Arizona releases Yarnell Hill Fire documents

 

Superintendent Eric Marsh
Superintendent Eric Marsh hikes ahead of his crew on the morning of June 30, 2013. Photo by Joy Collura.

The Arizona Republic obtained a large number of documents about the Yarnell Hill Fire from the Arizona State Forestry Division which provide more insight into the management of the fire. On June 30, 19 members of the Granite Mountain Hotshots were entrapped by the fire and killed.

Notes from interviews with firefighters further confirm and flesh out some of the issues that we knew from previous reports.

The two investigations completed so far about the fire revealed little if any interaction on June 30 between the Granite Mountain Hotshots and their day to day supervisor from the Prescott Fire Department, Darrell Willis, who was not in charge of the crew on that fatal day, but was a Structure Protection Group Supervisor attempting to prevent homes from burning in Yarnell. The Arizona Republic article said there was communication between Mr. Willis and the crew that day.

Darrell Willis of the Prescott Fire Department, who helped found the Granite Mountain Hotshots, told investigators he had pressed Marsh to complete a protective fire break around Yarnell before the accident, saying, “This thing is not anchored — we got to get an anchor on this thing.” The notes say Willis “seemed to have some ‘minor guilt’” in retrospect.

“This was the last conversation he had with Eric,” investigators wrote.

From that text, it is not clear WHEN Mr. Willis “pressed” Mr. Marsh, who is normally the Superintendent of the crew but was serving as Division Supervisor in charge of the area of the fire which included the Hotshots. If Mr. Willis’ conversation with Mr. Marsh resulted in a decision to move the crew from a safe, black, previously burned area, and walk through unburned brush into a box canyon where they were overrun by the fire, this is significant news, previously unreported.

This information, interpreted by a reporter from interview notes we have not seen, makes it sound like Mr. Willis wanted the Hotshots to construct a fireline around the town of Yarnell, but under the conditions that day, it is unlikely that would have been feasible, and was certainly too big a task for one crew.

We went back and reviewed the video recordings made by John Dougherty of Mr. Willis’ press conference at the scene of the tragedy. They were uploaded to YouTube on July 23 and 24 and are in two parts, Part 1 and Part 2. Below are transcripts of portions of Part 1:

3:12: Most of this information that I’m giving you is information that I gathered based on some of the information, maps, and stuff like that. I happened to be on the fire on the north end of the fire that day doing structure protection. So I wasn’t really involved with what they were doing but we are able to monitor the radio frequencies they were on and we heard that they were gonna move out and start coming in a southerly direction based on the fire behavior.

[…]

4:32: I believe that they were, felt that they weren’t doing good where they were at, they had to abandon their tactic of trying to anchor and flank the fire and go into what we call point protection, and that’s to move fire around the houses and protect structures. I believe that that’s what their intent was and when they moved down off of there you know they’re carrying 40 or 50 pounds of tools, equipment, and a pack, upwards of 70 pounds when you put a saw, fuel and stuff on their back and they were moving down to protect this house. That’s my theory on it. Like Jim Paxton said, we’ll never know, because we don’t know what 19 of the Granite Mountain Hotshots were thinking at that time and there’s no confirmation radio traffic that we’re aware of.

At first he said he heard on the radio “that they were gonna move out and start coming in a southerly direction based on the fire behavior”. And later said, when talking about why they moved from the black to where they became entrapped, “there’s no confirmation radio traffic that we’re aware of.”

The article also reported that members of the Blue Ridge Hotshots described the aerial firefighting personnel as sounding “overwhelmed”.

Visibility over the fire area during the entrapment and the effectiveness of air tankers due to smoke has been discussed before on Wildfire Today. According to the article, an air attack person said about the entrapment:

We have a crew in trouble. We are going to go look. … It was just a sea of black. … There was too much smoke.

In discussing the predictions of the weather moving into the fire area which caused the fire to change directions and increase in intensity, a meteorologist wondered at what point, during a chaotic incident like that, does weather information need to be translated into direct decision-support actions.

Below are some excerpts from the article.

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“A group interview with four Blue Ridge Hotshot crew members provides the first detailed account of the day they spent working near the Granite Mountain team. The U.S. Forest Service, which employs them, refused to allow them to be interviewed for the workplace-safety investigation.

In one set of notes, members of the Air Attack crew — responsible for surveillance and assistance to air tankers — told investigators they did not realize they were in charge until minutes before the fatal burn-over, when another aircraft abruptly left the fire.

The air-crew members said they weren’t sure where to make fire-retardant drops as the blaze reversed directions and bore down on Yarnell with a 2-mile- long wall of flame.

