Reports released about fatality on the 2020 El Dorado Fire

“The system was not designed to handle this”

Map El Dorado Fire
3-D map of the north side of the El Dorado Fire, from infrared flight, 11:38 p.m. Sept. 17, 2020. Looking south.

About 15 months after Charles ‘Charlie’ Morton was fatally burned on the El Dorado Fire on the San Bernardino National Forest in Southern California, the US Forest Service released a series of reports about the incident. 

According to one of the documents, titled Narrative, Charlie, a squad leader on the Big Bear Interagency Hotshot Crew was scouting the fire alone around 7 p.m. September 17, 2020 when it overran his location. Crews had just stopped igniting a burnout. As the fire intensity increased, one of the crew captains asked him on the radio if he was going to be able to get out of the area. Charlie’s response was, “We’ll see.” Following that, the Captain called him several times with no response. He then heard Charlie call in desperation, “I’m in a corner.” It was the last time he transmitted on the radio.

Due to extreme fire behavior, including counter-rotating vortex pairs that formed at his exact location as a result of the burnout operation underway, it was hours before anyone could access Charlie’s location. During that time he was assumed to be missing and the Operations Section Chief assigned the Contingency Branch Director as the Incident-Within-an-Incident Commander to lead the search.

El Dorado Fire Progression map
El Dorado Fire Progression map for September 5 to 17, 2020. The report covers activity in Divisions L and O.

For nearly two hours a sheriff’s helicopter utilized their loudspeaker to call out “If you are a lost hotshot firefighter, give us a signal. If you are a lost hotshot firefighter, give us a signal.” At that time firefighters were very busy attempting to suppress numerous spot fires. Some of them were not aware of the missing firefighter when they heard the announcement from the helicopter.

From the Learning Review Narrative, about the beginning of the search:

BR 5 [Branch Director 5] tried to gain access to the bulldozer line from the Camp Round Meadow area and was accompanied by Division L Medic. Although the medic had limited wildland fire experience, it was apparent that the situation was dangerous. He noted falling snags, extreme temperatures, and that fire flanking below them could cut off their egress back to Camp Round Meadow. He thought he was going to die in there and sent a pin of his location to the Division O Medic so that someone could locate Division L Medic if something bad happened.

Meanwhile, SBC Type 2 Initial Attack Crew tied in with Branch and was allowed to fly a small [CAL FIRE] drone equipped with an infrared camera down the bulldozer line to assist with the search. Drone footage showed significant heat along the line which rendered the infrared camera useless. They switched camera modes and flew a few more missions searching various areas.

The conditions were so dangerous that the Safety Officer decided to call off the ground search.

The time of day or night was not mentioned very often in the report, but some time later:

Big Bear captain 1B (who was filling the role of DIVS L trainee) arrived and announced that he was going to search at the bottom of the bulldozer line. BC#1 [Battalion Chief] didn’t want him to go into the area alone, so he decided to join. Big Bear Captain 1B searched the right side of the bulldozer line and BC#1 searched the left. Even with their big flashlights, it was difficult to see through the darkness, smoke, and flames. A quick reflection of light from an accordioned and undeployed fire shelter caught BC#1’s eye on the edge of the bulldozer line near a bend. They stopped 25 feet away and were able to determine that Charlie had not survived.

fatality site at the El Dorado Fire
The yellow shirt marks the September 17, 2020 fatality site at the El Dorado Fire. From the report.

The area was still very hot and smoky, and the captain and BC#1 returned to the road below. A medic suggested that she could go to the scene to pronounce Charlie’s time of death, but the decision was made that it was too dangerous. The Safety Officer inserted guards at the bottom of the bulldozer line to keep people from going to view the scene and to prevent another fatality.

