Lessons learned after the entrapment on Mendocino Complex of Fires

Six firefighters received burns and other injuries when they had to escape from the fire by running through unburned vegetation

fire wildfires crew carrier damaged burned injuries
Crew carrier that was damaged during burnout operations on the Mendocino Complex of Fires August 19, 2018. Photo from the report.

A facilitated learning analysis (FLA) with dozens of valuable lessons learned was just released about an incident where six firefighters were entrapped on a wildfire and had to run to safety through unburned vegetation. The incident within an incident occurred August 19, 2018 on the Mendocino Complex of Fires east of Ukiah, California. Six firefighters received burns and other injuries when the fire crossed a dozer line in multiple locations during burnout operations and cut them off from their planned egress. Some of the firefighters refused treatment, while others were transported to hospitals where they were treated and released.

You can download the entire report here: (large 7MB file).

One thing to keep in mind when you read the lessons learned is that the organizational structure on the fire, which ultimately burned more than 459,000 acres, was very unusual. Two complete Type 1 incident management teams were ordered for the fire due to its enormous size. Normally when there are two teams on a very large fire they divide it into two geographical zones, with each team assuming responsibility for one. Logistically, in this case, there were not enough logistical resources available to support two large incident command posts, so everyone worked out of one base. The two teams were merged into one, which produced duplicates in some overhead positions.

The report was very skillfully designed and written and could be a valuable resource for wildland firefighters.

Below we have a very brief summary from the report of the entrapment, and following that, all of the lessons learned attributed to the personnel who were on the fire, in their own words. We did not include another section from the report that contains analysis from the FLA team.


BRIEF SUMMARY FROM THE REPORT

During burnout operations, a sudden wind shift and explosive fire growth happened and personnel were cut off from their escape routes. Most of the firefighters were able to move back to their vehicles to exit the area. However, six individuals farther down the dozer line were forced to run in front of the advancing flame front, through unburned fuels to a nearby dirt road for approximately one mile before they were picked up and transported for treatment. Five Los Angeles Fire Department firefighters and one CAL FIRE firefighter were injured. Two unoccupied CAL FIRE emergency crew transports parked in the vicinity sustained damage from the fire when it jumped containment lines.


LESSONS LEARNED BY THE PARTICIPANTS

Interviews were conducted with key personnel involved in the entrapment on the Ranch Fire. At the conclusion of each interview, each person was asked what they learned for themselves from this event and what they believe the greater wildland fire community could learn. The following are the subsequent lessons the participants shared with the FLA Team that they believe could benefit others. When possible, these lessons were written in the words of those interviewed, though a few places lesson were edited for clarity. These lessons were broken into four categories: Aviation, Inter- Crew, Fireline, and Overhead.

AVIATION

  • I’m not sure what lessons I learned could apply to the ground. It is not my job to second guess what folks are doing on the ground. My job is to support them and give them our perspective to help them to succeed. They use our input as another tool.
  • Let incoming aircraft know what type of response they are being requested. This is what it would sound like, “Declare an IWI and have them report to Mendo IP (initial point – aviation) for an IWI.”
  • We had an awareness of not taking risks that would incur potential damage or injuries or add more complexity. There is a balance when you are dealing with a life threatening situation that we didn’t make things worse, i.e. compromise ourselves in poor visibility. We ordered additional support to maintain span of control. We immediately ordered up additional support and didn’t try to tackle it ourselves. Didn’t want to be a liability.
  • Declare an IWI when injuries are discovered and follow IWI protocols so communication is clearer. Not declaring this an IWI created a lot of confusion because others did not understand the extent of the injuries or people involved.
  • I knew the voice on the ground so I did not provide decision points or trigger points. I just gave him the facts based upon what he was seeing. If it was someone else, I might have said no to the operation (in reference to when Dep. Branch II was asking about location of the fire for the burnout operation).

INTER-CREW

  • Everybody has a responsibility to run a risk management profile and use Crew Resource Management.
  • Ask questions when something does not make sense to you.
  • Ensure you and your resources are briefed thoroughly and information is flowing. People need to understand the assignment and have buy in.
  • Maintain transparent communication between resources and within your crew.
  • Speak your mind if something does not feel right. Make sure your voice is heard and understood when doing so. Validate subordinates concerns by passing them up the chain of command. If you are asked a question and don’t have an answer, re-evaluate.
  • Trust but verify. You will receive intel from other resources, but validate that information for yourself. Gather your situational awareness.
  • Rely on your experienced personnel within the group, no matter what position they hold.
  • Do not let urgency influence your actions.

