that assignment the crew cut a tree that was outside their falling qualifications, which resulted in the injury of FC1.

Upon arrival to the Incident Command Post on July 23, EM reported mechanical problems with the engine that required CAPT to drive the vehicle into Redding, California for warranty service. EM-CAPT stayed at ICP and on July 24, were given a logistical assignment in camp. On July 25, while CAPT was attempting to obtain a replacement engine from Whiskeytown National Recreation Area, EM-CAPT were given an assignment as a falling module to Division B on the Eagle Fire. The assignment was to mitigate hazard trees along the fire line, so crews could safely work in the area. At approximately 1350, FC2 called ICP for medical assistance for severely injured FC1. Emergency medical personnel responded and treated the injured FC1 for severe bleeding. Due to heavy smoke conditions requiring Instrument Flight Rule (IFR) capability, primary helicopter resources were unable to respond to FC1’s location. Firefighters carried FC1, by litter, to a location where FC1 was hoisted into a United States Coast Guard Helicopter, at approximately 1630. The USCG helicopter carrying FC1 arrived at Redding Municipal Airport, where FLN, in consultation with a Mercy Hospital Emergency Room Physician, pronounced FC1’s death at 1710. The Coroner later determined the cause of death to be blood loss due to blunt force trauma to FC1’s left leg.

The report includes this statement on the page before the executive summary:

SAIT Disclaimer

Based on all evidence available to the SAIT, we know that FC1 was injured from being struck by a tree during a felling operation. From the time of the accident, until the preparing of this report, no individual member of EM-CAPT could be positively identified, nor excluded from being the sawyer at the time of the accident.

Evidence collected by the SAIT included 54 manual and electronic time-stamped documents. These documents were collected from multiple entities, in three different counties. Comparing documents that logged the same event, the SAIT noted time stamps often varied by 5 to 10 minutes.

“SAIT” is the Serious Accident Investigation Team.

Page 87 of the report includes this information:

Technical Assessment of Accident Site

Due to the lack of eye-witness accounts, a number of key facts are unclear; therefore actual events have been pieced together from interview statements and evidence at scene. FC2 and FC3 are the only surviving witnesses to the accident and they have not granted interviews to the Serious Accident Investigation Team. While it is impossible to determine at this time who actually fell Tree 1, it is possible for experienced observers to read the stump, the lay of the felled tree, and the felling area to determine how the felling of Tree 1 set into motion the sequence of events that lead to FC1 being injured.

On page 5 of the report is a description of the accident:

A decision was made to fall a large ponderosa pine (36.7” at the point of the cut). Downslope from the ponderosa pine was a 54” DBH sugar pine that had an uphill lean and a large cat face on the uphill side. When cut, the ponderosa pine fell downslope toward the sugar pine. It was contact with the sugar pine, or vibration from the ponderosa hitting the ground, that caused a portion of the sugar pine, approximately 120 feet long, to break off and fall upslope, hitting FC1 resulting in severe injuries.

The report includes the information that on August 6, 2008 the Serious Accident Investigation Team (SAIT) gave the case file to a National Park Service Special Agent. On August 7 the SAIT was “disengaged” from the “safety investigation” until further notice.

On January 26, 2009 the Federal Prosecutor issued a “Declination of Criminal Charges related to the death of FC1”. In early March the safety investigation resumed. The SAIT completed their report on May 18, 2009.

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