Sadler fire: who should have been held accountable?

A rocket scientist who calls himself “old coyote” wrote a ridiculous post on another wildland fire web site about accountability. He or she was offering an opinion about the disciplinary actions that were taken after the accident in which eight members of the Klamath Hot Shots were injured when their crew carrier was hit by a semi truck and rolled over on August 22, 2009 in northern California. According to rumors on that site, some members of the overhead on the hot shot crew were forced to take some time off as a result of their actions or inactions related to the cause of the injuries, reportedly for some members of the crew not wearing seat belts. “Old coyote” wrote:

When you think about it, the personnel actions fall right in line with the fall-out from the Sadler Fire. Now, why did practically a whole platoon of team overhead lose their quals due to an independent decision of a certain dumb-ass Crew Boss?

For the December/January 1999-2000 issue of Wildfire magazine (vol 9, no. 1) I wrote an analysis of the findings from the Sadler fire investigation report. I was moved to write the analysis due to the unique nature of the August, 1999 incident. The sheer number of errors in judgement that were made on that fire were astounding. Never before or since have I been aware of a large fire being run by a Type 1 Incident Management Team where so many poor decisions were made that seriously and adversely affected the safety of firefighters.

To imply that the single cause of the entrapment on the fire was the fault of a “dumb-ass Crew Boss”, or that the IMTeam should not be held accountable, is absurd.

The Incident Action Plan written by the Type 1 IMTeam for the Sadler fire stated that the tactics for every Division that day “will be announced at briefing”. And, neither the Division Supervisor nor the Branch Director were given copies of the written plan.

The strategy of backfiring from a dozer line out ahead of the fire that was developed by the Branch Director was presented to two hot shot crews by the Division Supervisor, but the crews refused the assignment. The Crew Boss of a Type 2 crew of National Park Service regular employees accepted it. They were not a full time organized crew.

The entrapment happened to six members of the crew as they were igniting the backfire along the dozer line in grass and sage vegetation. There were no lookouts posted, and unexpectedly to the firing team, the head of the main fire overran their location.

The entire article as it appeared in Wildfire is on our Documents page, but below are some excerpts, including a long list of some of the mistakes, errors in judgement, and sheer laziness in emergency management that were exposed in the report.

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…All six people started running toward the west, but dense smoke soon made it impossible for them to see each other and they became separated. The heat was intense. One person ran along the dozer line directly to a safety zone. The other five were driven into the unburned green area due to the heat and the fact that they could not see the safety zone through the dense smoke. Three of them removed their fire shelters from the cases. Two of these removed the shelters from the vinyl bags, but only one actually deployed the shelter.

The 15 GNP3 crewmembers that were left in the Black safety area heard a radio call for help from one of the crewmembers that had run into the green. Concerned, they moved deeper into the safety zone.

Shifting winds momentarily caused the smoke to clear and the five crewmembers in the green all moved into a safety zone.

Injuries

Two people on the firing team had second degree burns on their faces and necks and some were coughing severely.  The Crew Boss borrowed  the Branch Director’s vehicle and drove himself and the other five crewpersons west to a helispot where the two people with burns were flown to the Incident Command Post for initial treatment, and then transported by ambulance to a hospital where they were treated for the burns and smoke inhalation. The other 19 crewmembers eventually joined them there and the other 4 members of the firing team were treated for smoke inhalation. Three people were admitted to the hospital and remained there overnight before being released the next day. They were expected to fully recover.

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Mistakes, Concerns, And Contributing Factors