FIRELINE

  • Remain vigilant and consider the worst-case scenario. Play the “What if?” in your mind.
  • Take the time to assess the situation and determine if it fits an IWI circumstance. ”I was mad at myself for not following the IWI in the 206.”
  • Good communications are critical. Validate the information you are given. Take time to scout the line. The best thing to do is ask questions for the things that are unknown and communicate with your people frequently.
  • Have the courage to turn down an assignment.
  • Vulnerability and approachability are key traits of a strong leader.
  • There was a perception that refusing an assignment could get you less desirable jobs or reassigned on the fire.
  • Rank adds to the confusion and tension around speaking up.
  • I think the dysfunction and disconnect between commanders intent and what was happening in division and branches was a contributing factor to the very rushed firing operation.
  • The CAL FIRE/Fed rivalry was evident on this fire and I believe it was a detriment to the operational tempo and production.
  • Help your supervisors and use humble inquiry to have a discussion about tactics. Do things make sense? What is the end state?
  • There was no good vantage point for the lookout. Our perception is that a lookout can see the fire but is maybe in a less than desirable location.
  • If you don’t get a good briefing, ask for it. Make sure to receive a thorough briefing from supervisors.
  • I think we need to encourage a culture of voicing concerns in a professional manner. Leadership needs to be approachable. I’ve been a metro firefighter for more than 30 years.
  • I’ve only been in wildland for 6 years, and I’m like born again after doing some structure protection just a few weeks before on another fire (burning out around six homes, we saved five of them). I really believe in that – this highly influenced my decision to accept the assignment. Huge mistake.
  • PPE. We have it for a reason. Wear it all appropriately, in particular shrouds and gloves.

OVERHEAD

  • Who can call for a “Roll Call” to ensure everyone is accounted for? Should it be done at the division or with the Team?
  • Command channel was never cleared. Weather was read over Command during the incident.
  • It was a difficult unified command. We typically go unified with an IC and maybe OPS, but not unified with two whole teams.
  • Trying to meld two Type 1 teams is not advantageous. There are too many voices and it muddies the water. That was happening on this incident. Having Deputy Branches was a side effect of blending two teams together. We had different operational mindsets and they weren’t communicating clearly enough. If we ever have two Type 1 teams again we need to address this more clearly.
  • Don’t get down into the weeds. This is very difficult when there is a Branch and a Deputy Branch. They need to stay up and out of weeds.
  • Don’t use deputy branches. I will fight tooth and nail not to have a Deputy Branch again. Next time I can isolate branches, make them smaller or broken apart.
  • Regardless of how good the plan is, timing is a critical element of the development of the plan. Sometimes we get wrapped up in the plan and fail to reassess the plan. When conditions changed, we needed to reevaluate.
  • I should have spoken up sooner. When I drove up, I should have voiced more that this was not a viable plan.
  • Put too much time in trying to salvage a line that was already lost.
  • I need to ask more questions to get a clearer picture.
  • Make sure everyone has a clear plan. The basics. LCES. Where are we going? Who is in charge? Leaders Intent, even if briefing has to be hasty.
  • Drop points are not safety zones. TRAs are not safety zones or deployment zones.
  • When you have two teams there can be difficulties like one team pushing for one thing and the other team pushing for another. You have to be more vocal. If we make deputy branches, they have to ride in the same vehicle. They cannot divide and conquer tasks because there is confusion about who is in charge.
  • We created a hybrid of the ICS system. The two ICs got along great. Below OPS is where it got muddled. Both teams had some failures when it came to how we were organized and communicated below us. Once we got feedback from the field, we cleaned up and it went better. There are definitely ways to make it work better.
  • I should have come up on Command and at least notified the medical unit there was an IWI. I should have forced myself to help Branch check those boxes. I’ve been thinking how I could have helped. “At all costs you have to address what you feel isn’t safe.”
  • I’m not blaming CAL FIRE or the Forest Service, I’m blaming human nature. We have to let go of what’s on your shoulder [referring to the organization/agency patches].
  • Talk to each other. We have qualifications for a reason. At the end of the day, we have to work together and realize there are good people out there in all agencies. Talk with people to determine their experience levels and comfort in different fuel types, conditions, etc. If someone is a qualified division, they are qualified. Base actions on the complexity of what the fire is going to do instead of I don’t know this guy or trust him so I’m going to just take this on myself.
  • It took too long for the FLA team to get here. Quite honestly, we were talking to you seven days later. Guys were barely at the hospital when I requested a team. Bring someone in to look at this objectively. I’m a little frustrated that it took a while to get here.
  • When we decided to meld the teams, we asked for Agency Administrators and Incident Commanders to get together and have a frank discussion behind closed doors. I believe that should happen more.
  • Letter of delegation is not real. You need closed-door discussions and talk about it. This settled things down a bit. It might be a best practice.
  • I believe that CAL FIRE and Forest Service are going to work together in the future. Anytime we are going to do that we need to work out HOW beforehand. Every time we have worked out something it’s been during a fire and that’s not the time to do that. We need to look at how both sides operate and drill down how it works and whose going to do what, before the fire bell rings. On the dirt, we fight fire, and it shouldn’t be that different on the teams.
  • For me personally, as Operations when I am in the field I try not to be overly involved in tactics so I don’t know all the details of what has already being looked at. If you get too involved you can get things messed up. I should have spoken up sooner. When I drove up I should have voiced more that this was not a viable plan. Looking back, we should have just fired out to protect people. I took for granted that was what was going on.
  • Branch was calm when the separation happened. He handled it well. It was textbook on how to help folks that are cut off and running. He asked for resources and kept his voice calm. Once the message was passed to all resources that we would shelter in place in the saddle we realized it was not the best place for a safety zone. People stayed calm, folks understood what they needed to do, and it allowed Branch to deal with separated folks.
  • Peer support is important. Having CISM there was awesome. They had a couple of therapy dogs. We now want to have a permanent CISM and dog on our team.
  • OPS leadership out there at the time helped people. They had their heads down on the mission and OPS being there may have helped them survive.
  • We recognized radiant burns can be misdiagnosed or dismissed as minor or superficial. Blisters and swelling can occur many hours later. The burns need to be looked at by a specialist and we had to convince the doctor to get referral to a specialist. We also had firefighters refusing treatment. One firefighter that went in had red ears the night before and the next day they looked like cauliflower. We need a universal protocol.

911 call from entrapped dozer operator: “Don’t risk anybody’s life for mine”

(Published at 8:30 a.m. PDT October 22, 2018)

During the Carr Fire earlier this year at Redding, California a dozer operator entrapped by the rapidly spreading fire told a 911 operator, “Don’t risk anybody’s life for mine”.

The Redding Searchlight obtained the recording of the July 26 call in which the dozer operator said there were two other dozers with him and, “There’s a CAL FIRE pickup just exploded right in front of me. I think the guy didn’t get out.”

“I don’t know if the two guys behind me are alive,” the man told a dispatcher, possibly referring to the other two dozers working with him.

There were two deaths that day on the Carr Fire, but the 911 caller who identified himself as “Don”, was not one of them. Redding Fire Department Inspector Jeremy Stoke was burned over in his truck on Buenaventura Boulevard, not far from the location of the caller. On the other side of the Sacramento River, the west side, Don Ray Smith was entrapped and killed in another dozer.

The caller said the windows in his dozer had been blown out and he had lowered his curtains, referring to the drop-down curtains made of fire shelter material that can reduce the amount of radiant heat entering the cab.

Below are excerpts from an article at the Redding Searchlight:

“Don’t risk anybody’s life for mine, but as soon as it lays down…” he trails off in a 911 call obtained by the Record Searchlight on Friday in response to a California Public Records Act request. “As soon as it lays down, send somebody for me, please?”

“I’m in a dozer. All the windows got blown out. I got my curtains down,” he starts off telling the dispatcher.

“OK, sir, I need you to get out of there,” she tells him with urgency.

He’s still calm as he tells her the horrifying truth.

“I can’t.”