At that moment, according to the interview notes, they heard a distress call over the radio — apparently from the Granite Mountain Hotshots — and called a ground supervisor to ask, “Do we stop and go look for the crew?” The answer came back: “No, they’re safe.”

Eric Marsh, a division supervisor with the Granite Mountain squad, calmly reported that they were OK, but moments later, the crew began calling for help, and Marsh followed with an announcement that the crew was trapped and would be deploying its fire shelters. [Note from Bill: according to previous investigation reports, the “calling for help” did not come “moments later”. It was much later.]

“I looked at (another crew member), and he did this (slash across the throat),” the Air Attack flier said in the interview. “We have a crew in trouble. We are going to go look. … It was just a sea of black. … There was too much smoke.”

[…]

Throughout the interviews, key figures in the fire-suppression effort criticized almost every aspect of planning, oversight and execution.

Members of the Blue Ridge crew said they dealt with a leadership dispute among supervisors and got no instructions, records show. They characterized the overall operation as “total non-stop chaos” and “Swiss cheese” because it was so full of holes.

[…]

The Blue Ridge members said that they witnessed “a near miss” with aircraft, who they described as sounding “overwhelmed” adding that “the air show seemed troublesome.”

[…]

Keeping track of the treacherous weather conditions also proved problematic before the tragedy. Some personnel said they hadn’t received updates; others had. Chuck Maxwell, a predictive meteorologist at the Southwest Coordination Center, told investigators that as storms moved toward the fire in the early afternoon, he warned about shifting winds. Maxwell believed there was “a generally high degree of situational awareness” about the approaching thunderstorm and its impacts.

In a separate synopsis recounting June 30, however, Maxwell wrote, “Things were in relative chaos” on the Yarnell and another blaze near Kingman that was competing for resources. Maxwell said he warned that conditions in Yarnell were similar to those that led to multiple fatalities in the Dude Fire.

He questioned whether he should have personally warned firefighters to get to safety, noting that his job was to support commanders and not get in the way.

“At what point within the chaos of an incident like this,” he wrote, “does the weather information need to be translated into direct decision-support actions?” “

Photos from the Arizona OSHA meeting about Yarnell Hill Fire fatalities

Marshall Krotenberg, (left) Arizona Division of Occupational Safety and Health Safety Compliance Supervisor
Marshall Krotenberg, (left) Arizona Division of Occupational Safety and Health Safety Compliance Supervisor, explains his recommendations to members of the Industrial Commission of Arizona.

Tom Story shot these photos today at the meeting in Phoenix where 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 and approved by the Industrial Commission of Arizona.

We have more on the fines and today’s investigation report about the fatal fire.

Thanks for the photos Tom.

Industrial Commission of Arizona Vice Chair Susan Strickler
Industrial Commission of Arizona Vice Chair Susan Strickler, questions Marshall Krotenberg, (left) Arizona Division of Occupational Safety and Health Safety Compliance Supervisor, during his report to members of the Industrial Commission of Arizona.
Marshall Krotenberg
Marshall Krotenberg, Arizona Division of Occupational Safety and Health Safety Compliance Supervisor, explains his recommendations to members of the Industrial Commission of Arizona
Dan Parker, father of Wade Parker
Dan Parker, father of Wade Parker, one of the Granite Mountain Hotshots, talks to the media following the state industrial commission meeting December 4, 2013. 19 members of the Granite Mountain Hotshot Crew, including Wade Parker, perished in the fire.
David Turbyvill, father of Travis Turbyvill
David Turbyvill, father of Travis Turbyvill, one of the Granite Mountain Hotshots, talks to the media following the state industrial commission meeting December 4, 2013. 19 members of the Granite Mountain Hotshot Crew, including Travis Turbyvill, perished in the fire.

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.
Continue reading “State analysis of Yarnell Hill Fire fatalities proposes $559,000 fine for Arizona State Forestry Division”

Arizona State OSHA to release findings on Yarnell Hill Fire fatalities Wednesday, December 4

Granite Mountain HotshotsThe Associated Press and the Prescott Daily Courier are reporting that the Arizona version of the federal Occupational Health and Safety Administration will disclose their version of an investigation into the deaths of 19 members of the Granite Mountain Hotshots on Wednesday. The firefighters were entrapped and killed while suppressing the Yarnell Hill Fire in Arizona on June 30. Their requirements are that the report must be complete no later than six months after their investigation was announced, which would make it due no later than the first part of January, 2014.

The Arizona Division of Occupational Safety and Health will formally present their findings to the Industrial Commission of Arizona, their parent agency, at a 1 p.m. public meeting Wednesday, December 4, in the 1st Floor Auditorium, 800 West Washington, Phoenix, Arizona.

