State analysis of Yarnell Hill Fire fatalities proposes $559,000 fine for Arizona State Forestry Division

Yarnell Hill Fire at 1549 June 30
Yarnell Hill Fire at 1549 June 30, 2013. Photo by Chris MacKenzie of the Granite Mountain Hotshots. The arrow represents the location where the lookout had been positioned earlier.

(Originally published at 2:46 p.m. MT December 4, 2013; updated at 8:30 p.m., December 4, 2013)

Today the Arizona Division of Occupational Safety and Health (ADOSH) proposed fines totaling $559,000 to be imposed on the Arizona State Forestry Division as a result of the fatalities on the Yarnell Hill Fire near Yarnell, Arizona. Their findings were presented to the Industrial Commission of Arizona during a 1:00 p.m. public meeting in Phoenix. The documents can be found HERE.

On June 30, 19 members of the Granite Mountain Hotshots were entrapped by rapidly spread flames from a brush fire and were killed. One member of the crew who was in a different location serving as a lookout was not injured.

Two citations were proposed, one “willful serious” with a tine of $545,000, and another that was “serious” with a fine of $14,000.

[UPDATE at 6:46 p.m. MT December 4, 2013; The commission approved the fines. The Arizona State Forestry Division has 15 days to appeal the decision.]

The willful serious citation included the following (paraphrased):

  • Failure to furnish a place of employment which was free from recognized hazards that were causing or likely to cause death or serious physical harm.
  • Implementation of suppression strategies that prioritized protection of non-defensible structures and pastureland over firefighter safety.
  • The employer knew the suppression was ineffective, and that the wind would push the fire toward non-defensible structures, but firefighters were not promptly removed from exposure to smoke inhalation, burns, and death.
  • Thirty-one members of a structure protection group charged with protecting non-defensible structures were exposed to possible smoke inhalation, burns, and death.
  • A lookout was exposed to the same dangers.
  • Approximately 30 firefighters working on an indirect fireline in Division Z were exposed to the same dangers.
  • The Granite Mountain Hotshots continued with suppression activities until 1642 hours on June 30 when they were entrapped by a rapidly progressing wind driven wildland fire.

The serious citation, totaling $14,000:

  • The employer failed to implement appropriate fire suppression plans in a timely fashion during a life-threatening transition between initial attack and extended attack.
  • When the fire escaped initial attack none of the following analysis procedures were implemented: Incident Complexity Analysis, Escaped Fire Situational Analysis, Wildland Fire Situation Analysis, Wildland Fire Decision Support System, or Operational Needs Assessment.
  • On June 29 an Incident Action Plan was not completed for the next operational period prior to transitioning to a more complex management team.
  • The positions of Safety Officer and Planning Section Chief were not filled on June 30.
  • On June 30 the Division Z Supervisor (adjacent to the Granite Mountain Hotshots’ Division) departed from his assigned position which left Division Z without supervision during ongoing fire suppression operations.

Today, in addition to the citation information, the following documents were released by the Industrial Commission of Arizona:

We will add to this article later with more details about the investigation report, but below are the conclusions reached by Wildland Fire Associates, the consultants hired by the Arizona Division of Occupational Safety and Health:

  • Fire behavior was extreme and exacerbated by the outflow boundary associated with the thunderstorm. The Yarnell Hill Fire continually exceeded the expectations of fire and incident managers, as well as the firefighters.
  • Arizona State Forestry Division failed to implement their own extended attack guidelines and procedures including an extended attack safety checklist and wildland fire decision support system with a complexity analysis.
  • The incident management decision process failed to recognize that the available resources and chosen administrative strategy of full suppression and associated operational tactics could not succeed. This also remained the case when the strategy changed from full suppression to a combination of point protection and full suppression.
  • Risk management weighs the risk associated with success against the probability and severity of failure. ASFD failed to adequately update their risk assessment when the fire escaped initial attack leading to the failure of their strategies and tactics that resulted in a life-threatening event.

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UPDATE at 8:30 p.m. MT, December 4, 2013

We just finished reading the “Inspection Narrative” compiled by AZ OSHA, and the “Granite Mountain IHC Entrapment and Burnover Investigation” report written by Wildland Fire Associates (WFA).

The Inspection Narrative

We noticed a couple of interesting tidbits in the Inspection Narrative that we don’t remember being pointed out in the previous Serious Accident Investigation Team report which was released on September 28.

One was found on page 18. At approximately 1545 hours, one of the the Type 2 Operations Section Chiefs called the Granite Mountain Hotshots and asked if they could spare resources to assist in Yarnell. Either Marsh or GMIHC Captain Steed responded that they were committed to the black and he should contact the Blue Ridge Hotshots.

While the GMIHC said they were not available for the change in assignment, the request from the Ops Chief informed them that they were needed in Yarnell. This may have influenced their decision to move toward the ranch, perhaps with the ultimate goal of assisting in the town. We could not find a mention of this in the WFA report.

One other item in the Narrative (on page 17) we noticed was a disagreement and/or confusion about the break between Divisions A and Z. The Division Z Supervisor didn’t arrive on the fire line until 1 p.m. on June 30. I in addition to the Division break fiasco, he was not clear at all about what tactics in the area could be successful. He left the fire line to head to the Incident Command Post and did not return. Parts of this were also mentioned in the WFA report. The problem with filling the Division Z position was mentioned in the citation.

Below are some quotes from the WFA report:

P. 15: At 1558, ATGS abruptly leaves the fire and goes to Deer Valley. He turned air tactical operations over to ASM2 who was busy dealing with lead plane duties at the time. ASM2 got a very brief update from ATGS that did not include division breaks locations and the location of the on-the-ground firefighters. ASM2 had been ordered as a lead plane because ATGS functions were covered.

P. 30: Based upon our interview with ICT2, we have concluded that when ICT2 arrived at the Incident Command Post (ICP) he observed an obviously fatigued ICT4. Realizing that the fire situation was very dynamic and intensifying, ICT2 took over the fire despite the fact that certain key members of the team had not yet arrived. ICT2 provided the 0930 briefing to resources that had arrived at the ICP. Some resources were not at the 0930 briefing because they had already been assigned and [were] working on the fireline. Based upon incident documents and interviews, ICT2 was working in a diligent and professional manner, although the situation was deteriorating.

P. 31: The ultimate result was that ICT4 and ICT2 failed to convey a coherent strategic plan for suppressing the fire that was uniformly understood by ground and air resources from initial attack through the entrapment and burnover. An IAP with formalized strategies and tactics known to all resources assigned to the Yarnell Hill Fire, starting with initial attack, would have decreased the amount of confusion and miscommunication that occurred.

P. 31: The ASFD failed to give clear management direction to the incoming IMT2 because they had not completed the Escaped Fire Situation Analysis (EFSA) required by their own policy for fires escaping initial attack22. A Complexity Analysis was not completed until June 30, after the IMT2 had taken over the fire. ASFD published their Wildland Fire Situation Analysis (WFSA) decision on July 4.

P. 31: We also examined the Type 1 Certification for the Granite Mountain Interagency Hotshot Crew (GMIHC), along with the training records for each firefighter. We have determined that GMIHC met the Type 1 Crew

P. 32: By mid-afternoon on June 29, the fire jumped over the two-track trail. ICT4 started ordering additional resources. The initial attack forces had clearly failed to “stop the fire and put it out in a manner consistent with firefighter and public safety and values to be protected.”23 ASFD did not declare that the fire had escaped initial attack. Had they made that declaration, the decisions from that moment forward would have been proactive, rather than reactive. Based upon the Wildland Fire Incident Management Guide (PMS 210), the ICT4 would have completed a complexity analysis, implemented risk management protocols from Incident Response Pocket Guide (IRPG), determined and documented incident objectives, and reviewed the Extended Attack Safety Checklist. Based upon interviews and incident documents, we have found no evidence that this occurred.

P. 33: An alternative to the implemented tactics could have been to establish the anchor point as they did, burn out along the two-track trail that existed at the top of the ridge, and then burn out along the jeep trail that they used to hiked in, ending at the old grader. This tactic would entail indirect attack with burnout, and would have provided a secure line from the ridgetop to the valley floor. This tactic would have supported the strategy of point protection in Peeples Valley and the town of Yarnell. This concept is displayed in Figure 15.

P. 36: The short Type 2 Incident Management Team did not arrive as a cohesive and functioning unit and spent the day, June 30, trying to bring order to a very chaotic situation.

P. 36: Communications on the Yarnell Hill Fire were inadequate from the time IMT2 arrived because the COML arrived late. COML was not available to clone radios at the morning briefing. Tone guards were also a problem. Lack of communication is a significant safety problem.

P. 36: An additional problem with the way the team arrived is that without a PSC, maps are not readily available to resources going to the fireline. GMIHC was not provided with a map or aerial photo by ICT4 when they arrived on the fire. A map would have helped the crew estimate how far the Boulder Springs ranch site was away from the lunch spot and evaluate alternative escape routes including the two-track road to Boulder Springs Ranch.

