Loop fire, 43 years ago

On November 1, 1966, the El Cariso Hotshots were trapped by flames as they worked on a steep hillside in Pacoima Canyon on the Angeles National Forest.

Ten members of the crew perished on the Loop Fire that day. Another two members succumbed from burn injuries in the following days. Most of the nineteen members who survived were critically burned and remained hospitalized for some time.

Lessons learned from the Loop Fire resulted in the checklist for downhill line construction, improved firefighting equipment, better fire behavior training, and the implementation of new firefighter safety protocols.

Findings from the Andrew Palmer safety investigation

After reviewing the “Accident Investigation: Factual Report” of the tree falling accident on the Dutch Creek Fire in which Andrew Palmer was killed, Wildfire Today compiled these findings, causal factors, and contributing factors from the document.

Findings

  • EM-CAPT was given a line assignment without adequate supervision for the assigned task. FC2 failed to exercise proper supervisory control by allowing EM-CAPT to cut trees above EM-CAPT’s level of certification.
  • Excessive motivation for EM to obtain a line assignment led to a series of inadequate communications and assumptions which subsequently led to a mismatch between resource request and resource assignment.
  • A class C tree was felled by an unqualified sawyer. Escape routes/safety zones were not effectively utilized by FC1.
  • There was insufficient pre-planning to integrate incident personnel and resources into the local emergency management system, taking into account local factors, including environmental conditions, to effectively manage a serious injury and the subsequent medical evacuation.
  • Inadequate leadership, communication, and risk management resulted in a lack of clarity in communicating the severity of the injury, resource availability, and a failure to evaluate the most appropriate method of evacuation relative to risk exposure, resources required, and timeliness.
  • The incident was operating with inaccurate or incomplete IAPs.
  • The National Park Service fleet management procedures for quality control are inadequate to ensure mission ready condition of new wildland fire engines and to appropriately handle maintenance and repair issues.
  • Iron Complex Ground Support failed to take appropriate measures to red tag EM’s engine.

Tree falling findings

  • Tree 1 was a class C tree. The stump measured 36.7” in diameter at the point the cut was made.
  • The highest saw qualification of any of the crew members present was that of a faller B.
  • The undercut of Tree 1 was not cleaned sufficiently as to provide an adequate “hinge” to direct Tree 1 during the felling process.
  • The undercut of Tree 1 exhibits two distinct horizontal (gunning) cuts and two sloping cuts. Multiple Dutchmen that would have altered the holding wood were also present.
  • Tree 1 fell away from its intended lay due to lean, possible limb weight, and an inadequately cleaned undercut.
  • Tree 1 appeared to have been a sound, green tree with no readily apparent defects that would have required it to be felled as a hazard tree.

Medical Treatment

Causal Factor

  • Failure to adequately control FC1’s arterial bleeding of the left femur injury received during a tree falling accident resulted in death due to excessive blood loss.

Contributing factors

  • There was inadequate accident scene command and control which led to a failure to communicate the extent and severity of the injuries and to evaluate the most appropriate evacuation method.
  • There was a delay in delivering FC1 to definitive medical care because personnel involved in the incident focused on the use of air resources, most of which were unavailable due to the smoky conditions.

The accident report is HERE.

Andrew Palmer fatality report released

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Andrew Palmer, NPS photo

The National Park Service has released the report about the accident in which an NPS firefighter, Andrew Palmer, died. Mr. Palmer was killed during a tree falling incident on the Eagle fire, part of the Iron Complex on the Shasta Trinity National Forest in northern California on July 25, 2008. He was a firefighter at Olympic National Park in Port Angeles, Washington.

Here is a link to the report.

Below is the complete executive summary from the factual report:

Early in the day on July 22, 2008, an engine from Olympic National Park received a resource order to report to the Iron Complex, on the Shasta-Trinity National Forest, near Junction City, California. The crew and line supervision at the park were so motivated to see the engine crew obtain an immediate assignment that the NPFMO accepted the resource order despite not being able to contact all crew members who were on their day off. NPFMO tried all day to contact the crew and eventually assembled and dispatched the crew at 2100. Despite a late start and a series of complications enroute to the fire, which included mechanical problems with their engine that lead to the separation of their crew and engine captain, the remaining crew members were encouraged to continue to pursue a line assignment as a falling team. Because Incident Management personnel were equally motivated to find a line assignment for the eager crew, the crew was ultimately given an assignment as a falling module that they were not qualified for and without qualified first or second line supervision. During that assignment the crew cut a tree that was outside their falling qualifications, which resulted in the injury of FC1.