Both media organizations said the agency will recommend citations and penalties against state organizations. An agenda that has been released for the meeting said “Discussion & Action of OSHA Proposed Citations & Penalties. Arizona State Forestry Division, State of Arizona”, but does not mention the Yarnell Hill Fire.

The Arizona State Forestry Division, responsible for the management of the fire, released a Serious Accident Investigation report on September 28, 2013. That report, produced by an army of 54 people, found:

The judgments and decisions of the incident management organizations managing this fire were reasonable. Firefighters performed within their scope of duty, as defined by their respective organizations. The Team found no indication of negligence, reckless actions, or violations of policy or protocol.

Prescribed fire photos

Prescribed fire, Indiana Dunes National Lakeshore
Prescribed fire, Indiana Dunes National Lakeshore near Ogden Dunes in northwest Indiana, NPS photo.
Prescribed fire, Kaibab NF
Prescribed fire, Kaibab National Forest, Arizona, “Wrd Mccracken CP”, November 13, 2013 Inciweb photo
Tunnel Hill Prescribed fire
Tunnel Hill Prescribed fire, Arapaho-Roosevelt National Forest, Colorado, November 14, 2013. USFS photo.

Evacuation and planning during Yarnell Hill Fire criticized

There are reports that residents said they were not notified about evacuation before the Yarnell Hill Fire burned into their town and fled only after they saw the nearby wind-driven fire approaching their house.

Yarnell Hill Fire burns into Yarnell, Arizona
Yarnell Hill Fire burns into Yarnell, Arizona, June 30, 2013. Photo by Joy Collura.

An article written by reporters for the Arizona Republic which also appeared in the USA Today provides details about the evacuation of Yarnell and Glen Ilah, Arizona when the Yarnell Hill Fire burned into the town destroying 127 homes. The article reports that some residents said they were not notified and fled only after they saw the nearby wind-driven fire approaching their house.

The fire burned into the towns on Sunday, June 30, the third day of the fire, the same day that 19 members of the Granite Mountain Hotshots were entrapped and killed. The plans the fire organization had in their heads called for short time frames to notify residents and for them to get out of the community. Below is an excerpt from the article:

On that Sunday, residents watched the fire and smoke plumes grow. The wind was blowing the fire toward Peeples Valley, about 3 miles to the north.

That morning, automated emergency alerts went out by phone, text and e-mail to Yarnell residents: Be prepared to evacuate. You will have an hour to get out if evacuation is ordered. You will get another notice beforehand.

State fire officials had established three geographic landmarks that would act as evacuation “trigger points” when the fire reached them. The first, fire officials thought, was far enough away to give residents an hour to get out, according to an investigative report on the fire. A second trigger was set to evacuate firefighters. The third was set for the edge of Yarnell. If flames got there, everyone would have to get out immediately.

[…]

According to the investigative report, a fire official who wasn’t named said the evacuation trigger points were off by more than 50%, meaning the fire reached key points much faster than expected. “The fire outperformed their expectations, even with many knowledgeable people there,” the report said.

The article appears to say that no written Incident Action Plan (IAP) was prepared until Monday, the fourth day of the fire, the day after the 19 fatalities and the loss of 127 homes:

No fire-action plan was written until Monday, the day after the evacuations.

Written plans, which include decision points for evacuations, are standard procedure early in a fire, said Will Spyrison, a 35-year wildfire veteran who has evaluated fire-commander candidates.

If that is true, that no written IAP was prepared until day four of the fire, that helps to explain some of the chaos, supervision problems, and poor decisions that were evident during the first three days.

We were not able to find any reference to a written IAP in the official investigation report on the fire. On page 15 it mentions that in a briefing on day three some of the attendees “review the area using Google Maps on an iPad”. It also said, “Incoming resources receive a communications plan”. If there was no written IAP, it is very odd that important fact was left out of the report. If there WAS one, that very important document would have been mentioned at least once in the 116-page report.

A written IAP does not have to be 40 pages of flowery language, but by the second day of any uncontained fire there should be a few pages passed out to the fire leaders that at least list the Command and General Staff, the Operations Section chain of command, what resources are available, their assignments, communications, evacuation plan if applicable, structure protection plan if applicable, and a map. To not have any of that in writing by day three is bush league and nonprofessional, and can lead to disorganization and safety issues. Firefighters deserve better.

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UPDATE at 2:29 p.m. MST, November 18, 2013:

We confirmed that there were no Incident Action Plans written for any operational periods until the fourth day of the fire, July 1, 2013. Below is a list of IAPs and maps that the investigation team listed on a web site that has these and other documents related to the fire.

Yarnell Hill Fire, list of IAPs and maps