P. 38: Planning OSC stated that “since we had not developed a plan…as we got…things going we would just assign them out.”

P. 38: Once the SEAT drops had extinguished the test fire [for their intended burnout operation] that GMIHC was igniting, the crew tried to build direct handline, which subsequently failed. We found no evidence that DIVS A notified Planning OSC that the tactic of going direct had failed. Such a notification should trigger a reassessment of both strategy and tactics.

P. 42: Based upon interviews, fatigue appears to be a factor in the decisions that were made by ICT4 during the Yarnell Hill Fire. Timesheet records indicate that he had worked 28 days straight as of June 28.

P. 42: Fatigue may have been a factor for GMIHC as well. Their work records indicate that they had worked 28 out of 30 days during the month of June. The crew had worked 13 of a 14-day tour. Although technically not a violation of the work-rest guidelines, cumulative fatigue resulting from working 28 out of 30 days may have been a factor in their decision making process.

 

Typos, let us know HERE, and specify which article. Please read the commenting rules before you post a comment.

Author: Bill Gabbert

After working full time in wildland fire for 33 years, he continues to learn, and strives to be a Student of Fire.

107 thoughts on “State analysis of Yarnell Hill Fire fatalities proposes $559,000 fine for Arizona State Forestry Division”

  1. Simple question, there was a comment way back in one of these threads that talked about radio,conversations on the line with the overhead. It said something along the lines of only Marsh and Steed would hAve only been privvy to the conversation, as they are the only ones with radios.

    Is this to assume that on a 20 person hotshot crew that there is only 2 radios?

    Just wondering. In BC, everyone on the line has a radio. Period.

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  2. Thanks forreiterating this,Bill

    Somehow this will have lasting affects/ effects on the all risk / all hazard will have the same lasting impressions if they have not already

    Questioning folks about their fire quals as if those are the only things that are important……..bring that into the all risk all hazard world and see how far that gets ya with others who don’t exactly see it as the Gods of wildland fire…..

    But the realty is……..people are losing theirives over resource and WUI issues that are not new and both State Gov and Feds are equally complicit in both training and establishing real laws with real teeth

    Hence lawsuits and investgations and keeping lawyers busy because others have failed to do their gigs

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  3. I want to emphasize that EVERYONE is welcome to post a comment about any topic on Wildfire Today regardless of their position in life, their profession, or their qualifications as a firefighter or sous chef. There are no basic requirements, other than, and this is important, complying with the rules of engagement. And a rule that we thought never had to be written is that thou shalt not attempt to discourage others from posting their comments. If someone wants to establish their own rules for a website, well, that’s already been done here. They will have to explore other options.

    Having a broad spectrum of views can bring a lot more to the table than restricting it to a very narrow focus. Many people are very interested in wildland fire and for a huge variety of reasons, which can change depending on the exact topic.

    EVERYONE IS WELCOME TO LEAVE A COMMENT.

    (This is being posted in two locations in this thread.)

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  4. QUESTION for all of you: I am looking at a report (provided on the AZ.gov website) that is titled “WildCAD Incident Card – Arizona Dispatch Center, ‘YARNELL HILL SUPPORT’ Medical Aid.” It seems to be a dispatch log regarding the Yarnelll Hill Fire burn-over, showing what air resources were used or dispatched immediately after the burn-over.

    My QUESTION is this: Who prepares this document, or is it automatically prepared by a computer with voice-recognition software that sort of transcribes the calls/dispatch as they come in?
    Do we have any investigators or folks with dispatch experience who can tell me or help me understand this document? Or Bill? Thank you very much in advance. I will explain more afterward.

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  5. Woops the one thing I didn’t say was we were not faced as much with urban interface as today.

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  6. we hiked yesterday to do a WEATHER CHANNEL documentary and we had one absent due to asthma attack and the other their back yet it was a very chilly and windy hike but we had the pleasant surprise and honor to walk with a 06′-13′ GMHS and we learned alot from the hike. We really appreciate the insight John Dougherty is doing for everyone- thank you John! We know it is hard to piece a puzzle like this but in His time it will be pieced together— yet it does take Y O U to come forward and open up what Y O U saw that day. Please do the right thing.

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    1. Sonny and Joy, I may be reading more into what you have posted, so I could be all wrong.

      Your note IMPLIES to me that you had a conversation with someone who KNOWS ALL, but is not speaking up, telling what he/she knows…

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  7. Fullsail, I have to diassagree with you on people without fire fighting experience posting. It is an open website, for all to post questions. Some of the “no fire experience” people ask some really good questions. They should not be frowned upon. They are feeling the pain of this loss, from a community / ownership perspective. Restricting their questions will not help figure out what went wrong and why.

    For all we know, some of the people posting questions, with no fire experience, have the power to exact change. They could be Mayors, politicians, Fire Investigators (structural), construction contractors (Firesmart), or even just a person of the general public that is passionate to find out WHY the Granite Mountain Hotshots died…

    For example, Joy and Sonny have no fire experience, but their contributions to the investigation and discussion has been critical in finding answers. Let’s not discourage others from asking.. Leave it up to the administrator to decide if the questins are pertinent to the discussions.

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    1. Rocksteady:
      Two things:
      1. Thanks for speaking up on behalf of those of us who are not firefighters or fire professionals, but who are still trying to be of value in this discourse.
      2. FYI, *I* was not the person who called Rory Collins “cowardly,” nor do I feel that way about him. (You (rocksteady) had suggested on another thread that I called Mr. Collins “cowardly,” but I assure you that I did no such thing, nor would I!) We have no idea why Rory Collins “abruptly” left (in the words of OSHA). Perhaps he was ordered to do so. We don’t know, and, unfortunately, it appears that Mr. Collins refused to return OSHA’s phone calls, so we are not likely to know any time soon. But I would NEVER call Mr. Collins cowardly – just the fact that he was flying (in a small plane) above a massive fire suggests that he is no coward!

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      1. It was RTS for reasons unknown to us but not him, enough said.

        Who ever fullsail is he is not especially complimentary to us old retired not current FF. After 30 plus years of eating, breathing, training and living wild land fire. You remember everything. Fire Fighting doesn’t change, it always has its challenges. If you follow the rules todays fires are no different Than past ones, just heavy fuel loads which believe it or not there were fires with the same high burning conditions then as now.

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      2. Elizabeth, p27 SAIR says air attack’s pilot (Collins) is getting short on duty time so he departs about 1600 after a brief handoff with ASM2. ASM2 had been over the fire since 1447.
        I am confused as to why Marsh would have asked Frisby to come to the top of the ridge. The pictures and reports indicate that Frisby could have been forced to deploy if there were any unexpected issues (mechanical, crash, etc.) I agree there is an unspoken dynamic here. I still do not know what other road Frisby could have possibly thought Marsh was referring to when he says “Yes, the road I saw you on with the Ranger [UTV]” p24 SAIR.
        However there are two important events that occurred at 1630 that have been previously unidentified. Page 15 Worksheets for Proposed Citation ASFD…… At approximately 1630 Marsh spoke with ASM B33 (ASM2) and reported that they were going down their escape route to the safety zone. B33 asks if everything is okay. Marsh responded that everything is okay they are just heading to the safety zone. To my knowledge this is the first time communication has been verified so close to entrapment/ deployment time.
        Next is p 20 Inspection Narrative… top of page 20…. Cordes reported that two engines working Shrine Road got pinched. This does not have an associated time but the paragraph falls in between two other paragraphs that are timed 1630 and 1634. I would imagine this scenario diverted some attention to the missing engines in a very crucial time.
        I agree with Mr Powers from IM when he and RTS suggest that BR Supt basically filled in for Marquez once Marquez abandoned his position. Frisby and Tyler Esquibel (a trainee) seemed to have had their hands full and were in a dangerous position.
        The WAFR also provides some new information stating that Mcdonough was serving as a lookout for GM and BR.
        Wildland Firefighters….. Is there punishment within the ICS for abandoning your assignment, like Mr Marquez seemed to have done?

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        1. Calvin
          Now a days I don’t know. In my day you would no longer be going on fires and if you were in fire control you better be looking for a new job. Mr. Marquez would have been kicking the preverbal Horse “T” down the road.

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        2. Calvin, very astute, as always. Thank you. As I re-read the resource forms tonight (on the azsf.gov website), I saw that Mr. Collins had been on a different fire the day or so before, had been “standing down,” appears to have gone over to the Yarnell Hill Fire while standing down from the other fire, and then was seemingly chastised for doing so. Maybe I was not fully understanding the dispatch notes, but it seems as though Mr. Collins was perhaps feeling some of the fall-out from what seems to have been a sometimes poorly-managed set of resources (poorly-managed not by Mr. Collins, but by others). I need to look more into this.
          By the way, what is the WAFR?

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        3. Just an observation: Marquez might actually be an unsung hero. We don’t know, in part because neither the OSHA investigation nor the SAIR give us access to the interview transcripts – contrary to investigation reports on other fires.

