Draft report released for the Woolsey Fire has 94 recommendations

The fire burned over 96,000 acres and destroyed 1,600 structures in southern California in November, 2018

Above: Progression map of the Woolsey Fire, November 17, 2018. Perimeters produced by the Incident Management Team. Adapted by Wildfire Today.

A draft After Action Review was released by Los Angeles County that details some of the issues that affected the management and suppression of the Woolsey Fire that destroyed 1,600 structures and burned nearly 97,000 acres.

When fire started at about 2 p.m. on November 8, 2018 the humidity was five percent and the wind was gusting out of the north and northeast at 40 to 50 mph. At 5:15 the next morning, Friday November 9, it jumped the 12-lane 101 freeway and before noon it ran for another six miles to the Pacific Ocean, a distance of about 15 miles from the point where it started 22 hours before.

Thursday November 8 was a busy day in California. Just before midnight the night before there was a mass shooting incident leaving 12 dead at a bar in Thousand Oaks, just west of where the fire was hours later. The Camp Fire started early Thursday morning wiping out much of Paradise in northern California before noon. Then the Hill Fire started at about 1 p.m. south of Thousand Oaks about 13 miles southwest of where the Woolsey Fire started an hour later. The Hill Fire eventually burned over 4,500 acres and required the evacuation of 17,000 residents. While firefighters were still initially responding to the Hill Fire the Woolsey Fire ignited at about 2 p.m. Strike teams of engines and crews were already en route to northern California, so right away there was competition for firefighting resources with three major fires burning simultaneously in the state.

The Woolsey Fire started in Ventura County but spread into Los Angeles County. Very large portions of the blaze were in both counties, testing the capabilities of LA City, LA County, and the Ventura County Fire Department. The report states that even though the three organizations “regularly plan for and practice their response to a large fire in the region, they could not have planned for a complete exhaustion of California’s limited firefighting resources brought on by a regional wildfire weather threat in conjunction with the Camp Fire, a mass casualty shooting in Ventura County, and the Ventura County Hill Fire, which began just before the Woolsey Fire started.”

With large numbers of firefighting resources committed to the three major fires, and with the dry, windy weather continuing, many agencies had to think hard about continuing to send more and more firefighters to the Hill and Woolsey Fires in case more incidents broke out. Approximately half the resource orders for the Woolsey Fire were UTF, Unable to Fill.

The fire presented a number of complexities, according to the report:

  • The location and topography, which presented severe challenges for initial attack.
  • The early November sunset, which grounded non-night-flying aircraft.
  • Early and mid-evening wind shifts when the fire was still outside heavily populated areas.
  • The fire’s crossing of the 12-lane Highway 101 before dawn on Friday.
  • The defense of both sides of the populated areas along Highway 101 consumed fire attack resources just as the fire began the run to Malibu.
  • Very limited initial resources in Malibu Friday morning due to fire ferocity and fire- or wind-caused road damage blocking Santa Monica Mountain and Malibu roads, including evacuation routes.

In Los Angeles County 1,075 homes and 46 commercial structures were destroyed. Approximately 57,000 structures were saved.

The After Action Review was written by a consulting firm, Citygate Associates of Folsom, California. The draft 204-page document has 155 findings and 94 recommendations, including:

  • Improve methods and tools for communicating with the public.
  • There was not a clear, single, comprehensive voice speaking to evacuation, and not all notification tools were used or used often enough.
  • There was an over-reliance on Twitter; care must also be taken to account for the digital divide in which not everyone is on Twitter or even the internet.
  • Entry and repopulation policies were not well briefed to checkpoints or the public.
  • There is a need for greater inter-agency pre-incident evacuation and repopulation planning for the communities in Fire Hazard Severity Zones. No pre-prepared traffic evacuation plans/scenarios exist for the areas impacted by the Woolsey Fire. Evacuation plans also need corresponding repopulation plans at the earliest moment.
  • The following are needed to improve situational awareness: Research and investment in emerging technologies to reduce the “fog of war”. Increased practice, procedures, and technologies in melding the large County agency DOCs and Incident Management Teams (IMTs) into a virtual unified command, as if they were in one physical location, to reduce lag time in fast-tempo, complicated decisions. Real-time display of fire perimeter, hazards, actions, shelters, and evacuation orders for public consumption.
  • Improve coordination of multiple-agency emergency public messages.
  • Increase the speed and use of all alerting tools in wide-area, fast-paced disasters.
  • Address the impact of long-distance fire storm ember spotting through education and an emphasis on using layered buffer zones of appropriate defensible space and structure hardening techniques.
  • Encourage the major fire departments in the area to evaluate creating a sub-regional (three county) Multiple-Agency Coordination and Control Center within the State mutual aid system that will utilize technology to enhance situational awareness and create a shared, real-time intelligence, information, and command center on a round-the-clock basis. This concept should further existing agreements and enhance the ability of agencies to work collaboratively during the first one to two days of a catastrophic disaster, for the common welfare, at a pace faster than the Statewide mutual aid system can provide.