At the bottom of the bulldozer line, BR V blew past the guards and went up to the site to be with Charlie and stayed there with him. Some people said to just let him go, but after a period time people began to assume that BR V was fatally lost as well. A second search was organized for BR V. Searchers were unable to access the site due to the heat and falling trees. For approximately a two-hour period, nobody was able to reach BR V because his radio and his cell phone were left in the pickup. Division O Medic returned to stage at DP 45, now waiting to render aid if needed. About 0145, BR V returned down the hill and notifications were passed that he was safe. BR V came down the hill as soon as he realized he’d left his communication devices in his truck.

Charlie is survived by his fiancée, a daughter, parents, and two brothers.

The fire began at 10:23 a.m. September 5, 2020 in the El Dorado Ranch Park in Yucaipa. It was caused by the use of a smoke generating pyrotechnic device. The intent was to produce pink or blue smoke to inform bystanders about the gender of a fetus. A couple was charged with involuntary manslaughter and 29 other crimes.

Other reports

The information above came from the Narrative, a 29-page document that unlike recent facilitated learning analysis (FLA) documents, only covers the very, very detailed chronological facts of what happened on September 17 on the north side of the El Dorado Fire. It does not address, like the FLA for the Cameron Peak Fire for example, 250 Lessons Learned broken down into 14 types of resources (e.g. Finance Unit, Contractors) and 7 categories (e.g. COVID mitigations and testing/contact tracing).

But two other documents were also released about the fatality:

The latter, the Organization Learning Report, breaks with recent established practices, as the Narrative did.

It does not drill down into minutia of what occurred on the El Dorado Fire. It looks at it from 30,000 feet and extrapolates the significance on a much broader scale about the current state of wildland fire management.

It was led by Bill Avey who was appointed to the position of acting director for Fire and Aviation Management in Washington for five months in 2021. He retired December 31, 2021 as the Forest Supervisor of the Helena-Lewis and Clark National Forest in Montana.

Below are excerpts from the seven-page Organization Learning Report. It appears that much of the information came from interviews — not all of the topics are covered in the Narrative. For example, it suggests that perhaps firefighters (or forestry technicians) should be called “fire responders” so they don’t “view fire as an enemy.” Other than that many of their conclusions are very reasonable, even though most of them have been previously identified in various forms. But having so many of them listed in one fatality report is unique, and could be useful. Unless it just disappears into files like so many others.

In his September 24, 2020 testimony before Congress, John Phipps, the Forest Service’s Deputy Chief of State and Private Forestry, stated “the system is not designed for this,” to illustrate the misalignment between the design of the wildland fire system and the reality that wildland fire responders routinely experience.

The El Dorado Fire burned as an area ignition resulting from high accumulations of long-burning fuel materials present in the unhealthy forest conditions at the time of the fire. This type of fire behavior was once rarely seen among our wildland fire responders but is becoming increasingly more common because of the current condition of our forests and the influences of climate change. Our current paradigm of treating fire as an enemy that must be defeated contributed to the condition of the forest at the time of the fire. Until we figure out a way to form a new, sustainable relationship with fire, we can expect forest conditions to continue to deteriorate. This deterioration will continue to make situations like this fatality event more probable into the future. We need to see fire’s role on the landscape differently.

Viewing fire as the enemy also may have had an influence on local resources “trying to protect their home turf” against that enemy. We are trapped in the paradigm laid out by the philosopher William James’s “Fire is the moral equivalent of War” essays of the early 20th century. Calling our fire employees “firefighters” only contributes to the metaphor of declaring war on an enemy. Perhaps a shift in language (to say…fire responders) may prove beneficial.

We continue to ask our wildland fire responders to save communities that are becoming increasingly unsavable. At what point do we declare communities without any semblance of defensible space not worth the risk of trying to save under extreme fire behavior conditions?

Two common refrains were heard: “Why am I risking my life and losing time with my family for such futility?” and “The things we did ten years ago are no longer working.” Wildland fire responders feel increasingly isolated and misunderstood, with the expectations from the agency and society to “save the unsavable” while “managing risk.” This coupled with the pay, work-life balance, and hiring issues is eroding the trust and the implicit social contract among wildland fire responders, the Forest Service, and American society. This is another other factor that is quickly resulting in a lack of qualified (or any) applicants and the growing vacancies in fire response crews. On the El Dorado fire, due to a lack of resources, there were four Interagency Hotshot Crews on an incident that would normally have ten.