          For all we know, Marquez might have left b/c he quickly realized that the entire situation was a train wreck from the word “go” that morning, and he was unwilling to participate in any way in front line efforts that were going to keep crews in the line of death. For all we know, Marquez (DivS Z) might have said to Marsh (Divs A) before Marquez left:
          “This is insane – this is way too dangerous. I saw the weather reports for the gusts of up to 40 mph, thunderstorms are predicted, and we don’t have nearly enough crew or overhead support to be safe with our guys digging lines out here. Frisby agrees that the briefings were a joke. This situation is way too dangerous – I refuse to be a part of the crews having to work out here. I’m not willing to supervise men who are digging a line in a place that could turn into a death trap in an instant.”

          Marquez might have saved lives: As I understand it, the Blue Ridge guys were cooling their heels at the buggies by the old grader for quite some time waiting for DivsZ (Marquez) to initially appear, while the DivsA guys (Granite Mountain) were climbing out into the field, into the line of fire. (I can’t quite tell, but it sort of seems like maybe the Blue Ridge guys were originally supposed to be under Marquez’s leadership?) The fact that Marquez was slow to arrive, such that the Blue Ridge guys did not go out with the GMIHC, and the fact that Marquez left shortly after finally arriving might well have saved the lives of the Blue Ridge crew. (Meaning: If Marquez was supposed to stick around and coordinate efforts with GMIHC, it is entirely possible that that “coordination” would have led to the BR Hotshots going with the GMIHC into the death trap.)

          To that end, while some are suggesting that Marquez was not viewed as the best leader at the Doce fire, it is entirely possible that he stuck out like a sore thumb or was viewed as a poor colleague because he refused at the Doce fire to engage in what he viewed as unsafe processes or strategies – that everyone ELSE viewed as normal AZ fire-fighting procedures. My understanding is that some suggest Marquez did not know what he was doing, but, if the norm in this area is to knowingly do things that violate the 10 and 18 (which is what Marsh/Steed unfortunately did (no blame – just fact)), then it seems to me that Marquez likely could have been trying to do things the RIGHT way at the Doce fire, but the RIGHT way was not the way that the crews were always used to doing things, such that it raised some hackles. I can totally see that type of dynamic, because I have BEEN in that situation, where I was the one doing things the RIGHT way, but the leadership was so ass-backward that it made it seem as if *I* were the one doing things the wrong way.

          Example: I once worked for an employer that had a HUGE, HUGE rape problem in the workplace. The employer knew it had problems with the way that women were treated in the workplace, but it flatly did not care. As part of my job, I was asked to work on the employer’s “recruiting” committee, to recruit more women to come work at the employer (despite my knowing that the work environment for women was, at best, horrible, and, at worst, flatly dangerous). The idea of doing so, and thereby of recruiting women to join an arguably *dangerous* workplace, made my skin crawl. I was not eager to take that assignment, and, as a result, I was viewed by one colleague as NOT a team player or a hard worker. Apparently the “team player” or the “good” co-worker would have tried to recruit hapless women to join a workplace that was KNOWN to have grave, grave issues. Do you see the analogy I am drawing? We don’t know why Marquez did what he did, but it is entirely possible that he was doing the RIGHT thing and the SAFE thing, just like I was.

          Something to think about, anyway.

          Marquez is obviously welcome to join this discussion, and I hope he does. I wish more of the guys who were there at Yarnell Hill that day (and who are surely reading these threads) chimed in. Obviously it is perfectly acceptable to post anonymously here. Many people do. The further this discussion goes, the better chance the men who work on these fires can get the sort of workplace safety in the future that they need in order to avoid another burn-over tragedy….

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        1. Walking off the line, leaving an assignment, whatever you want to call it is never acceptable.

          Sure, you can see its a cluster, but you NEVER just throw up your hands and leave. You suck it up, try your best to make “chicken soup out of chicken poop” and hope for the best… Then you try again the next day, of course voicing your opinions and concerns to the Management Team.

          It is better to be there and try, than to just leave the area, with no one to oversee that Division. Even if you are just there taking pictures and video of fire behaviour, its better than going home.

          I do not belive that Marquez just “left”… He was probably doing something else within the organization, but doubt he just pulled the pin and got in his truck and left.

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  8. From page 19:

    “At 1601 hours, radio transmissions captured on videotape documented portions of a conversation between Marsh and Steed. Marsh reported that “he knew this was coming” and inquired about Steed’s comfort level. ”

    This seems to me to be a key point in time, and a key conversation to be elaborated further. If these portions of conversation/radio transmissions were captured, can the entire (portions of the) conversation recorded be presented?

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    1. Bob, as I understand it, the references to the audio were references to Chris McKenzie’s Iphone/Android/whatever clips that were miraculously recovered from Chris’s Iphone/whatever, which was preserved under his body when he died in the fire. God bless him and his family.
      As I understand it, there are two clips, and neither clip has the full conversation between Marsh, Steed, and, allegedly, some third person. As I understand it, some people believe that the full clips are not being shared and that the clips that have been publicly released have been edited. It may instead be the case, however, that the clips were just clips, and the full conversation between Marsh et al was just not captured on MacKenzie’s video. On one of the threads on John Dougherty’s site, there is a BRILLIANT analysis of the fragments of conversation by a couple of the commenters. They do as good a job as any in trying to figure out what the men were saying and why. But, despite this, it is still unclear exactly what was being said and what was being referenced. I have to believe Brendan might know, since he was likely listening in (even if just tangentially) on the transmissions.

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      1. There has been some discussion that the center part of the two clips were edited sence they splice togather with no change in the people in them. It runs as a full sequence with the middle missing. There was quite a bit of research on this it is only one clip that got confused with 2 because they were referring to the second part of the clip. The clip could have been edited and there is a full original still out there. that’s been another one of those black holes.

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  9. It pains me to read some of the comments on this article (as well as the previous articles) regarding the GMIHC tragedy. I realize that some of you have come to feel personally involved in this tragedy, whether that be because you are a member of the Prescott community or a resident of one of the communities directly affected by the fire or witness to the events that day. It seems that many of you have very little knowledge or experience of wildland fire prior to becoming involved in this tragedy. I don’t think this is the proper venue to be trying to educate yourself about the principles involved in wildland fire management (both with regard to fire behavior and tactics) at the expense of belittling this tragedy or raising inane questions that are irrelevant and/or only serve to fuel the fire of controversy.

    In my opinion there are three main points of discussion regarding this tragedy:

    The first is with regard to the initial attack decisions and how the AFS & Type 2 team was mobilized and engaged on this rapidly expanding incident. This is the “Monday morning quarterbacking” that warrants discussion among fire manager’s and fire crews across the country: risk management during IA, indefensible structures, area specific fire management plans, interagency communications and cooperation, trigger points, 10 & 18, etc. At this point, and in my opinion, this is where the discussion can be most productive.

    The second part of the picture, is the discrepancy between the two investigations. I think most of us in the fire world have agreed that the federal investigation does a disservice, not only to those involved directly with the incident who want the plain truth laid out, but also to those of us who want to understand how things played out for GMIHC and what we can do better during rapidly escalating incidents. At least we now have two reports to compare, contrast and learn from. Hopefully someone with the power to do so will step up and call the federal investigation process out for what it has become.

    The third aspect of this tragedy is Granite Mountain IHC actions that day. The crews assignment was not out of the ordinary nor unsafe. Anchor, flank and pinch, whether that be with direct hand line or through indirect line prep and burn operations along the two track. They had an anchor point and they had their escape route and safety zone. There were only two people who would have made the decision to leave the black and lead their crew down the two track to the shortcut to the ranch, Steed and/or Marsh. I don’t know any IHC Superintendent who would allow any Div. Sup. or Ops. Section Chief influence their decision with regard to their crew. Obviously there would be some priority/ urgency on the part of the crew to stay engaged and involved in a fire in their own backyard. At that point in the fire, the crew needed to get back to their buggies in order to stay engaged. IN MY OPINION, this led the crew overhead to attempt to reengage as quickly as possible. When they left the two track and the ridge line, they lost sight of fire progression and became entrapped. Were there outside pressures/influences? Of course; hotshots don’t sit around during a going incident, they find ways to engage in productive work. But the final decision to leave the black, to leave the two-track was the responsibility of the overhead, no matter how hard that is to accept.

    I have the utmost respect for the crew and it’s overhead, and it is hard to admit to myself, that if this could happen to someone with Steed and Marsh’s experience level, that it could most definitely happen to me. This tragedy will forever serve that reminder. I am sure there are no words that can express the depth of loss that those family members have experienced and for what it’s worth, I am sorry for your loss.

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    1. You made some good points but you might be surprised at how many people on this comment string are in fact wildland fire fighters. And we are looking for answers and have found some major discrepancy’s in the first report and some questionable items in this one whether it leads any where it is an investigative process. Sorry if that doesn’t set well with you.