The county expects to hold at least two public meetings to present the report and solicit public input.

The Draft Woolsey Fire AAR is a very large 22 Mb file.

Click here to see all articles on Wildfire Today tagged “Woolsey Fire.”

Thanks and a tip of the hat go out to Tom. Typos or errors, report them HERE.

Report released for a firefighter fatality in Texas

Occurred on a wildfire in March, 2018

Texas LODD firefighter 2018 map
The initial firefighting operations with Grass 5-1 and Grass 5-2. The green
arrows indicate the direction of travel for the brush trucks. The red arrow is the
direction the fire is traveling. The time is approximately 1124 hours. (NIOSH)

The National Institute for Occupational Safety and Health (NIOSH) has released a report about a 68-year old firefighter that died from burn injuries while fighting a grass fire in Texas last year.

“Firefighter A” was one of three firefighters on a Brush Truck, Grass 5-1, that was initial attacking a grass fire on March 10, 2018 that was burning in two to three foot high Little Bluestem grass. He was riding on an open side step behind the cab when he fell off and was overrun by the fire. The firefighter was flown to a burn center but passed away March 23, 2018.

Below is an excerpt from the report:


“Grass 5-1 began attacking the fire from the burned “black” area. Grass 5-1 was attempting to extinguish the fire in the tree line and fence line while moving north. A bulldozer was operating north of Grass 5-1. A citizen was operating a private bulldozer independent of the fire department operations. The bulldozer was attempting to cut a fire break in the very northern part of the property ahead of the fire.

“Grass 5-2 arrived on scene at 1121 hours. Another fire fighter from Fire Station 5 had responded in his POV to the scene. He got in the cab of Grass 5-2 at the tank dam. Grass 5-2 went east in the field towards the fence line. The grass fire was near the POV owned by Fire Fighter “B” on Grass 5-1. Grass 5-2 extinguished the fire around the POV and moved north towards Grass 5-1.

“Grass 5-1 reached the head of the fire and lost sight of the bulldozer. The driver/operator of Grass 5-1 attempted to turn around and the wind shifted, causing the smoke to obscure his vision. The driver/operator inadvertently turned into the unburned grass. The driver/operator described the grass as two to three feet tall. The time was approximately 1124 hours.

“The wind shift caused the fire to head directly toward Grass 5-1. Grass 5-1 Fire Fighter “B” advised the driver/operator to stop because they were dragging the “red line” (booster line). Fire Fighter “A” and Fire Fighter “B” exited the vehicle to retrieve the hoseline. The driver/operator told them to “forget the line” and get back in the truck. Fire Fighter “B” entered the right side (passenger) side step and Fire Fighter “A” got back on Grass 5-1 on the side step behind the driver. Fire Fighter “A” had a portion of the red line over his shoulder. When the driver accelerated to exit the area, Fire Fighter “A” was pulled from the apparatus by the red line that remained on the ground due to the gate not being properly latched. Fire Fighter “B” started pounding on the cab of Grass 5-1 to get the driver/operator to stop the apparatus. Grass 5-1 traveled approximately 35 – 45 feet before the driver/operator stopped the apparatus. The time was approximately 1127 hours.

“When Fire Fighter “A” fell off of Grass 5-1, he fell into a hole about 6 – 12 inches deep and was overrun by the fire. The driver/operator and Fire Fighter “B” found Fire Fighter “A” in the fire and suffering from burns to his face, arms and hands, chest, and legs. They helped Fire Fighter “A” into the cab of Grass 5-1 with assistance from the two fire fighters on Grass 5-2. The driver/operator of Grass 5-1 advised the County Dispatch Center of a “man down”. Once Fire Fighter “A” was in the cab of Grass 5-1, the driver/operator drove Grass 5-1 to the command post, which was located near Tanker 5. Fire Fighter “B” was riding the right step position behind the cab of Grass 5-1. The time was approximately 1129 hours. At 1131 hours, the County Dispatch Center dispatched a county medic unit (Medic 2) to the scene for an injured fire fighter.”


Texas LODD firefighter 2018 side step
The side step position on Grass 5-1 showing the gate latching
mechanism and the short hoselines on each sided of the apparatus
(NIOSH Photo.)

Instead of wearing the fire resistant brush gear or turnout gear he had been issued, Firefighter A was wearing jeans, a tee shirt, and tennis shoes.

Contributing factors and key recommendations from the report:

Contributing Factors

  • Lack of personal protective equipment
  • Apparatus design
  • Lack of scene size-up
  • Lack of situational awareness
  • Lack of training for grass/brush fires
  • Lack of safety zone and escape route
  • Radio communications issues due to incident location

Key Recommendations

  • Fire departments should ensure fire fighters who engage in wildland firefighting wear personal protective equipment that meets NFPA 1977, Standard on Protective Clothing and Equipment for Wildland Firefighting
  • Fire departments should comply with the requirements of NFPA 1500, Standard on Fire Department Occupational Safety, Health, and Wellness Program for members riding on fire apparatus

The report referred to an August 17, 2017 tentative interim amendment to NFPA 1906, Standard for Wildland Fire Apparatus, 2016 edition with an effective date of September 4, 2017.

“NFPA 1906 Paragraph 14.1.1 now reads, “Each crew riding position shall be within a fully enclosed personnel area.”

“A.14.1.1 states, “Typically, while engaged in firefighting operations on structural fires, apparatus are positioned in a safe location, and hose is extended as necessary to discharge water or suppressants on the combustible material.” In wildland fire suppression, mobile attack is often utilized in addition to stationary pumping. In mobile attack, sometimes referred to as “pump-and-roll,” water is discharged from the apparatus while the vehicle is in motion. Pump-and-roll operations are inherently more dangerous than stationary pumping because the apparatus and personnel are in close proximity to the fire combined with the additional exposure to hazards caused by a vehicle in motion, often on uneven ground. The personnel and/or apparatus could thus be more easily subject to injury or damage due to accidental impact, rollover, and/or environmental hazards, including burn over.

“To potentially mitigate against the increased risk inherent with pump-and-roll operations, the following alternatives are provided for consideration: (1) Driver and fire fighter(s) are located inside the apparatus in a seated, belted position within the enclosed cab. Water is discharged via a monitor or turret that is controlled from within the apparatus.
(2) Driver and fire fighter(s) are located inside the apparatus in a seated, belted position within the enclosed cab, but water is discharged with a short hose line or hard line out an open cab window.
(3) Driver is located inside the apparatus in a seated, belted position within the enclosed cab with one or more fire fighters seated and belted in the on-board pump-and-roll firefighting position as described in a following section.
(4) Driver is located inside the apparatus in a seated, belted position within the enclosed cab. Firefighter(s) is located outside the cab, walking alongside the apparatus, in clear view of the driver, discharging water with a short hose line.

“Under no circumstances is it ever considered a safe practice to ride standing or seated on the exterior of the apparatus for mobile attack other than seated and belted in an on-board pump-and-roll firefighting position. [2016b].”

Report released on 120,000-acre fire in Utah

Bald Mountain and Pole Creek Fires south of Provo in 2018

Pole Creek Bald Mountain Fires
Pole Creek-Bald Mountain Fires. Photo from the report.

The Bald Mountain and Pole Creek Fires started last year on August 24 and September 6 respectively about 15 miles south of Provo, Utah in the Uinta-Wasatch-Cache National Forest. Both fires were initially managed in a less than full suppression mode — allowed to spread within lines drawn on a map. Rainfall amounts ranging from 1.3″ to 2.3″ on August 25 put a damper on the fire activity, but within days the Energy Release Component had returned to the 90+ percentile range. Meanwhile the area had been classified as in Severe Drought by the Drought Monitor.

The weather changed on September 10, bringing strong winds and a series of Red Flag Warnings causing the two fires to burn together. The final size was 120,851 acres.

Map Utah Pole Creek - Bald Mountain Fire
Map of the Pole Creek – Bald Mountain Fire. Wildfire Today

The Bald Mountain Fire caused mandatory evacuation of two cities: Elk Ridge and Woodland Hills. The Pole Creek Fire triggered mandatory evacuations for the Covered Bridge Community of the Spanish Fork Canyon along with the Diamond Fork Canyon and the Right Fork Hobble Creek Canyon areas.

Below are excerpts from a Facilitated Learning Analysis recently released:


First WFDSS Decision

Late afternoon on August 24, the District Ranger wrote a Wildland Fire Decision Support System (WFDSS) decision for the Bald Mountain Fire, which was then at 0.1 acre in size. This decision was published on August 27 at 1018 hours. Based on map estimates, the planning area boundary was 3,280 acres.

The relative risk was determined to be low, as were the probability of a significant event or extreme fire conditions. A Type 4 organization was determined as appropriate for staffing. The course of action recorded in WFDSS was to: “Allow fire to burn to north, northeast and east. However, consider and allow suppression actions on the southwest and southern boundaries to prevent fire from reaching private lands and minimizing the need to close the Mona Pole Road. Fire behavior may dictate a different outcome, but where management of the fire through suppression or other tactics allow for steering the fire in the right direction, implement those.”

[…]

Fire managers assessed the opportunity to take advantage of this fire to meet restoration objectives by taking into account such factors as: a lack of values at risk (campgrounds, private inholdings, power lines, etc.), the composition of the surrounding vegetation, time of year, remote location, recent precipitation, and potential hazards (standing dead trees, steep terrain, and loose rocks). They expected the fire to go out by itself like other recent fires on the Forest.

“We put the Bald Mountain Fire into monitor status due to issues with snags and associated safety concerns, but also because it was Wilderness where fire is OK as a natural process,” said the Zone Assistant Fire Management Officer/Duty Officer (ZAFMO/DO). “But firefighter safety was the primary driver for our decision.”

[…]

September 10

Shortly after 1400 hours, ICT4 called Dispatch, informing them that the winds had increased and the fire had aligned with the south fork of the drainage and was making a run. He requested that they order a Type 2 Incident Management Team (IMT) and multiple aviation resources. ICT4 was new to the Region but came from a high complexity forest with a heavy fire load. Where he was from, an order for a Type 2 Team and significant aviation resources would have been automatic.

Meanwhile, ZFMO had just left the fire an hour before, when it was still 25 acres. “When I hit the bottom of Nebo Loop [Road] I could hear clearly a Type 2 Team being ordered from the fire,” said ZFMO/DO, a long-time UWF employee who had also been a hotshot superintendent on a northern Utah crew. He thought, “We need to ‘pump the brakes’ on the team order.” He told ICT4, (also a qualified ICT3) to hold on until he could get a look at the fire.

At the time ICT4 was calling for a Type 2 Team, the Forest DO and Forest FMO were briefing the Forest Supervisor. Not knowing the details of the rapidly evolving situation and thinking the fire was approximately 75 acres, the Forest Supervisor asked the Forest DO to put a hold on the aircraft and Type 2 IMT. After the Forest Supervisor’s review of WFDSS, it didn’t make sense to take such aggressive suppression action. The fire was well within the planning area, meeting objectives, and not close to threatening values at risk (see Figure 13). Parts of the order for aircraft went through, however, and shortly thereafter a Type 1 Helicopter and some “Fire Bosses” (water-scooping single-engine air tankers) were on scene.

[…]

September 13

[…] At 0836, the Forest Supervisor canceled the Type 2 IMT and ordered a Type 1 IMT to assume command for both the Pole Creek and the Bald Mountain Fires. At 1030, ZFMO flew the fires with ICT3 and ICT3t. The flight was rough due to unstable air and high winds. Both fires were actively burning and had already formed columns. They witnessed extreme fire behavior along the Highway 89 corridor with ongoing firefighting efforts. ICT3 noted that the Pole Creek Fire would likely impact Highway 6. ZFMO contacted Forest DO and recommended that the Forest Supervisor order a second Type 1 Team for just the Bald Mountain Fire due to fire behavior, values at risk, and the complexities of both fires.

September 13: Bald Mountain IC Transitions

At approximately 0500, a local Fire Chief arrived on scene and tied-in with Bald Mountain IC. The Chief ordered three engines from his department. All resources on the Bald Mountain Fire were now engaged in evacuations.

[…]

The WFDSS for Pole Creek published on September 13 included these courses of action:

  • Only commit firefighters under conditions where firefighters can actually succeed in protecting identified values at risk.
  • Utilize direct and indirect tactics to fully suppress the fire. This action will take into account: first, risk and exposure to firefighters and the public; and second, the protection of identified values such as utility corridors and infrastructure, private structures, the railroad corridor, and the Highway 6 corridor.

The WFDSS for Bald Mountain published on September 13 included the previous courses of action for Pole Creek and added:

  • Assign a Public Information Officer in order to disseminate timely information to the public, partners, and cooperators, including local government and law enforcement. All closures and evacuations will be coordinated with the Utah County Sheriffs’ Office.
  • Agency Administrator approval is required prior to any mechanized tool use within the Nebo Wilderness Area. Outside the Wilderness, the full range of tools and tactics are authorized. Work with READ [Resource Advisor] to mitigate impacts and assess rehab needs

[…]

Lessons Learned by Participants of the Incidents

Preparedness

  • Reading the 7-10 day outlook along with the spot weather forecasts can assist in gaining a better long-term perspective, which may lead to making different decisions in long-term events.
  • Using the 10 risk questions in WFDSS can open our thinking to options we may not have considered. These questions could encourage us to more carefully consider a wider array of possible outcomes from the decisions we make.
  • Fire modelers and weather forecasters are able to make better predictions with accurate and timely field observations.
  • Collaboration with predictive services early in an incident around long-term outlooks may help fire decision-makers. They are constantly producing tools to help firefighters in the field.
  • “Normalization of deviance2” (also referred to as “practical drift”) led us to not consider the worst-case scenario. Without planning for the worst-case scenario, we are constantly behind the power curve.

Operations

  • Nighttime fire behavior surprised us, especially this late in the season. This experience showed that high winds can override cooler temperatures and still create extreme fire behavior late in the fire season.
  • Understanding the capability and capacity of your resources is critical to ensuring the probability of keeping your resources safe.

After Action Review released for the Carr Fire

In 2018 the fire burned 229,651 acres at Redding, California, destroyed 1,077 homes, and killed 3 firefighters and 5 civilians

Fire tornado Carr Fire
Fire tornado filmed by the Helicopter Coordinator on the Carr Fire July 26, 2018 near Redding, California.

The National Park Service has released an After Action Review (AAR) for the Carr Fire that burned into Redding, California in July, 2018. Ignited by the mechanical failure of a travel trailer, it started within the Whiskeytown–Shasta–Trinity National Recreation Area (WHIS) on National Park Service-administered lands. The fire covered 229,651 acres, destroyed 1,077 homes, and killed 3 firefighters and 5 civilians. Many of the burned structures were in Redding. It became the 7th largest fire in California recorded history.

The decision to conduct a very brief one-day AAR administered by two facilitators for this very large, complex, and deadly fire rather than a conventional-months long investigation was an interesting choice. The reason given, “Unfortunately, incidents of this complexity are becoming more of the norm than the exception, and there is not a realistic capacity within the Service for each qualifying incident to receive the traditional level of review and analysis.”

No names were used in the report and the process was designed to be non-punitive. The goal was to identify issues, successes, and recommendations  in planning, operations, administration, or management which could be addressed at the local, regional, or national level to improve future incident management.

The report uses dozens of acronyms, very few of them defined, which may not be familiar to the casual reader. A glossary would have been helpful, or defining the acronym the first time they were used.

You can download the entire 20-page report. All of the recommendations from the AAR are listed below:

  • All wildland fire management units are encouraged to develop a roster of high-quality, relief duty officers from their interagency organizations as part of their pre-season fire preparedness planning.
  • Initiate stakeholder engagement early on all incidents that demonstrate a likelihood to impact multiple jurisdictions. Early, forthright, open dialogue is critical, and was cited on this incident with contributing to the success of the IMTs response to multiple firefighter fatalities and incidents within the incident. Consistency of personnel within unified command representation has value and is a best practice worth striving for.
  • Participation in the cost-share agreement is not a mandatory prerequisite to joining a delegation of authority or leader’s intent letter to an incident management team (IMT). All primary landowners with values at risk in the fire planning area should receive consideration for inclusion in the decision making process. The transfer of DPA among federal agencies is intended to provide efficiency in fire response, but is not intended to replace agency administration on complex, long-duration incidents.
  • A future topic for discussion within the California Wildland Fire Coordinating Group (CWCG) should be the subject of agency DPA versus agency ownership and how that relates to agency administration, agency representation, delegations of authority, and ultimately unified command. When feasible, a single federal IC should be delegated authority to represent all of the affected federal agencies in unified command.
  • The Wildland Fire Decision Support System (WFDSS) needs to be reviewed annually at the unit level to ensure that management requirements and strategic objectives are current and applicable. