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:
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FINDINGS
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.
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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
He isn’t a relative of our family that we know of, sorry. Wish we could help.
I am looking for a gentleman named John Hamm out of Houston Texas that is an accident investigations specialist. If anyone can help me find him that would be great.
does anyone know to whom the fire crews, (hotshots, forest service, whoever) answer to once they have done their report-Serious Factual Investigation Report? Or, is it just shoved on a shelf somewhere, just left to collect dust? Seems there is no accoutabilitity for anything these crews do once they leave their home. Am I right> or can you convince me otherwise??
“they said” on willdland fire has realeased a report on “Heat Illness Basics for Wildland Firefighters” . I notice the date on this was June 2010. Under one of the titles “Heat Stroke” is the last Action: EVACUATE THE FIREFIGHTER IMMEDIATELY”
I have a question. When something like this happens, and the injured ISN’T evacuated, just who/what is ther criteria for any repurcussions? Who then steps in and makes any changes for the upcoming season? Or, do we let the past be the past? Who is really in charge to watch these things?
To who or whom are the firefighters accountable?
Please refer to today’s edition of the Idaho Statesman, can be found online. We are forging ahead to get our questions answered……,
Thanks Lynnette. Here is a link to the article in the Idaho Statesman.
By the way, I did forget this. Caleb’s electrolytes were only taken from his eye fluids not by blood! Since he was already dead upon entering the hospital at Palo Pinto General Hospital, we got to ask them direct and in person. His blood was never checked, since he was already dead. 2 members of his crew said they knew he was dead while they were trying to get him up that steep ravine he was in! So, Ken, you don’t know a darn thing as to what really went on, you can just speculate. Again not trying to argue or past judgement, but those are the FACTS! What about never leaving anyone by theirself? Just like in Combat, YOU DON’T DO THAT! Do you get what I am saying?
DAVE
I would like to hear from the people that knew Caleb. Mike, John and Tyler! You all seem to get what I am saying here. Our son was the 2nd most physically fit on his crew. He stayed like that year around. And NO, Ken, it is not miscommunication, because the BLM hasn’t communicated with us, really, since his death. We knew our son better than any one else. Please don’t start saying that until you have lived in our shoes.
The BLM has hidden alot of things. The Texas forest service, which was listening and watch what happened, told us that the Helicopter, was called on from them, Not the BLM. This happened 10 – 15 minutes before the BLM made it a priority. This terrain was very rugged. I have hunted Elk in less rugged terrain and for him to be left by himself, is UNCALLED FOR! Sorry if this sounds rough, but evidently you weren’t there and don’t know what we have gone through with the BLM. I am not arguing or have a chip on my shoulder, I just don’t ever want this to happen to any other parents.
Mike, John and Tyler, any or all of you please feel free to call me or email me! My cell phone, which is Caleb’s old number is: 208-310-9259 and my email addresses that I can be reached at are: mudbath1@msn.com or mudbath01@yahoo.com. I would love to visit with any or all of you. I know that any names on here might not be the real names, but that doesn’t matter to Lynnette and I. Yes, I also realize that Ken may not be a real name either. Really sounds to me to be someone from the BLM trying to cover more. That is what has been going on since Caleb’s death. Nothing or no one has ever came forth with answers, when it comes to the BLM
Thanks,
DAVE HAMM
Caleb’s Father and still proud to be that, even through our grief of losing him.
well, Ken, it is painfully obvious you haven’t visited the site, saw what we saw, or tried to “match” the report with what has happened. Until you have, don’t put your “expert” opinion on here. This is exactly what we are saying, “oh, the report is right, blah, blah, blah, everyone is telling the truth”. Well, they aren’t. And we will not stop till the truth is out. We have heard from too many others who WERE on site, and telling us this is not what happened at all. So save your “expert” opinions for someone who is willing to believe whatever is shoveled at them, ’cause we are not.
“Cloud of War” vs “Fog of War”… Both entirely different… but closely entwined terms if folks actually seek common ground in understanding the horrible loss. IMHO.
There are not any covert “cover-ups” happening when a firefighter dies in the Line of Duty. It is rather a communication and support problem.
The Wildland Firefighter Foundation can HELP get the Family; the Agency; and the firefighters connected and talking.
Something is amiss is the statement/finding.. “Hamm was not severely dehydrated and his electrolytes were within the normal range.”
There is obviously more going on if someone dies of “hyperthermia” without dehydration or electrolyte imbalance… What that is, needs much more study and emphasis to prevent future tragedies.
I doubt there is any form of “cover-up” intentionally happening, but rather, it probably is a group of folks within the wildland fire community honestly searching for the same answers as the Family…. with far too few answers readily at hand. Call it whatever you prefer, but the “cloud of war” best describes the aftermath of line of duty deaths. IMHO.