Upon arrival to the Incident Command Post on July 23, EM reported mechanical problems with the engine that required CAPT to drive the vehicle into Redding, California for warranty service. EM-CAPT stayed at ICP and on July 24, were given a logistical assignment in camp. On July 25, while CAPT was attempting to obtain a replacement engine from Whiskeytown National Recreation Area, EM-CAPT were given an assignment as a falling module to Division B on the Eagle Fire. The assignment was to mitigate hazard trees along the fire line, so crews could safely work in the area. At approximately 1350, FC2 called ICP for medical assistance for severely injured FC1. Emergency medical personnel responded and treated the injured FC1 for severe bleeding. Due to heavy smoke conditions requiring Instrument Flight Rule (IFR) capability, primary helicopter resources were unable to respond to FC1’s location. Firefighters carried FC1, by litter, to a location where FC1 was hoisted into a United States Coast Guard Helicopter, at approximately 1630. The USCG helicopter carrying FC1 arrived at Redding Municipal Airport, where FLN, in consultation with a Mercy Hospital Emergency Room Physician, pronounced FC1’s death at 1710. The Coroner later determined the cause of death to be blood loss due to blunt force trauma to FC1’s left leg.

The report includes this statement on the page before the executive summary:

SAIT Disclaimer

Based on all evidence available to the SAIT, we know that FC1 was injured from being struck by a tree during a felling operation. From the time of the accident, until the preparing of this report, no individual member of EM-CAPT could be positively identified, nor excluded from being the sawyer at the time of the accident.

Evidence collected by the SAIT included 54 manual and electronic time-stamped documents. These documents were collected from multiple entities, in three different counties. Comparing documents that logged the same event, the SAIT noted time stamps often varied by 5 to 10 minutes.

“SAIT” is the Serious Accident Investigation Team.

Page 87 of the report includes this information:

Technical Assessment of Accident Site

Due to the lack of eye-witness accounts, a number of key facts are unclear; therefore actual events have been pieced together from interview statements and evidence at scene. FC2 and FC3 are the only surviving witnesses to the accident and they have not granted interviews to the Serious Accident Investigation Team. While it is impossible to determine at this time who actually fell Tree 1, it is possible for experienced observers to read the stump, the lay of the felled tree, and the felling area to determine how the felling of Tree 1 set into motion the sequence of events that lead to FC1 being injured.

On page 5 of the report is a description of the accident:

A decision was made to fall a large ponderosa pine (36.7” at the point of the cut). Downslope from the ponderosa pine was a 54” DBH sugar pine that had an uphill lean and a large cat face on the uphill side. When cut, the ponderosa pine fell downslope toward the sugar pine. It was contact with the sugar pine, or vibration from the ponderosa hitting the ground, that caused a portion of the sugar pine, approximately 120 feet long, to break off and fall upslope, hitting FC1 resulting in severe injuries.

The report includes the information that on August 6, 2008 the Serious Accident Investigation Team (SAIT) gave the case file to a National Park Service Special Agent. On August 7 the SAIT was “disengaged” from the “safety investigation” until further notice.

On January 26, 2009 the Federal Prosecutor issued a “Declination of Criminal Charges related to the death of FC1”. In early March the safety investigation resumed. The SAIT completed their report on May 18, 2009.

Esperanza fire, three years ago today

Five U.S. Forest Service wildland firefighters were entrapped and died on the Esperanza fire near Cabazon, California on October 26, 2006. Killed were engine Capt. Mark Loutzenhiser, 44, of Idyllwild; engine operator Jess McLean, 27, of Beaumont; assistant engine operator Jason McKay, 27, of Phelan; and firefighter Daniel Hoover-Najera, 20, of San Jacinto. A fifth firefighter Pablo Cerda, 23, of Fountain Valley, who was injured along with the other four, passed away on October 31. The five firefighters comprised the crew of a wildland engine, Engine 57, from the San Bernardino National Forest. They were assigned to a state managed fire approximately 60 miles east of Los Angeles and were entrapped while protecting a structure.

For more info:
Esperanza Fire Factual Report, and the USDA Office of Inspector General’s Report on the fire.

Widow of firefighter killed during chain saw training sues fire department

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John Curry. Photo: Volusia County Fire Services

The widow of John Curry, who was killed during tree felling training in Florida on November 27, 2007, is suing the Volusia County Fire Services. Kristen Curry is claiming a “lack of training, instruction, preparation and warning” led to her husband’s death.

Wildfire Today covered this accident on April 7, 2009 when the report was issued:

Curry was 30 years old and had been a member of Volusia County Fire Services  for 10 months. He was training to be a member of the elite Firewalker Wildland Team and left behind a wife and two children.

The incident occurred during a training class at the Volusia County Fire Training Center near Datona Beach, Florida.