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      1. actually bob, i don’t think it’s difficult at all to figure out which comments carry with them a degree of wildland fire experience and which don’t. regardless even of whether that comment/viewpoint is outdated or not.

        the third paragraph in my comment recognizes the discrepancies that you mention. the teasing out of those discrepancies is not what “doesn’t set well.”

        my issues are with people trying to make controversy where there is none, because they lack the fire knowledge as to what makes a good safety zone, or why Div Sups might be negotiating land, or insinuating issues between crews or overhead.

        i think a more thorough reading of my comment may have helped you understand that it had nothing to do with you.

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        1. Got ya- I did not think you were talking to me and like I said I agreed with a lot of what you said. Misunderstood where you were going. I tend to let people say what they have to in hopes of something coming out of it. But try to educate them too. This fire was a real mess and has a lot of twists and turns in it. To have a real answer of why they left the black is my sticking point. Several theories by some but no proof.

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        2. xxfullsailxx:
          If my comments are the “inane” ones that you rue, please let me know, and I will happily reply to the substance of the rest of your objections.

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    2. I want to emphasize that EVERYONE is welcome to post a comment about any topic on Wildfire Today regardless of their position in life, their profession, or their qualifications as a firefighter or sous chef. There are no basic requirements, other than, and this is important, complying with the rules of engagement. And a rule that we thought never had to be written is that thou shalt not attempt to discourage others from posting their comments. If someone wants to establish their own rules for a website, well, that’s already been done here. They will have to explore other options.

      Having a broad spectrum of views can bring a lot more to the table than restricting it to a very narrow focus. Many people are very interested in wildland fire and for a huge variety of reasons, which can change depending on the exact topic.

      EVERYONE IS WELCOME TO LEAVE A COMMENT.

      (This is being posted in two locations in this thread.)

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  10. A lot of people are questioning BR not responding to the state investigation. Let me say first they were interviewed for the first report. We never saw there statements. I know the BR supt. has been to the site with other hot shots to develop Training, so he is not inactive in this. The Feds have silenced him and it may not be about any thing. Its just the way they do things. I am wondering if any of the first investigation was released to the OSHA investigation, or kept privet?

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    1. “Better to keep your mouth shut and have folks think you are a fool than to speak and remove all doubt.”

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  11. It troubles me that the Blue Ridge guys were not allowed to speak with OSHA. It actually does more than “trouble” me – it makes me angry for all of you fire-fighting types who are now losing out on important safety lessons to be learned. People will continue to die in fires – needlessly – as long as everyone is less than 100% candid about what went wrong. That troubles me.

    Equally important, I think pages 19/20 at the following link are very, very important,… but I am not exactly sure why. I think those pages somehow give us new material that fit together with what we already know – what people like Calvin, SR, and others have pieced together by reading everything obsessively. Because I am *not* as familiar with everything as some of you are, I cannot tell right now how, exactly, pages 19-20 fit with everything else. I think it is really subtle, and I think it is going to escape most of us. I think there are likely only one or two people on this thread and the thread over on John Daughrty’s site who have enough fragments of information filed away to figure out how pages 19 and 20 fit together. Or maybe somebody reading this thread is one of the guys who has been forbidden to talk publicly about this, but *he* knows how pages 19/20 tie everything together. I wish I knew. I’m in a position to make a bunch of FOIA/FOIL requests, and I am happy to do it, but I think I need to know more about what I am looking for to be able to ask for it. Who was Bravo 33 – what was his name? Who was the guy who left Bravo 33 – what was his name? Does anyone know Figley (sp?) – the Blue Ridge HS guy? What was going on between Marsh and the BRHS? I’m not suggesting anything *bad* was going on, but there is a dynamic here that seems important that I am trying to get a grip on. I feel like pages 19 and 20 sort of move me in some of the right direction, but I am not sure exactly how. I need help….
    https://1bbaaf77-a-62cb3a1a-s-sites.googlegroups.com/site/yarnellhillinformation/InspectionNarrativeforASFD.pdf?attachauth=ANoY7cpd2BK-NJ8Uf7LiBpWtaUBZksCxnIblwdwh_m63Oa2iSRzodi5xSdLhVmZDNOAIvZiMu8zRFWDIElIzcLdBZBwgL_G-liGvV8MzJdVUcsAKxRDtp04tXnYEnmAYHdI1x1eTYE7N1cfVKTUuv-YV0I2nXVP3qi_Y-1Re6iSlt2X4BZ_FKIHR67BBbhaeHfsxCneDzLoHDLodC4Jv-hRddVUvL04zaN5b0Sm4VrGEeeRh_nqnd_VqvQoVLD_NDp9OjUgq_Qab&attredirects=0

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    1. Bravo 33 also known as ASM2. Pilots names were Thomas French and John Burfield. Air attack left at approximately 1558. His name is Rory Collins.

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  12. Yavapai Co. Residents
    on December 6, 2013 at 10:28 pm said:

    “Thank you WFFs, active and retired.

    It’s hard for our community, for those folks who knew Eric Marsh (we didn’t know him), and his always vigilant concern for safety. FFs in our area say he did at least one staff ride to Storm King Mt. He also helped in the formation of the Arizona Wildfire and Incident Management Academy.

    So, it’s hard to wrap our thoughts around the decision to leave the black, because Marsh was so safety oriented.”
    ——
    we agree- it is hard for Sonny and Joy who watched this man Eric Marsh on 6-30-13 to have him ask redundantly “where you headed?” three times on every conversation and Joy replied “we are taking the mountain top south to the end and drop off in Glen Ilah.” First time he asked- understood it so he knew our area. Second time he asked- felt like ??? but third time I knew why because they were soon to drop retardant and needed to know where we were headed because they could not drop retardant with civilians in area since we were not geared up for such. We watched this man at times with another “mystery man” that I have a photo of and we saw mainly solo that day. When the report shows he was frustrated by the retardant drop—we were eye-witness and THERE and we agree—we were frustrated. When Eric Marsh stated the winds were “squirrely”—we 100% agree there and we were there. I strongly believe in Eric Marsh’s statement that he was wanting to remain in the black. We watched this man “in action” and he was so conditioned to do his job. He was not spent or sweating and he had a load on his back and heavily geared- I really have a HARD time thinking Eric Marsh led these men down. I saw him that morning scouting a wash out by the old grader area and to this day I wonder did he come up that way or scout it- I really do not think Eric Marsh would of scouted that early being he was headed straight to the fire edge. I have so many questions that I hope the right person one day answers because it is not like I watched the fire from in town but I was at the fire edge—we started our hike 3:48am and almost 12 hours later ended it—so we saw ALOT. We agree that Eric did his job. We saw him.

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    1. Thank you so very much. We know this is painful for you both to keep talking about what you saw. So, again, thank you for your response.

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  13. I am more concerned with actions taken at the crew level.
    It seems we have to take the 10 standing Orders and 18 situations that watch out more seriously. Even if we are a Hot Shot crew and not a type 2 crew.

    A wind driven fire cannot be managed by suppression activities, you have to nibble on its flanks and let it run till the wind stops and then contain it.

    Never trust the overhead. You are responsible for your and your crews safety alone.

    Never trust the Fire Camp to have a handle on things for the first 72 hours of an op. It takes them that long to verify whats going on and get the Command structure smoothed out. During that time, your crew should verify what they are being told using local knowledge and other resources to confirm official info.

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    1. I believe if the GMHS had felt as strongly as you do about following the 10/18 to the letter, they would be alive today. There was good black all around and the thought that they could have walked out alive is heartbreaking.

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  14. Fire Guys (those of you with experience): This new report says “DIVS A and DIVS Z
    could not agree on the division break location or associated supervisory responsibilities.”
    Please read between the lines for me – does this *honestly* mean that DIVS A and DIVS Z got into a spitting match or were, at least to some degree, locking horns? I am not looking to chastise anyone or cast blame. I just want to understand the dynamics. Was there likely a power struggle or a bit of mild … snark (for lack of a better word), or am I misunderstanding the likely dynamic that is being represented? (I think this matters, as I continue reading the report, so I want to be sure I am understanding.) Thanks.

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    1. I think DIV A had a lot of line to construct and DIV Z did not want to take part of it which meant there was a lot of open line some hot which finally broke loose. Working back towards DIV Z with no one working towards them was probably at least upsetting.

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      1. Bob, thank you. FYI, only last night did it dawn on me that your father died in Rattlesnake Creek. I was awake way past my bedtime finding and reading the report from that tragedy. I am so sorry for your loss. It sounds like your dad was doing his best to get the team out of there when he died…. Your efforts toward transparency here, and your willingness to do so under your real name rather than anonymously, honor your father’s memory.
        Thank you for giving insight regarding the Div A and Div Z issue. That helps.

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        1. Thank you and John Maclean wrote about the Rattle Snake fire in his book Fire and Ashes. I learned some things I didn’t know from his research. I know he will do the same with this fire he is not afraid to tell it like it is.

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  15. Darkness, not sunset, on June 28th in central AZ occurs at approx. 8:45 to 9 pm. Over 3 hours after the report of the fire. More then enough time to “safely” suppress the fire that early evening.