The wildland fire culture has developed in such a way as to defer to the expertise of IHC crews above most other resources on a fire. If the hotshots like the plan, then it must be a good plan…or so the thinking goes. While this heuristic has treated the fire service well in the past; it becomes more problematic if deference is given mistakenly to a resource without the level of expertise that is assumed. Over the course of the last several years, the experience levels of hotshot crews have become diluted. Long-tenured Interagency Hotshot Crew Superintendents seem to be becoming a thing of the past. The Big Bear Interagency Hotshot Crew (IHC), due to a lack of available experienced personnel and coupled by issues with the temporary hiring process, were staffed by a significant number of Administratively Determined (AD) hires, formerly unheard of for an Interagency Hotshot Crew.

As federal Interagency Hotshot Crews continue to train and then lose the next generation of leaders, the question must be asked: “At what point will our hotshot crews’ experience levels thin out too much to fill the role we have traditionally asked of them?” And once that occurs, how should we fill that void?

The same concerns exist for Incident Management Teams (IMT). With the reduction of 39 percent of the Forest Service’s non-fire workforce since 2000, the “militia” available to assist in IMT duties is rapidly being reduced to a mythical entity, often spoken of but rarely seen. The 2020 fire year was simply the latest in a long string of years where we did not have enough IMTs, let alone general resources, to address suppressing fire in our current paradigm. On the El Dorado Fire, Region 5 took a creative approach to ensure Type 1 oversight by grafting a Type 1 incident commander onto a Type 2 team, when no Type 1 teams were available. While this met the need and policy requirements, one cannot help but wonder what the difference really is between a Type 1 and Type 2 team. Why not just create one national team typing system, and why not ensure that it is staffed to a holistic fire management response (see Theme 2) and not just a direct perimeter control response.

Scouting fire lines has proven to be a dangerous task. What barriers prevent federal crews from being able to deploy drones to do the preliminary scouting, rather than having a person do it? How do we overcome those barriers? Note: CAL FIRE crews owned and operated drones on the very same piece of line during the search and rescue operation undertaken to find Charlie.

We have the technology to comply with the Dingell Act, shouldn’t the Forest Service mandate, just like we do eight-inch-high leather boots or Nomex, that wildland fire personnel have on a personal tracking device while on the fire line?

What is the protocol to determine that a wildland fire responder is missing? What is the protocol to find a missing wildland fire responder? Should there be a national standard to follow to reduce confusion?

What is the protocol to obtain notification information for our employees? What is the protocol for notifying fallen employees’ next of kin? Should there be a national standard to follow to minimize confusion and disorganization?

CAL FIRE and many other organizations have standard and required emergency notification forms that are available electronically to select individuals.

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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.

11 thoughts on “Reports released about fatality on the 2020 El Dorado Fire”