‘I don’t know how long I can last’

According to a Green Sheet report by CAL FIRE, the conditions that resulted in the entrapment of the three dozers and the Redding Fire Department Fire Inspector that day were due to a fire tornado — a large rotating fire plume that was roughly 1,000 feet in diameter. The winds at the base were 136-165 mph (EF-3 tornado strength), as indicated by wind damage to large oak trees, scouring of the ground surface, damage to roofs of houses, and lofting of large steel power line support towers, vehicles, and a steel marine shipping container. Multiple fire vehicles had their windows blown out and their bodies damaged by flying debris.

The strong winds caused the fire to burn all live vegetation less than 1 inch in diameter. Peak temperatures likely exceeded 2,700 °F.

The conditions described by the 911 caller, including his location and the fact that he was with two other dozers, are consistent with the section of the Green Sheet report describing the entrapment of  three pieces of equipment identified in the document as Dozer 2, Dozer 3 and Dozer 4. Wildfire Today covered this report on August 20. Below is an excerpt from the section about the three dozers:


(From pages 13-14)
At approximately 8:02 p.m., Dozer 2, Dozer 3, and Dozer 4 continued northbound on Buenaventura Boulevard toward Keswick Dam Road. Approximately one-half of a mile from Land Park, all three dozers were violently impacted by flying debris, rocks, embers, smoke, and intense heat. The flying material shattered windows on all three dozers. As hot air entered the cab of Dozer 2, the operator repositioned the dozer and parked next to Dozer 3. When Dozer 3’s windows shattered, airborne glass entered the operator’s eyes. Dozer 3 stopped on Buenaventura Boulevard and deployed his fire curtains.

Carr Fire fatality report
From the CAL FIRE Green Sheet Report.

Dozer 4 became disoriented when impacted by the flying debris. As a result, the dozer hit a civilian vehicle that was stopped along Buenaventura Boulevard. The impact caused the dozer operator to land on the floor of his cab. The dozer continued to travel until it came to rest against a tree. Once stopped, the operator tried to drop the fire curtains. Due to burn injuries on his hands, he was unable to manipulate the straps, and had to cut the straps with a razor knife to deploy the curtains. He successfully dropped three out of the four curtains. The operator then deployed a fire shelter. In order to escape the intense heat, he exited the cab and sought refuge under the dozer, but saw a tree blocking his route. When the dozer operator reentered the cab, he saw emergency vehicle lights on Buenaventura Boulevard. He ran up to the vehicle where PREV1 directed him into the backseat. Once in the pickup truck, the dozer operator noticed there was also a civilian in the vehicle.

Prior to the rescue of the Dozer 4 operator, at approximately 8:01 p.m., PREV1 and SUP1 exited north on Buenaventura Boulevard from Land Park and Stanford Hills. SUP1 was now travelling back out of the subdivision with the evacuated family members.

Both PREV1 and SUP1 drove slowly, due to the heavy smoke conditions. Both vehicles were in close proximity to each other. As they approached the general area where the three dozers were stopped, PREV1 saw a civilian vehicle on fire. SUP1 passed PREV1 as he slowed to a stop. SUP1 continued north approximately 150 feet when both of their pickup trucks were suddenly impacted by flying debris, rocks and embers.

SUP1’s vehicle began to shake violently, and the passenger windows shattered. SUP1 ducked down to avoid being hit by flying debris and he momentarily drove off the road. SUP1 regained control of his vehicle, drove back onto the road, and exited the area to the north.Carr Fire fatality report

As PREV1 slowly approached the burning vehicle, he felt his pickup truck get “pushed” from the west. All the windows in his pickup truck except the windshield shattered. PREV1 took refuge in his vehicle. Approximately 30 seconds later PREV1 observed a male civilian attempting to get in his pickup truck. PREV1 directed the civilian to get in the back seat. Moments later, PREV1 saw a second individual (Dozer 4 operator) running toward him wrapped in a fire shelter. PREV1 directed the dozer operator into the back seat. PREV1 asked if they were injured. The dozer operator indicated that his hands were burned. PREV1 notified Redding ECC that he had a burn victim.

Six firefighters injured escaping from sudden flare up

The six firefighters on the Mendocino Complex of Fires in Northern California had to run for a mile through unburned vegetation when an unexpected wind shift caused explosive fire growth

The following “72-Hour Report” was distributed by the Wildland Fire Lessons Learned Center August 28, 2018 for an incident that occurred August 19, 2018 on the Mendocino Complex of Fires in Northern California.