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  16. Ok I’m going back to the old days. We Initial Attacked fires 24/7 and had little to no injuries clear up to the late 80’s when all of a sudden it became to hazardous to fight fires at night or even walk into them. I cant count the times I or my crews Engine and hand crews hiked at night into fires 1 or 2 miles some times in steep terrain like the Kern river canyon or the Angeles forest down into canyons or up on ridges. We had no injuries. I can remember saddling Horses just before dark and ridding 6 hours with a pack mule and equipment 2 of us IA a fire in the upper kern just after midnight others road in on tote goats from another Dist. 8 of us contained a 5 ac. fire by 10 AM the next day. So yes I’m old school and that ant all bad.

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    1. I have fought fires at night too. Saw a crewmember break his leg burning out a steep ridge in Idaho at 0100. It took over 3 hours to get him off the hill and to a hospital. I guess we aren’t made as tough any more.

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      1. Some times it happens and sometimes you have to make a call to wait till daylight. Would he have broken a leg in the daytime? I don’t think we were any tougher then than you guys are today.

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      2. The only other thing I can say Shane is working in the mountains on fires is inherently hazardous day or night there’s always more than the fire to worry about. luckily The worst thing any of my crews sustained were a twisted ankle or miscellaneous cuts and burses. Nature doesn’t provide safety devises or signs OSHA cant do much about that.

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  17. I have to respectfully disagree with those that think that marching a crew into a boulder field at night with no logistical support is a good idea. As an IC or Duty officer you need to ask yourself some questions when assigning resources. How will you support them? What will you do if someone gets injured? Is the risk worth the reward? That does not mean i am against aggressive initial attack, but it should have happened the next morning. If you know you have a fire on the hill, and especially in the Southwest, you need to hit it hard and early. That means calling resources in at 0600 maybe earlier. Get people on the line early in the day so you can get your line in with some mop-up and than watch through the heat of the day. This is something we struggle with throughout the US. So called “briefings” drag on until 0800 and that is if they start at 0600. You end up engaging the fire after 1000 or later, just as the inversion is lifting.
    This new report has highlighted 3 things I will bring up to my crews. First, I have already talked about, arriving at 1100 on a fire you know about is unacceptable. We need to arrive early. Second, the IA crews ran out of saw gas. When attacking fires in remote areas, we need to bring enough supplies for at least one shift if not two. This is especially important when being shuttled by aircraft. More than likely the ship will not be available later in the day so get your supplies early. Third, when conducting a burnout on a chunk of line, always update air attack. Even if the burnout was planned in the morning briefing. Those guy have a lot going on and the biggest attention getter is a new column. You need to make sure they know what you are doing and where.
    Finally I want to mention, once again, something that is getting some more attention now. Crew supervisors taking roles that put them in charge of their own crews. As I have said in other posts, I think this played a significant part in the decision making. The give and take between DIVS and IHC’s are the checks and balances of the fireline. I would almost guarantee that if some other DIVS had asked Marsh to leave the black he would have scoffed at it. As a DIVS you need those outside voices to check your decisions. It is a lot easier to have a disagreement with a DIVS that you may never see again, and don’t have to work with everyday. We all, no matter how good we are, need someone to call bull____ on us sometimes.

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    1. Shane, I agree with you about attacking fires aggressively early in the morning. Incident Commanders and Incident Management Teams need to change their thinking on this. As you said, firefighting can be much more successful when the temps are low, RH is high, and winds are more calm. I think day shift crews should REACH THEIR ASSIGNMENT 30 minutes before sunrise. That could give them four to eight hours of conditions in which they can do much more good than if they were on the fireline beginning at 9, 10, or 11 a.m.

      And yes, that could mean getting up in fire camp at 3 a.m., going on the clock at 3:30 or 4 a.m. when the briefing begins (which should be no longer than 15 to 30 minutes), and going off shift no later than 8 p.m.

      A lot more production can occur at 0’dark thirty than at 4 p.m.

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  18. As a family member I sit through these meetings, listening to so-called experts make comments and judgments about what the crew did or didn’t do and whether or not they did it right. And once that information makes it way to the public, again we see Monday morning quarterbacking, If only the crew would have followed the rules they would be here today, some say. Most of the people who speak on this matter have not been to area or the ridge where the crew had worked that day. I have made many trips to both the deployment site and the ridge that they worked. I’ve hiked the area from where they parked the buggies up the 2 track, to their ridge line work location for the day. And have walked from their working area to their deployment site. After doing these things my vision of what happened does not necessarily lineup with what investigators cited, found, or concluded.
    There is a huge part that is missing in is all the information and knowledge that probably is within the personnel of the Blue Ridge Hotshot Crew and the aircrews working overhead. As this latest report shows that the feds were not cooperative and allowing interviews or giving un-redacted information that they are clearly in possession of. Now is this a conspiracy theory or what, not necessarily, they could just be waiting for some time to pass before the information is revealed.
    I’ve always felt from the beginning, that there has been huge misjudgments and mistakes made by the fire management teams. From the time on Friday evening the decision was made that the fire was too difficult to get to, and the lack of a decisive aggressive attack on Saturday, June 28. You have to wonder about the decision-making process of officers that would put the incident command post to the northeast end of the fire to begin with, as a resident of this part of Arizona the normal airflow pattern is from a south westerly to northeast. For us Prescott residents this should be an easy observation, as you only have to think back to the DOCE fire which was only a week or so prior to the Yarnell fire, it quickly gobbled up nearly 8000 acres in one afternoon by high moving winds.
    Also it doesn’t take a real rocket scientist to figure out driving down the highway that radio communication would be difficult from Peoples Valley to the ridge line that the crew worked on or any low-lying areas around them.
    If you read through the report you will see on June 30, at around 9 AM the Incident Command Post was moved to Model Creek School in Peoples Valley. By 3 PM that same day incident command ordered the dozer be moved to the north end of the fire where the IC P was being threatened by fire at that time. This in itself could show the clear lack of understanding and judgment on the part of incident command of how the fire behavior could act in the area.
    But even amongst all this management chaos, and there certainly was that by the fact of the escalation of the type of incident command structure that was being put in place at almost an hourly basis and the decision to move incident command from Yarnell fire station to Peoples Valley. It is absolutely imperative that management not make mistakes and handoffs of management operations from one team to the next.
    As weather conditions changed that afternoon, in the fire change direction suddenly and unexpectedly, it should of been the utmost priority of the management team to assess, find, and aide if necessary, all the crews that were on the eastern flank of that fire. These things did not seem to happen from a management perspective.
    Having said all this and I’ve said a lot, I have some concerns of the ADOSH findings, and citations. If the Arizona State Forestry Division is found guilty of these citations, it could have real negative impact on wildland firefighting operations throughout the US, and particularly Arizona. ADOSH cited Arizona State forestry not just for losing Granite Mountain Hotshots, but for endangering the lives of other wildland firefighters present at Yarnell fire. Four of incident commanders have to withdraw firefighters any time the wind blows a lot more homes will be lost because of it. Think about that statement and apply it to the DOCE fire.
    David Turbyfill

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    1. Being on of those Monday quarterbacks let me say.
      The State did a disservice to the fire by lack of initial attack.

      They then ordered a incomplete team, no plans, no safety officer

      The team assigned a hand crew to construct line they had no way to complete with out help. (based on line construction calculations.)

      The state could have also ordered a fire communications system for the fire.

      The team put a crew out on a hand line with to much open line between them and the next DIV.

      Plans should have been very specific as well as the OPS to fall back into the black if the fire became active.

      Yes the State and the fire team are at fault. And my brothers on the hot shot crew made a terrible decision on there own to go where no man should have gone. Even if asked to go they should have done a lot more planning and talked to the OPS on there plan.
      David I feel for your loss I have been there and after 60 years its still painful But the few memories I have always been good.

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    2. David,

      Yes, the Doce Fire. I tell people that we all in the Prescott/Tri-city area are so struggling with the Yarnell Hill Fire fatalities, because of the tremendous success of the Doce Fire, and we all watched that fire grow and threaten so many homes.

      (Note for others, it was a human-caused fire on USFS land.)

      We all know how well it was managed, right David? We all watched. The Type 1 team kept everyone informed. Their IA was swift and aggressive.

      It’s hard to describe to those not in our area how we all feel. Because of those two fires and how well the Doce Fire was managed.

      And, how strong the monsoon storm was that hit Prescott around 3:30 that afternoon. Knocked the power out downtown for blocks, and a lightning bolt started a fire on P Hill/Mt. Even people who live on the west side didn’t know about that fire above Frontier Village. We watched it, and watched the rains extinguish it. (Prescott NF hotshots crews responded to that fire.)

      We have a purple Turby bracelet. We grieve with you and all the families and friends. And, BRIHC is grieving too. I hope one day they and the air crews will speak.

