The Serious Accident Investigation Factual Report has been released for the July 7, 2011 fatality on the CR 337 fire in Texas. Caleb Hamm, a crewmember on the Bonneville Interagency Hotshot Crew, collapsed and died from hyperthemia, which is uncontrolled heating of the body’s core temperature. Hamm went into full cardiac arrest 31 minutes after he collapsed and arrived at the hospital 37 minutes after the full arrest.
Here are the findings from the report:
Findings are the conclusion of the investigation team based on the facts, weight of evidence, professional knowledge, and judgment. Findings are grouped by category: human, material, and environmental.
Finding 01: Environmental Factor
While working on the fire incident, Hamm lost consciousness and subsequently died. Signs and symptoms indicative of severe heat illness were not observed by co-workers or verbally communicated by Hamm. Autopsy report states the cause of death as hyperthermia.
Findings below did not directly impact the cause or outcome of this accident; however, they are significant enough to potentially result in improvements in the specified program areas.
Finding 02: Human Factor
Hamm was not severely dehydrated and his electrolytes were within the normal range.
Finding 03: Human Factor
The designated Division A “point of contact” (POC) did not have direct communication with accident scene personnel.
Finding 04: Human Factor
Cell phones were used to coordinate medical response per Incident Action Plan, resulting in others not being able to monitor critical communications.
Finding 05: Human Factor
The Global Positioning System (GPS) coordinates for key locations were not identified in the Incident Medical Plan (ICS-206) on the Incident Action Plan (IAP) for the CR 337 fire.
Finding 06: Human Factor
The IAPs for the CR 337 fire for July 6 through July 8, 2011, and IAP Safety Analysis (ICS-215A) did not contain specific reference to extreme temperatures or hydration nor was it included in the IAP Safety Message.
Finding 07: Material Factor
Bonneville IHC was well prepared for a medical emergency with EMTs, backboard, trauma kit, and oxygen.
UPDATE May 19, 2012
The Centers for Disease Control/National Institute for Occupational Health and Safety (NIOSH) has released their report on the fatality.
Thanks go out to Dick