  1. RIP Charlie. Horrific tragedy that should have never occurred.
    This report is not worth the paper written on. Several insightful comments from the readers ring true with me as I read them.
    Having retired recently from another very large wildland agency what is, or more importantly what isn’t in these documents is very disturbing and very telling. Having some second hand knowledge of this incident, the Safety officer was involved in this incident/operation before the tragedy occurred, I won’t go into detail as it is second hand, but what I know makes sense.
    Who and or at what point does a leadership group on scene “allow” the Brach Director to “push past” security and go to the fatality site BY HIMSELF, WITHOUT communication devices and make a statement like “just let him go? Holy crap folks.
    In the organizational learning report the reference seems to repeat the theme that changing the name of Forestry Technicians to Fire Responders somehow makes everyone think differently and makes everything ok. We all know them as firefighters and a title change makes no sense in terms of safety. You can them ham sandwiches and we will all treat them the same.
    The same goes for the Theme that fire is treated like an enemy instead of what, a friend?, ally, an impartial observer? Really? Fire is ALL of that. It is an enemy when it threatens our lives, property, economy, and natural resources. It is also an ally and that relationship needs to be fostered much more, time and place.
    The same report also relates the lack of crews (4) when there should have been (1)0. Maybe it should be mentioned there were MANY more crews on this incident from many agencies with excellent training. It was Unified Command after all.
    I too would like the statement that the crew was depending on AD hires for its members be expanded upon. As far as I ever knew this was not a practice that was acceptable.
    The second hotshot member that went missing days after the fatality has been completely wiped from all records and has never reached closure in the public view, gone, just gone. Tragic no doubt.
    I am finding these reports more and more useless and devoid of facts to be more politically correct without the need for factual disclosure. They are with more for what they DONT say.

  2. Not sure where to begin, a rather odd report, much discussion about resources and their availability as to maybe suggest that these resource issues were a causal factor. Where are the findings and recommendations, certainly there are a boat load of them to review.
    No Doubt he was certainly well experienced and very confident, I am a bit curious as to going back in and scouting a line that was just abandoned for safety reasons, was there dialog between the captain and him concerning reentry to the dozer line, it seems to me that BB IHC was a bit spread out, which happens at times.
    It’s disappointing that it took nearly a year and a half to release this information. The fire community deserves more from a serious report such as this, I do not want to come off as insensitive, this is no doubt a very tragic loss for his family and the BDF. I hope the family received the answers they need and deserve.
    I guess I was expecting more from the report, it was only near the end of the report where we see what occurred leading to this tragic event, having a little background is important, this is to much.
    I pray for continued healing for all those impacted by this event…..Peace……

  3. RIP Charlie.

    I had a similar situation happen to me. We were conducting a burnout and I was burning out the third of three lines. My Crew Sup called over the radio and fire behaviour was getting too bad and they were going to have to light up on the guard ASAP. I stopped my burning ops and headed to the guard, but they had already light up and I had to find my way out of the area, snaking my way through areas that were burning. One of the scariest moments of my life. I can’t imagine what Charlie went through.

  4. Though I’ve been retired for many years I continue to watch for after action reviews of fire fatalities and near misses. The analyses based on the tens and thirteens (or however many there are now!), the maps and weather information, have always been valuable. Professional firefighters use that information to train their crews and evaluate their own tactics and strategies–learning lessons from others.
    This report, or at least the parts of it presented here, contains very little of value. Conjectures about job titles and war analogies may be interesting discussion points for some groups, but they have little to offer the important lessons that could be learned from this tragic incident.

  5. A lot to digest. Fire should be respected, not feared. Experience is needed to know when it’s unpredictable. But, you have to push the envelope sometimes to gain experience. That’s where the respect comes in. Follow the Fire Orders and be familiar with the Watchouts and you’ll gain the experience that’s needed to make the critical decisions on strategy and tactics. Too many resources these days don’t have that experience of pushing the envelope and having respect for what fire behavior is capable of. For some, it’s the belief that they can do more than they are prepared for, and get over extended. For others, it’s the opposite, and they are not aggressive enough, not gaining valuable experience. It’s easy to call in aircraft and drop on the fire until there’s no smoke left. It’s easy to burn out huge amounts of acreage. The problem is you don’t get any experience fighting fire, and that’s where we are today. Yes, climate change (whatever) and drought and fuel conditions have a lot to do with it, but that doesn’t mean we need to get away from the fundamentals of firefighting.
    This was an unfortunate tragedy that can be learned from and prevented in the future, just like most fireline fatalities. Follow the Fire Orders.

  6. RIP Charlie

    The Organizational Learning Report has some hard truths and some questionable wish-thinking.