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  19. In response to why the fire was not attacked the night it started. Had someone been injured or killed fighting the fire that night we would now be asking ASF why they didn’t wait for daylight and safer conditions to fight the fire. Remember we now have the clarity of time and all this information. I must side with the logic of the ICT4 that night. I would not have put people at risk for a small fire that was not very active up on that hill.

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    1. Eric
      There has been a growing trend not to fight fires at night. Which is really stupid. It was on top of a ridge accessible and from the looks of the terrain there would have been no rolling rocks. Suppression at night or first light ferried in by Helicopter before dark or hiked in on the 2 track from the ranch. I believe a crew of 5 men could have controlled the fire by early morning if the State had got with it. Their is no longer the 10AM policy so wild land fire, people tend to not go all out on IA. This a real example of not controlling a small start when you have the opportunity. Lost what 200+ homes and 19 Fire Fighters by not being aggressive.
      Ya the State should really have a big lawsuit from Home owners and the families of the Hot Shots. They could have put this fire out in the first 12hrs.

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  20. To all: Why was the small “lightning strike” fire NOT suppressed the late afternoon & early evening of June 28th when it was detected? It all starts with that question that no one wants to ask or get an answer. Calm winds, higher humidity’s, cooler temps, very little fire activity & spread, what else could you ask for??? The reason is: The current ideology of wildland fire suppression and the lack of it, lackadaisical/uncaring attitudes, disrespect of wildland fire potential and the lack of qualified experience in directing and leading resources properly & actively when you have the offensive ability of suppression. Until responsible agencies change and adopt a more aggressive initial attack policy we will continue to see these wildfire tragedies. The larger the fire gets the more complex it is, more resources (ground & air) are required to engage the fire and the longer it takes to contain & control, the result is risk of serious injury & death increases with every shift due to extended exposure to the hazardous condition . Not to mention the cost of suppression, rehab and the loss of private, public & natural resources ends up in the hundreds of millions of dollars. A proper, aggressive initial attack the evening of the 28th would of cost a few thousand dollars and of course prevented an entire Hot Shot crew losing their lives and we would not be trying to figure out what happened or who to blame. Why make a simple task so difficult and more dangerous?

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  21. Bill brings up a couple interesting points as to what is present in this investigation that were absent in the SAIR. The real question is “why?” OSC inquiring Eric about sending people to Yarnell is a big deal, why was this not in the SAIR? It may explain why the crew did not inform anyone when they left the black.

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    1. This makes a lot of sense. Some of these odd facts are beginning to fall into place.

      If the SAIT knew about this and left it out, it would be beyond inexcusable.

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      1. Yes Eric was asked if he could spare a few men to go to Yarnell. He declined and told them to contact Blue Ridge.

        At that point, if Eric later decided to take the GM to Yarnell, he did so on his own, without alerting anyone. He also chose to move without a lookout, without being able to see the fire and to bring the crew into a green fuel laden canyon in unpredictable weather.

        Because this would have been such a deadly and amateurish mistake with so many of the 10/18 rules broken it’s hard for me to believe Eric made that decision.

        There will always be questions and we don’t know what was in Eric’s mind. We do know that he made some poor choices and didn’t follow protocol.

        I believe the 19 would be alive today if they had simply stayed in the black as they reported.

        God bless them all.

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  22. Thank you, everyone. I appreciate your comments very much, and educating this lay person.

    I’m not sure where their Comment is, but I think either Tex or Joy (the 2 hikers) wrote that there is a boulder field near where GMIHC was, where some adult deer survived the fire, but fawns did not due to not having the strength to get up into that boulder field.

    Hoping that Joy might read this poor description on my part, and repost what she had written earlier about deer surviving the fire by being in a boulder field near the GMIHC Lunch Spot.

    Joy, forgive my inaccuracies, and I look forward to your clarification. I’d really like to read it again. It’s getting harder and harder to find things in all of these blogs and their Comments sections. LOL.

    If you can, please describe for me where that boulder field is again. And, I’ll try and find it using Google maps.

    Thanks so much.

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    1. this is Sonny. They had a boulder field directly to the south within less than 100 yards. The field itself is on perhaps a 25-30% grade. Appx. 1/2 a football field in size. Directly to the north; at about 100 yards is another boulder field on the side of the ridge the GMHS went down. It is at least the size of a football field. Now, Ted Putnam said on our hike that those were not necessarily safe areas yet some smokejumpers/firefighters believed that was an option of safety- Ted stated the problem was the deployment bags needed a level flat area. I personally would have went to those areas had I found myself in their position. To me, there was little vegetation/fuel in the boulder fields as well the possibility of getting between boulders or underneath in some cases.

      Joy now here. Yes, the older deer did survive in boulder areas though somewhat damaged on their coats as shown in some images I show- we found fawns that perished because they could not get through the manzanita as well as the older deer could. Sad indeed. I am having a report being looked into on how many were carried out wildlife wise from the Game and Fish- they are coming to my home Monday. Know more hopefully by then-

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      1. Thank you both. Yes, I now see those two boulder fields on Google maps.

        Ted Putnam is very well respected, and it would be nice to hear more from him.

        If you feel up to it, get John N. Maclean’s book on the Thirtymile Firefrom the library. Four WFFs perished – they deployed their shelters on a scree field. Just an FYI only. (We read all of them this summer that way.)

        All of his books are available from Prescott’s library via the county’s inter-library loan.

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        1. we hiked with him and he gifted us a book and the rest we got-
          You are right- excellent reading and information and top notch man. He has excellent people working around him as well— TOP NOTCH! They were are most educational hike teaching us firefighter/smokejumper lingo.

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  23. First let me say since 1994 and even before that The main cause factor by any stretch of the imagination has been fire fighters in unburned fuel with a highly active fire close to them. This activity need to stop there is no good green in those circumstances. Indirect attack has always been with a lot of safety in place and fire behavior and weather with you. Going down hill into unburned fuel has always been a bad decision building line or walking to a location. The percentage of a burn over and fatalities is very high. As I said a couple of weeks ago you are playing Russian roulette with your life and your crews. Leaving the black on the fire was the worst thing that GM could have done, next was not discussing the move with the OSC. A DIV. Supervisor not attached to the crew may have told them to stay put. We go back to group think.

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  24. I was involved in fire fatality investigations starting with the “Loop Fire” and helping with over a dozen investigations. I say this to set a framework for the following: Neither of the reports tell the complete story, each report comes from a particular viewpoint. I have seen in Federal investigations a limitation place on what could be said publicly by Assistant U.S. Attorneys protecting the “Government”, I’ve seen OSHA presenting a case to try and prevent the unpreventable i.e. all injuries or deaths in firefighting. My personal feeling is every piece of information should be gathered, presented to the public without bias or filtering. Then we as instructors/teachers use this information to reduce the likelihood of the same mistakes being repeated.

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    1. As a retired wild land firefighter who has survived a minimum of three burn overs and trained a lot of crew members! I could not agree with this statement more and it is basically what I said from day one would happen. 1. Get the facts. 2. Investigate the facts. 3. Establish a white paper report, publish the report. 4. Use the results wisely in training to establish SAFETY! Investigators are fact seekers, not arm chair quarter backs! Violations in this tragedy go from start to end, and will probably never give closure to the Families left behind, neither will law suits they have lost Love Ones that can not be simply replaced. Hopefully some day they can remember the good times! God Bless them and the 19!

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  25. The Picture at the top of this posting, Picture 26 and 31 all show the crew in a well burned black area and 100 plus feet back from the unburned fuel area and there hand line. They were hunkered down and watching the fire for some time in this good SZ. It was in fact a very good location from my experience on fires. THEY WERE IN GOOD BLACK watching the fire they could do nothing else at that point, there hand line was being compromised.

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    1. Hi, Bob: Thank you for your comment, and we’re forever grateful to your late father for his service.

      We took Matt Oss’ video of the beginnings of the column collapse which he filmed, time lapse for 17 seconds, beginning at 1630.

      We did a topographical “match” of his image to the area via Google street view (Hwy 89 just north of Congress) and Google Maps, and matched those to the fire growth maps from the video in the 9/28/2013 SAIR. We did that a while ago.

      Even though Oss’ video is only 17 seconds, near the end, the column’s collapse begins and one sees an explosion of smoke and flames that breach the top ridge of Yarnell Hill, and then a separate column of smoke off to the left of the Lunch Spot/Anchor Point area. Flames are burning to the left of the Lunch Spot/Anchor Point as well.

      Extrapolating wind and fire movement from descriptions in both the SAIR and yesterday’s reports from ADOSH and Wilderness Associates, including Eric and Marsh stating that the winds were “squirrely” and talking about their “comfort level” where they were in the black, we came to the conclusion that the crew leaders did not feel safe in the “good black”.

      It’s morning and I don’t have URLs, etc., for this post, but we’re going to work on that. We do want the opinions from fire science experts, because we are not. We have to go to work, so we make try and create what I describe above over this coming weekend.

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      1. With hundreds of burned acres available, I am convinced that Granite Mountain Hotshots had adequate access to plenty of good black safety zone accessible from their lunch spot. Check out the fire perimeter on Figures 9 and 10 on page 23 and 24 of the Wildland Fire Associates report.