According to the report the trainees watched only 2 hours of a 4 hour training video. Then during tree felling field training, the cuts on an [18-inch] pine tree were not completed properly, causing the tree to fall in an unexpected direction.  It fell onto Curry’s escape route, killing him.  The report said there was no one at the training site to keep him from running where the tree eventually fell.

The State Fire Marshal’s office issued a Notice of violation for:

  • Failure to provide adequate training to meet “Trained Commensurate to Duty” requirements.
  • Failure to provide a safe workplace.

The State Fire Marshal’s report is available on our Documents page.

Kristen Curry is seeking compensation for the loss of her husband’s future “support and services”, as well as compensatory damages for her and her son’s mental pain and suffering.

OIG still has not completed investigation into Esperanza fire

Monday will be the third anniversary of the Esperanza fire in which five U. S. Forest Service firefighters died in southern California. Raymond Lee Oyler has been tried, convicted, and sentenced to death for setting this fire, but the U. S. Department of Agriculture’s Office of Inspector General (OIG) has still not completed its investigation.

One of the problems with this is that many people are waiting to hear if the OIG will recommend that criminal charges be filed against firefighters, as happened in two other fires, the Thirtymile and Cramer fires.

The Inspector General, Phyllis Fong, testified before Congress in March that the report would be issued by the end of the month. Now they are saying it will be done by the end of November.

John N. Maclean, the author of “The Thirtymile Fire”, is in southern California right now collecting additional information about the Esperanza fire for a book he is working on. Who knows, his book may be out before the OIG’s report is issued.

The Press Enterprise has an article about the OIG investigation. Here is an excerpt.

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… The delays have caused anxiety and frustration for both the firefighters who fought the 43,000-acre blaze and the families of those killed.

“We’re just waiting. We are surprised it has taken so long,” said Vivian Najera, aunt of firefighter Daniel Hoover-Najera, who was killed in the fire. “All of us have questioned when it is coming out, and we haven’t got any answers. We are anxious to find out what it has to say.”

The investigation is just the third of its kind and was required by a 2002 law mandating the office investigate deaths of federal firefighters killed in burnovers or entrapments.

The five killed in the Esperanza Fire were overrun by flames as they fought to save a lone, unoccupied home near Cabazon.

The two previous investigations led to charges against two fire commanders in the deaths of federal firefighters in Washington state and Idaho. The law was created after the 2001 Thirtymile Fire in Washington state, which killed four firefighters. U.S. Forest Service supervisor Ellreese N. Daniels was indicted on charges of involuntary manslaughter and lying to investigators.

After the 2003 Cramer Fire in Idaho, in which two firefighters died, the U.S. attorney’s office filed charges against that fire’s incident commander, Alan Hackett, who was found to have been negligent in his management of the blaze. However, Cal Fire’s jurisdiction over the Esperanza Fire is a key difference from the previous two cases and one that presented a “unique challenge” to federal investigators,” Fong told members of the House Appropriation Committee during a March 11 briefing. “The fire occurred on non-federal land, and (the Forest Service) was assisting in the suppression effort as part of a cooperative agreement with the California Department of Forestry and Fire Protection, an entity for which OIG has no oversight jurisdiction,” Fong said.

‘TYPICAL,’ ‘FRUSTRATING’

That question of jurisdiction and the relationship between state and federal agencies battling the same blaze is certain to be addressed in the report. The firefighting community, both locally and nationally, has long awaited the investigation’s findings, said Casey Judd, business manager for the Federal Wildland Fire Service Association, which represents federal firefighters around the country.

“It’s typical of the agency — typically frustrating,” Judd said. “I can’t for the life of me see why the OIG can’t get this out.”

In the aftermath of the fire, the U.S. Labor Department’s Occupational Safety and Health Administration and a joint state-federal task force launched separate investigations of the fire. Not wishing to obstruct the latter, OIG investigators delayed their interviews, Feeney said Thursday.

“This was done to ensure that OIG’s inquiry did not interfere with theirs,” he said. “That decision significantly pushed back the start of OIG’s primary investigative work.”

Both of the earlier inquiries found fire personnel took unnecessary risks.

Killed in the fire were Engine 57 Capt. Mark Loutzenhiser, 43, of Idyllwild; Jason McKay, 27, of Apple Valley; Jess McLean, 27, of Beaumont; Pablo Cerda, 23, of Fountain Valley; and Hoover-Najera, 20, of San Jacinto.

Oyler was convicted of five counts of murder for setting the blaze and was sentenced in June to die.

Relatives of the firefighters and others will gather Monday at 11:30 a.m. at the Cabazon Fire Station, 50382 Irene St. in Cabazon, to memorialize the third anniversary of the fire and the deaths of the five men.

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UPDATE November 12, 2013:

Esperanza Fire Factual Report, and the USDA Office of Inspector General’s Report on the fire.