Thank you for publishing my quotes! I think it is about time someone did. I really appreciated it. I hope it made someone think of what the report (factual) really said and how it contradicted some of the other statements in this FINAL REPORT.
Thank YOU again!
David Hamm
Do any of you people read the FACTUAL report fully. To many things don’t, time wise, line up. He was not with anyone when he collapsed, He DID tell someone that he wasn’t feeling Good!, Hot and have a headache, And he was FOUND all alone, YES, BY HIMSELF! HOW did they find him? It doesn’t say. Some speculate that he laid there for an awful long time and his crew missed him at their buggies. There is no way on This great earth, what I believe God created, it only took 2-3 minutes to get back with him. How did they find him, think about that. The time it took, because he was not where that person, and yes I know who it was, left him. NO WAY, was it just 2-3 minutes, then the phone communication were bad, how much longer? Think people, whether you are a fire fighter or not. Yes, my son never ever complained about feeling bad, so to complain that he had a headache and was Hot was a big thing for him. All of these fire fighters know the truth, but are to afraid to come forward, for whatever reason. Whether it be the law, conscious, to weak to admit there was something not done right. How would they feel if it were their parents having to fight this battle, because we have not been told the truth from the start. I know that seems harsh to say, but it is what is the truth. No where, also, in the final report was the matter of our son throwing up, which he did do. He had just eaten lunch, but only 100 cc of stomach contents was in his stomach. Does that tell you something, either? Where oh where is someone with enough inward fortitude to step to the plate, like our son would’ve for them. Caleb did go to the beat of a different drummer, but in my opinion all SHOT crew members do. If you have that inward fortitude that I am talking about, you can contact me at mudbath1@msn.com or call-HOME-208-906-2155 or cell, Caleb’s old one: 208-310-9259. I don’t think this will get published though because everyone just takes the final report as the “BEST ANSWER TO THE PROBLEM!” Believing this is no laughing matter. Not to us his parents, his little brother, nor Tysha, his girlfriend that was to be permanent after this his final fire season.
BTW: I realize a lot of people don’t believe in God, but we do and the truth will come out. One more thing: “NO, I am NOT JUST A GRIEVING PARENT EITHER”. I am fighting this fight because that is what we taught both of our son’s. Don’t stand by the wayside and just let things slide, “MAN UP AND BE ONE!”
Sincerely,
DAVID HAMM
Proud to be Caleb Hamm’s Father.
DEAD, yes, but not forgotten, by any means.
e-mail is LHamm@republicservices.com or Dave’s e-mail, mudbath1@msn.com, the report is a lie, read page 8, he told his SUPERIOR he felt hot and had a headache. ARE those not signs/symptoms???? and then they contradict themselves by saying no signs.symptoms????? GET REAL. Investigation will continue, you bet your firefighting britches……….
I agree completely Lynnette. A lot of things Do NOT line up in that report! I hope things get straightened out. I wish the best for the family. I miss caleb so much and this could have been prevented.
His father and I are going to visit Mineral Wells Texas, going to the site where Caleb died, on Sunday Nov 20th. We are placing a barbed wire cross in our son’s memory. Just a warning to anyone involved in the COVER-UP of his death, the truth will come out, you better believe it will. You have messed with the wrong parents.
please, any of you, contact his father Dave or mother, Lynnette, at the above listed e-mail, or home phone 208.906.2155 or 208.310.9259
I know caleb very well and worked on a crew with him prior to the incident and I also heard the same information. A couple days earlier he went to the hospital and was given an IV. I’m assuming the IV was for dehydration. It’s a horrible loss that could have been prevented especially if he was having medical issues days prior. I’ll miss him for sure! super strong healthy guy!
they seemed to not go into the fact that caleb was in the hospital hooked up to an IV days before his death, and the superintendents insisted him to continue working.
Mike, you got anything to back that statement up? That’s a pretty strong accusation if you are shooting from the hip. Not saying you are by any means, but this statement has not come out anywhere else.
Why was he given an IV?
Ya know Mike, it’s funny, I don’t remember Caleb being hospitalized a few days before his passing. I do remember watching fire works with him and hearing his karaoke stories form a few nights before… but no hospital or IV’s. When you MAKE UP negative stories surrounding his final days, it takes away from all the REAL memorable ones that could be shared, SHAME ON YOU MIKE! The best way for the fire community to honor Caleb, is by learning from his passing and sharing his stories. Don’t go dirtying his legacy by spreading false rumors.
That’s what I had heard from multiple people close to the crew and caleb, but have now heard from the family and know it was not caleb that was hospitalized but other people on the crew earlier that roll had gone down from heat. I would NEVER want to take away from Caleb’s legacay nore start false rumors, that was just what I had heard. Caleb lived his life to the fullest and was a hard worker in great shape! I miss him more than anyone would know, and just want the truth to come out because some things in the investigation just doesn’t line up with what really happened. Thats all, I never ment to hurt anyone, or start rumors.