THE FOLLOWING INFORMATION IS PRELIMINARY AND SUBJECT TO CHANGE

Location: Ranch Fire, Mendocino Complex, east of Ukiah, CA
Date of Occurrence: Sunday, August 19, 2018
Local Agency Administrator: Ann Carlson, Mendocino Forest Supervisor
Activity: Wildland Fire Suppression
Number of Injuries: 6
Number of Fatalities: 0
Property Damage: Radios, packs, 2 vehicles with paint blistering.

SUMMARY

On August 19, 2018, six firefighters received injuries when the fire crossed the dozer line in multiple locations and cut them off from their planned egress. At the time of the incident, firefighters were en-gaged in firing operations off a dozer line near the division break between Hotel and Juliet on the Ranch Fire of the Mendocino Complex.

CONDITIONS

Information from RAWS nearby around the time of this incident, showed temperatures at 93.3 Fahren-heit, RH 11.3%, and winds at 6.6 mph with gusts to 13.3 mph.

NARRATIVE

The Mendocino Complex consisted of the Ranch and River fires that started on July 27th. The fires experienced significant growth during the first ten days, growing 30,000 acres on August 3rd, 40,000 acres on August 4th and 50,000 acres on August 5th. Up until August 19th, the fire growth had been steadily moving both south/southeast and north/northeast. Most days experienced warming and drying trends with very poor recoveries and critically low fuel moistures and afternoon relative humidities near single digits. Steep terrain, poor ventilation, fire intensities and long travel times made it difficult to insert crews and utilize aircraft in certain areas of the fire.

On August 19th, the plan for the fire’s northeast flank was to secure dozer line north of DP25 near the division break in Branch II with a firing operation. Resources from other divisions were brought over to help with the operations. These resources included federal and local fire resources and strike teams from the Los Angeles Fire Department and CAL FIRE. After arriving near the drop point, the personnel staged their engines and vehicles, reconfigured, and were split into two modules to support burning operations and hold the line along a Forest Service road and the dozer line.

During the burnout operations, a sudden wind shift and explosive fire growth happened and at about 1733, personnel were cut off from their escape routes. Most of the firefighters were able to move back to their vehicles to exit the area. However, six individuals farther down the dozer line were forced to run in front of the advancing flame front, through unburned fuels to a nearby dirt road for approximately one mile before they were picked up and transported for treatment. Five Los Angeles Fire Department firefighters and one CAL FIRE firefighter were injured. Two unoccupied CAL FIRE emergency crew transports parked in the vicinity sustained damage from the fire when it jumped containment lines.

Injuries include 1st and 2nd degree burns and a dislocated shoulder.

Report released for entrapments on Horse Park Fire

Above: photo from the report.

Additional information has been released about the entrapments that occurred on the Horse Park Fire May 27 in a remote area of Southwest Colorado. Earlier we posted two videos that were shot when firefighters hurriedly retreated as the fire advanced, plus information from a “72-hour report”.

Now a 56-page Facilitated Learning Analysis and a 12-minute video are available that break down the incident in even more detail.

To very briefly summarize what happened, while scouting a road for a potential burnout operation, a hotshot crew superintendent and foreman encounter a wall of flames and attempt to retreat. Their truck becomes stuck, forcing them to flee on foot, narrowly escaping the rapidly advancing fire front. Just as they reach safety, they learn that their crew lookout is missing. After nearly 40 agonizing minutes, the lead plane pilot locates her after she ignited an escape fire. It is a compelling story, which is pretty well summed up in this video.

The 56-page report only has one recommendation:Recommendation horse park fire

Information released about entrapment on 2016 Canyon Fire

Dozens of firefighters were entrapped and endured a harrowing escape through very thick smoke and flying embers.

Above: an image from the official report, showing the conditions as firefighters were making their way to the safety zone.

The Wildland Fire Lessons Learned Center has released a review of the entrapment of dozens of firefighters that occurred six months ago on the Canyon Fire at Vandenberg Air Force Base.

On September 19, 2016, two days after the fire started, approximately 50+ firefighters were assigned to Division Zulu on the north side of Honda Canyon (about a mile east of the site where four Air Force firefighters were entrapped and killed on the Honda Fire in 1977).

Assigned to the division on the Canyon that day in 2016 were 8 engines, 4 dozers, 1 water tender, and a 20-person hand crew comprised of 3 helitack crews. All were ordered by the Division Supervisor to take refuge in a safety zone.

Canyon Fire entrapment
3-D map of the Canyon Fire looking east. The red line was the perimeter of the Canyon Fire at 11 p.m. PDT September 20, 2016. The white line was the perimeter at approximately 11 p.m. September 19.

After observing conditions that morning last September the tactic decided on was to fire out the ridge on the north side of Honda Canyon, which runs east and west. The main fire was to the south on the other side of the canyon. The operation was going well until the intensity in the burnout increased dramatically; fire whirls developed and the fire began spreading to the west more quickly than the igniters and holders could keep up with it.

The Division Supervisor ordered, “All Division Zulu resources pull back to the safety zone”. Even though some of the personnel were about 600 to 700 yards from the safety zone, the smoke-obscured visibility occasionally made movement difficult or impossible. At times the engines had to stop when they could not see the ground in front of them. Burning embers, some of them fist-sized, pelted the vehicles and the 20 people in the hand crew that were walking to the safety zone.

In the video below, it appears to have taken about 10 minutes to travel the 600 to 700 yards. The recording shows how harrowing it must have been as day turned to night. At least two firefighters were later transported to a hospital suffering from smoke inhalation injuries.

The video is incredible and at times has on the screen views from three different cameras, apparently time-synced. Pretty impressive editing (by Mark Pieper and Tony Petrilli) for a government-produced video. The maps and annotated still images are also very useful.

Canyon Fire entrapment
A screenshot from the video, at minute 7:39.

Some firefighters, approximately two, removed their fire shelters from their gear. One was fully deployed and another was partially unfolded.

From the report:

When asked: “How scared were you on a scale of 1 to 10?” multiple crew members replied “9” and “10.”

We covered the Canyon Fire as it was burning and thought we were aware of the major developments at the incident, but we did not hear about this entrapment until today, March 27, 2017. Maybe we missed it, but it is possible that the fact that it occurred on a military base influenced an apparent desire to keep it low key, even though a California Type 2 Incident Management Team had assumed command of the fire the morning of the incident and, according to the report, “did start Regional notification regarding the shelter deployment”.

The Incident Commander and the Deputy IC were first notified more than three hours after the entrapment.

In spite of the late release of the information, firefighters can benefit from this lessons learned opportunity and the fact that the preparers of the report conducted it in such a way that there were apparently few if any efforts among those involved to “lawyer up” and shut up fearing litigation or prosecution. Many still and video images were made available and at least enough of the firefighters were willing to talk about what happened to allow a useful report to be completed.

Maybe the way this review was conducted can be a template to reverse the recent trend of investigations that are not as useful as they could be.

Honda Fire Fatalities 1977

On September 21, 2016 a Ventura County Fire Department firefighter was killed in a vehicle accident while responding to the Canyon Fire. Fire Engineer Ryan Osler, a passenger in a water tender, lost his life. The driver of the truck self-extracted and was transported to a local hospital with minor injuries.

Articles on Wildfire Today tagged “Canyon Fire”.

Five Corsica firefighters entrapped and injured

Above: Two of the fire engines that were entrapped on Corsica. The engine on the left appears to have small water nozzles on the bar that encircles the top of the cab.

During night firefighting operations on the island of Corsica overnight on March 24 and 25 three fire vehicles were entrapped by the fire resulting in five firefighters suffering first and second-degree burns. Some of the firefighters, it is not clear how many, took refuge in one or more of the fire engines that had vehicle protection systems consisting of water nozzles positioned around the truck that could be activated as needed.

Engine protection system

The fire occurred in the French commune of Bastelica in southern Corsica (map). Matthias Fekl, the Minister of the Interior, said Saturday morning:

In the early evening, a group of firefighters found themselves trapped in flames as a result of a change in wind direction. They then took refuge in their vehicles equipped with a self-protection device.

One person is in police custody, suspected of starting the fire.

Three firefighter vehicles were damaged or destroyed in the incident.

damaged fire engines

The fire engine in the above photo appears to be the same one in the photo (on the left) at the top of this article.

Wildland firefighters in Australia have also been using similar engine protection systems for years.