• When the safety team arrived that was asked to look into the incident, they were asked to review a “smoke inhalation” incident.  After they visited the Incident Command Post and the fireline, they learned from field personnel that it was a much more serious accident, and according to BLM policy, the investigation was upgraded to a Serious Accident Investigation with a different team leader.
• One flank of the fire was not secured while the indirect line at the head of the fire was being backfired.
• Four people (later joined by two more) and one engine were the only resources attempting to backfire and hold 1.3 miles (2.1 Km) of indirect line at the head of the fire. The Crew Boss did not feel confident about using the entire crew because of the inexperience and lack of fitness of some crewmembers.  Earlier, however, the Crew Boss had over-represented the experience levels of the crew, saying the crew had “lots of burning experience”.
• The Crew Boss became too involved in the actual ignition of the backfire to monitor radio traffic, weather, and fire behavior.
• The radio frequencies were overloaded and jammed.
• The Incident Action Plan (IAP) prepared by the Planning Section Chief and approved by the Incident Commander was extremely inadequate.  The only instructions on the Division Assignment Lists were “Will be announced at briefing”.  The Type 2 Incident Management Team that transitioned to the Type 1 team issued a complete IAP the previous day.
• Strategy and tactics had to be determined by the Branch Directors.
• The predictions for extreme fire behavior and red flag conditions, which proved to be true, should have led the Incident Management Team to direct that a flanking strategy be used, rather than a frontal assault.
• The Branch Director involved was not fully qualified for that position.
• Lookouts were not clearly posted and no one involved in the firing operation could directly see the main fire until just before the entrapment.
• Unassigned resources that were found at the main camp were automatically sent out to the fireline, some without having received a briefing or an assignment, and apparently with little regard for how they would fit into the organization.  This was the Incident Management Team’s standard policy for their first operational period on a fire.
• This contributed to the overwhelming workload for the Division Supervisor.  In the Incident Command System, a supervisor should oversee three to seven subordinates.  The Division Supervisor where the entrapment occurred was trying to supervise 22 to 26.
• The firing team moved so quickly that they did not bring enough black, or burned area, with them as they progressed along the line.
• The Branch Director “displayed minimal concern for the firing squad’s well being.  Immediately after the entrapment he had them provide for their own medical care and transportation to the helispot while he saw to the completion of the firing.”
• The Safety Officer “did not instigate an effective inquiry into the entrapment, overlooked the extent of the injuries, and downplayed the incident in his report and to the investigation team.”
• A relatively inexperienced crew was given a very difficult and complex assignment.
• One and one half miles (2.4 Km) beyond the indirect dozer line that got burned over was an area of sparse fuels.  When the fire reached this area, it virtually burned itself out.
• According to the report, “There was considerable pressure from local ranchers and elected officials to do more to limit the acreage burned on the Sadler Fire; this was a contributing factor to the strong sense of urgency on the line the day of the entrapment.”  Without this pressure, would the IMTeam have decided to let the fire burn into the sparse fuels and sacrifice acres, rather than endangering firefighters?
• After the burnover, the Incident Commander, Planning Section Chief, and the two Operations Section Chiefs refused the Division Supervisor’s request to stay with the crew the following day to assist with the critical incident stress debriefing, telling him to report to the fireline the day after the incident.
• The investigation team determined that all of the 10 Firefighting Orders and 13 of the 18 Watch Out Situations were compromised.

Accountability

After the preliminary investigation report was prepared, Ed Storey’s Type 1 Incident Management Team was placed into an inactive status.  When the final report was complete, the IMTeam was disbanded.  This may be the first time that a national IMTeam was disbanded as a result of performance.  In addition, five members had their fire qualification for their position on the IMTeam suspended until they could be recertified.  The positions involved included the Incident Commander, the Planning Section Chief, the Safety Officer, and two Operations Section Chiefs.

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Disbanding the IMTeam and de-certifying some of the members is a radical (but positive) action, at least when contrasted with what we have been doing in the past. This is something the Geographic Area Coordination Group did right.  Slaps on the wrist, if used at all, are not effective.  You can be sure that the other IMTeams are going to have the concepts of Disbanding and De-Certifying in the backs of their minds on the next few incidents.  And that is a Good Thing.

People that irresponsibly cause injuries or put lives at risk need to be prevented from doing it a second time.  Is One Strike and You’re Out too severe?  We all make mistakes, but some have more impact than others.  Some people learn from them; others don’t.  The trick is to prevent the first one.  And, if that does not work, what do we do to prevent the second one?  De-certify their fire qualifications, send them to remedial training, transfer them to a non-fire job, or terminate them?

What should an Incident Commander and an IMTeam think about first?  Even before how many acres of government-subsidized grazing may be temporarily affected?  The safety of our brothers and sisters.  That should be Rule Number 1.  FORGET THE DAMN ACRES.  REMEMBER THE FIREFIGHTERS.

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Read the official investigation report on the Sadler fire (2MB file).