        If you have never been a wildland firefighter it will be hard to visualize what makes a good safety zone, and the survivable environment inside one when the fire might be only a few hundred feet away, or even closer when using a fire shelter. Looking at photos or videos that were taken from miles away could lead to erroneous conclusions. If an area has completely burned, and the fire is hundreds of feet away, firefighters are unlikely to suffer burn injuries. Much more information on this is available, including research that has been completed. Guidelines are also published in the S-course curricula, Incident Response Pocket Guide (IRPG), and Fireline Handbook. Keep in mind, however, that there are many variables involved in selecting a safety zone, including weather, fuels, and topography, in addition to how long it takes to get to it.

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      2. I hate to disagree with you but where they were there was no fine fuel to carry fire. They could have backed up further on the ridge if things started heating up. The fuel type below them at the lunch site would have only produced 30 to 40 ft. flame lengths and the heat would not have been high in that area, a large rock area and well burned fuel. They had plenty of room to back up the mountain if needed. A lot of the 2000 deg. temp. is direct flame on or over an area. They would have been well away from that type of heat where they were and I’ve been there so I can tell you that for a fact. As long as your not in understory burn, and in open area burn with a lot of non burnable fuel (rocks) your in good black and if its big enough it a great SZ.

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      3. Your post sounds as if you may not have fire experience or utilized a safety zone? It can be hot as Hades all around, but if you have an area of clean black (as GMIHC did) you will be fine. It might get hot, you might have to scoot around a bit, but you’ll be fine and it is standard practice, especially in light and flashy fuels. There is nothing to indicate the crew felt uncomfortable in the black, nor should they have. They had plenty of room.

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        1. Thank you WFFs, active and retired.

          It’s hard for our community, for those folks who knew Eric Marsh (we didn’t know him), and his always vigilant concern for safety. FFs in our area say he did at least one staff ride to Storm King Mt. He also helped in the formation of the Arizona Wildfire and Incident Management Academy.

          So, it’s hard to wrap our thoughts around the decision to leave the black, because Marsh was so safety oriented.

          🙁

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  26. We are reading the report and we have concerns to the lack of weather information. Listen, at the time we topped the ridge the wind had already changed south—southwest and that was about 1pm not the time reported. Now, note that it was not extreme and it was at the top not the base, so maybe the wind conditions were different down in the bowl. Well, we didn’t have radio information about the weather. All we had was what we saw and Joy’s kestrel at the ridge as we went over to the Congress side. It was not a fast wind but I knew we had to get the hell outta there because it was coming our way.

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  27. SR, what are your thoughts about the Blue Ridge IHC refusing to cooperate with the ADOSH investigation? They were instructed to “file a Touhy request”. Then, every thing kicked up to General Counsel at the federal level. ADOSH even asked for help from federal OSHA’s Phoenix office, and even federal OSHA was refused. What BRIHC provided in its highly redacted comments is described in the report as “useless”.

    Any thoughts on what the ADOSH report states about BRIHC?

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    1. From my understanding, Blue Ridge was prohibited from talking to the team by the Forest Service- not due to a refusal on their part. (BRIHC is a USFS crew).

      The report sates “Through ADOSH, we were given access to all information and personnel that we requested with the exception of the employees of the USDA Forest Service. The USDA Forest Service declined the request to allow their employees to be interviewed for this investigation.” (p. 5)

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        1. Without thinking hard about it or researching it, I’d bet the answer is: “Some inaccurate beliefs about potential legal liability.” Note the word “inaccurate.”

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      1. I’m guessing the USFS simply has more to lose than to gain by participating in the ADOSH investigation. It could be because there is information that they want to conceal, or it could be that they simply don’t want to expose themselves or their employees to any legal risk than what is absolutely necessary. The exclusion of this information is extremely unfortunate for both the families and the wildland fire community as a whole. Even if there is not new or significant information to add from the USFS employees, it would be extremely important just to know that!

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  28. It’s important to look at the role that both Fed OSHA and State OSHAs play in this process: they are intended to look ONLY at the employing agency to see if it met it’s responsibilities to “provide a safe work environment”, not look at all of the possible causal factors. Did the Agency provide the training, equipment, direction and managerial oversight to insure that the workers did as they were supposed to do? Were the workers provided that elusive “safe work environment”? They can find that an Agency did not provide refresher training, but don’t address that fact that when the credible training was in fact provided, the individual firefighter was checking text messages instead of watching the Fire Shelter video.
    NIOSH serves the same role at the Natiional level, although they eliminate names & jurisdictions in most cases so that they can get to the bottom-line facts and issue widely distributed “lessons learned” documents, but no fines or blame placing by name.
    This AZ-OSHA report was prepared under contract by a group of well-experienced wildland firefighters who had no poliitical agenda, and so will be looked at as being possibly more credible than the officially sanctioned SAIT Report of a few months ago.
    Only time will tell if we hear the messages ………………?

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  29. Mike, we’ve been reading your posts for a while and very much respect what you share, and thank you. However, it’s becoming more clear, now, that there was no “good black” on that ridge. They would have perished up there due first to the superheated gases, and second, the fire did pass over the “good black” again. At 2,000 degrees F and 50 mph winds, the flames all around the area were a huge blow torch. ADOSH’s report confirms this and so does Wildfire Associates’ report. Phoenix videographer Matt Orr’s video confirms that the entire ridge line was no longer safe, even the “good black”. When that column collapsed, the GMIHC just didn’t stand a chance. RIP, our dear crew. Your city misses you all more than words can express, and the tears continue to fall.

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    1. Yavapai, you seem to believe that the “good black” was not survivable or was a good safety zone. I’m not sure that’s the case. If it had burned completely, there would have been no fuel left to burn. And depending on the size of it, if the fire burned AROUND it, the temperature inside the good black would have been far, far less than 2,000 degrees. Can you point out in the report where it says the good black was not survivable? Maybe I missed it.

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      1. I am having a hard time finding that too. But the report is long so I might have missed it. I have a hard time believing they left the black because they thought the black was unsafe. The report says there were 200 acres of black, I have seen higher estimates. If they did think the black was unsafe, would they not have moved towards Congress and not towards the fire.

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    2. If you look at the pictures of were the crew was looking at the fire and sitting quite a ways in the black all they had to do was move to the Helispot and back in from it 200 or 400 acres is a lot and it would not have reburned at any type of running fire. It looked like excellent black from what I’ve seen.

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    3. Where does it state the old black would have been unsafe? Even when you get hot pulses you can pick your way through the black. I think you may be confused about the “column collapsing.”

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    4. Yavapai, There is no way the crew would of perished by superheated gases and the fire passing over them other then doing just what they did, leaving a perfectly good safety zone. The black was perfectly safe and that is where the GMHS should of stayed. Any experienced, well trained, logical thinking module leader would of waited it out in the black. That burned area that is in the photo would not have reburned.

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  30. I look forward to our next hike—most important because OSHA explains the day with time stamps but there was wind changes almost 1pm and it happen a few times after that—maybe not at the base but at the top the wind was headed directly south—south west and Joy’s kestrel read 43mph.

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    1. I also remember very strong wind changes which are in time conflict with the report.

      This was VERY unusual for Arizona. I adjusted some outdoor furniture thinking it would be safe from the wind, only to have another huge wind change happen and was chasing furniture again.

      Would the Firefighters have been able to anticipate the changes as when the fire changed from North/ Northeast and then to South? It appears to me that anyone at that fire could have been in danger, no matter what plan they had. How do you determine what is safe and how to attack a fire when the situation is in constant flux?

      It was a changeable, unpredictable fire because of the wind. However I don’t think anyone was able to determine just how bad it would get at the time.

      It seems armchair quarterbacking is much easier than playing the actual game in real time. Human error is part of life. We are not computers and not perfect. And we as of yet, cannot predict Mother Nature.

      I don’t think fining the agencies will help anything. It will reduce funding and leave more gaps in the system. More training, better equipment and possibly more staff would be the answer. Money is not the answer.

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  31. The OSHA report seems to have made much more of a good-faith effort at assessing things, as opposed to being a CYA exercise. There still is no mention of comprehensively examining ALL cell records of all involved (and any other means of communication available). I believe given the pressures of the situation, it may be difficult for people to accept that a cover-up may well be present since one of the likely explanations for GM’s decisions is that they were ordered down.

    A couple curious things. Re: the 10 and 18, the OSHA report concludes that GM followed most of the 10, but its own analysis states that at least 5, possibly 6, of the 10 were in fact not followed.

    Unless I missed it, no discussion of lack of training in proper use of fire shelters (including when deployment may be survivable and when not). The 19 one could say were caught last-minute with few options, but their lookout also seemed to view deployment in similar circumstances as an ok option from the language of this report (and pressed his luck on trigger points, perhaps in consequence).