    Part 1: So they are saying that the Big Bear IHC was so inexperienced (filled with AD hires) that they opted to do the easier burn operation in DIVS O. Then, although the DIVS O resources were reluctant to proceed, Big Bear went ahead with the burn, leading to Charlie’s death? Basically saying Big Bear IHC didn’t want the (seemingly) harder work in DIVS L. Maybe they weren’t capable of the DIVS L burnout because they had a skeleton crew? Am I reading this section incorrectly? How can an IHC crew have AD workers and still retain type 1 status?

    Part 2: They basically elude to the fact that because we call the profession “firefighting” that we act irresponsibly. Well I have news for them, we are not called firefighters, we are forestry technicians. The only reason we want to be called “firefighters” is because that is what our society has chosen for the profession, and seemingly we will be compensated more fairly if we are recognized as equals to the rest of the firefighting world. In fact, calling us “firefighters” would help retain and recruit more people, maybe even Charlie would be alive today. I don’t think Charlie felt like he was on a WWII battlefield and was combating his enemy that day. He was just in the wrong place at the wrong time.

    Part 3: To me, this basically says that the USFS has failed and needs a National Fire Service, it’s gotten so bad that it is contributing to fireline fatalities. At a time when we need to be at our best, we are at our worst, with no plan to improve management or leadership over the next 5-20 years. They lament that people lean too much on depleted IHC crews for tactical strategies, but when firefighters aren’t allowed to move into management roles, and line officers think they can manage these incidents with little experience or knowledge, they have no choice but to ask others for advice on tactics.

    Maybe I’m way off? It’s just really upsetting reading this report, and hopefully we can either be pulled out of the Forest Service, or the forest service can start treating us like valuable employees. Now it really seems like Line Officers and DC managers simply don’t have a clue and don’t care.

  7. First, god bless Charles “ Charlie” Morton. May he forever rest easy in peace.

    The organizational learning report is mostly BS.

    They are not Wildland fire responders. They are FIREFIGHTERS. Congressional legislation signed by the president directing OPM to write the PD says so. The agency is undermining congress and the law with this tired philosophy.

    The “system” is failing because it’s never been maintained properly and is not fully staffed and not fully resourced per the National Fire Plan.

    The last thing the citizens, tax payers and communities in Southern California needs is ill prepared, inexperienced line officer/agency administrators “managing a Fire” in and near the WUI. They need to hit them fast, hit them hard and catch every one of them they they can early. The Chief of the Forest Service not only acknowledged the full suppression strategy on these Forests but issued direction for full suppression in the entire system this year, was he wrong?

    The comparison to a post WWII model is ignorant and I’ll informed. Some of those fire fighters, Fire Chiefs and IMTs are the best critical thinkers, risk management professionals, problem solving collaborators and conveners I know.

    Clearly academic, naive, Ill informed and dismissive of the reality we face. Congress should look at this report and ask why?

  8. has there been any word about the firefighter on this crew that went missing, on his days off, shortly after this fatality? It is a terrible tragedy. I was a wild land firefighter from 1976 -1998 and had many friends injured or killed. I worked engines, helitack, helishot, hotshots, smokejumpers, and municipal. But the size, scale, destruction and threat level since I retired has escalated beyond anything I ever experienced. I was in the Yellowstone fires in 1988, the “Firestorm” in California in 1987, the Marble Cone fire of 1977. These seem like such insignificant events these days.

    1. Joe, the other day I searched for updated info on that other missing firefighter, Carlos Alexander Baltazar, and could not find anything.

      For those that don’t know, another Big Bear crewmember disappeared under mysterious circumstances in the days following the death of Mr. Morton. Carlos Alexander Baltazar’s car was found abandoned on Highway 18 near Delta Avenue by the California Highway Patrol on September 20, about 75 yards from his backpack. He was reported missing by his family on September 24. His sister said on the driver’s seat was his ID, a money clip with $200, and on the passenger seat was a knife. His family said he was upset over the death of Mr. Morton, who they described as “his boss.”


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