    Regarding qualifications, the OSHA report again engages in some curious wordsmithing. It seems people are dancing around the email exchange from earlier in the year when Marsh was complaining he was being asked to cert to something when he knew qualifications weren’t met. It would be better to address that email exchange directly.

    Overall, though, I was waiting for the report to be a repeat of the last one, and instead believe that in the fact of what must have been tremendous pressure that the OSHA report authors did a stand-up job of which they should be proud.

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  32. SO THE ARIZONA STATE AGENCY gets fined $560K for the fire.
    Who pays and who loses?

    Far as I can tell, the Arizona taxpayers pay for this, and the AZ state fire agency has to juggle budget, lose money, pay the fine. So if the AZ state fire agency has to pay $560K for the OSHA fine, they lose $560K from their budget? Is this something like $560K that used to be in the state fire budget? How do they reconcile that? Lay off firefighters? Cut prevention budget? Seriously, where’s that half-million dollars come from or get moved to?

    What if the state OSHA fines were assessed onto individual state employees?
    What if the state OSHA fines are assessed onto the AGENCY which then has to cut its budget somehow and lay off fire employees or programs?

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    1. I understand the comment kelly on December 4, 2013 at 7:07 pm said…my husband and I discussed taxpayer topic and the very fact I love the state of
      A R I ZO N A so it was hard for me to release myself raw…genuine and 100% transparent because I was afraid where is the fine monies going to come from? It should not affect us the taxpayers but we discussed it and you asked a wonderful question—hope it is answered here.

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    2. When I hear members of the public complaining about having to pay for the fine as taxpayers, my first reaction is anger. Granite Mountain died protecting taxpayer homes. Many of the homes threatened in Yarnell were indefensible, meaning that homeowners had done little to no work to protect their own property. The neglect of homeowners to protect THEIR OWN PRIVATE PROPERTY directly increased the risk faced by firefighters- both by Granite Mountain and all others on the fire. 19 men were killed because of their desire to be of service to the public and because of the failure of their employing agency to prioritize firefighter safety over the interests of taxpayers.

      On EVERY FIRE, firefighters expose themselves to risk to protect the interests of the public. Firefighters, receive relatively low wages and many do not receive basic benefits. As the report indicates (or ask any wildland firefighter) employing agencies routinely fail to prioritize their safety over the enormous pressure to protect taxpayer interests- homes in particular.

      On any fire in which homes are threatened, the public cries “Do something!” even though they have often done nothing to protect their own property. “Doing something” demands that undervalued employees to expose themselves to extremely high levels of risk protecting private property. As a long term hotshot, there is bitter irony in this situation. 19 young men were killed as a result of their effort to protect private homes of the public. A citation and a $560,000 fine aimed at corrective action and providing VERY minimal compensation to the families who lost a loved one ($25,000/family) and the public is outraged about the injustice of having to pay. To me, the public’s unwavering expectation of structure protection and the failure of homeowners to establish defensibility on their own property makes the public at large as much a guilty party as anyone in the deaths of Granite Mountain.

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      1. Dear Hotshot:
        First, thank you for doing a job that is dangerous and heroic. I stand up for others and regularly put myself on the line for others, but I have NEVER done so in a way that involves me putting myself in the middle of a wildfire. You do, it is dangerous, it is selfless, and I thank you.
        Second, I do not think anyone was saying that the families or next of kin should be getting money. Rather, the point was being made that the fine does not really “punish” the “wrongdoer” (allegedly the forestry department), but, rather, it “punishes” the taxpayers who fund the department. Phrased differently, if the goal of the fine is to get the Dept. of Forestry to do better, imposing a fine might not be the most effective thing, since the money is not coming out of any one individual’s pockets. That is the point I think was being made, anyway.

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        1. Whoops – the first line in my second paragraph about is missing a key word, “not.”

          The line should read “Second, I do not think anyone was saying that the families or next of kin should NOT be getting money.”

          Sorry about that.

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        2. Thanks for your response Elizabeth. I agree that posing a fine is not the best way to improve the performance of the Dept of Forestry or firefighter safety as a whole. While blame has been assigned to the AZDF and likely to specific employees, I would argue that there is a much bigger picture of “blame” that is directly tied to public expectations of land management agencies to successfully protect homes that directly affects the way we fight fire. I believe these expectations directly affected the situation at Yarnell.

          Any public agency that engages in wildland fire suppression is under enormous pressure and expectation to effectively put fires out as fast as possible to protect public resources- this pressure and expectation increases exponentially when those resources are private homes. When homes are lost, there is often a public outcry against the “failure” of land management agencies to effectively manage fires, to provide enough resources, to drop enough retardant, etc. The public does not always see that protecting homes from fire is often impossible, no matter how well mangers perform, or how many hotshot crews or VLATs are on scene. Perhaps most importantly, it is difficult for the public to understand that that firefighters are placed at risk by protecting structures. In addition to the everyday exposure to risk by engaging in fire suppression, the conscience of firefighters is often pulled to do a little more, to stay too long, or make decisions they otherwise wouldn’t because of their moral inclination (and agency pressure) to protect someone’s home.

          On every fire, the first objective is to “provide for firefighter and public safety.” On any fire in which homes are threatened, the second objective is to protect the structures at risk. Given the current ways in which we engage in wildland firefighting (which to me, is largely driven by public perception/pressure), the objectives of firefighter safety and protecting structures are at odds with each other. If we continue to rely on aggressive fire suppression protect structures from fire (as opposed to homeowner/community level mitigation, etc) there will likely be more firefighter fatalities. If we truly do prioritize firefighter safety above the protection of structures, more homes (arguably many more) will be lost.

          In the case of Yarnell, (and routinely on other fires), fire managers placed the protection of structures above firefighter safety. Firefighters made unsafe decisions that were likely influenced by a drive to protect private property.

          I agree that the fine itself may not influence anything. But I think it is short-sighted and incomplete to assign blame strictly to the failure of the AZDF or to specific employees in the agency. It’s important to consider the reasons why the fire was managed the way it was, and why Granite Mountain made the decision to head to Yarnell. As I stated before, public expectation and pressure to protect homes (many that were ultimately indefensible) directly impacted what happened on this fire. While there were many factors that appeared to contribute to the fatalities, it is tough for me to swallow when I hear public outcry about having tax dollars go toward the fine- in the big picture I see the public as a partially responsible party.

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  33. osha report 12-4-13

    Tex (Sonny) Harold Eldon Gilligan and Joy A Collura’s —

    our involvement first only with OSHA from start to end is below. You can match it up to report to see if it is complimentary or if it was all reported or for the most part. We will soon post reaction to OSHA report.

    our communication record to OSHA shows-

    Sunday, August 11, 2013 4:35 PM our first email to OSHA.(photos)
    Mon, Aug 12, 2013 at 2:22 PM OSHA emails us.
    Thu, Aug 15, 2013 at 1:07 PM (communicate blank computer disks being mailed out and schedule a hike)
    Tue, Aug 27, 2013 at 9:04 AM (communicate hike details/OSHA received disks)
    Mon, Sep 9, 2013 at 3:09 PM (confirm Yarnell hike)
    Thu, Sep 12, 2013 at 10:01 AM (communication of areas restricted/Simmons/suicide hiker)
    Wed, Sep 18, 2013 at 9:37 PM (communicated we had excellent hike with Brett Steuter and Bruce Hanna)
    Wed, Oct 16, 2013 at 8:14 PM (communicated on topic of phone records “EN” is getting and we will forward her records to them when we get them)
    Wed, Oct 16, 2013 at 10:29 AM (OSHA replied may be interested- more details)
    Wed, Oct 23, 2013 at 10:06 AM (question of time we saw and photographed mystery man on ridge with Eric Marsh?)
    Sat, Nov 9, 2013 at 5:29 PM (in regards to “other” phone records of phones not offered and investigated/asked if they are able to delay report that is due out in January so we can offer more sources/documents)
    That was our email conversations yet we had phone call conversations as well since August only pertaining to hike/location/new evidence found on hike by Sonny with author John MacLean; burnt up pink ribbon roll. OSHA was notified on Veteran’s Day immediately.

    we have not fully read the report and we will state our reaction when we do but in skimming it—this came to mind—
    Everyone’s heard it, a lot of people believe it, and some even think it settles things—we have people going above the two reports and really dissecting that weekend beyond what is being shared in both reports. Some think it begs the question, others think it equivocates, still others think it merely oversimplifies the issue. Some might not want to read any further and be done with it—it was a fire; men perished–homes gone; lives changed. Yet we have people going the distance for not just these men but all the men who have died in tragedies of fire as well for the Yarnell community. It’s a complicated issue. There are lots of relevant factors involved and the truth will prevail.

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  34. I understand about exposing all those that did not perish to potential harm and hence the citations. I think that has been an underreported part of the story. But the GMHS were in the black, and hence presumably safe. Evacuation was not what they needed, they needed to stay in place. Unless fire command instructed them to do otherwise (?).

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  35. Now watch…….ADOSH will be accused of not knowing what they are talking about..

    Wait for it………

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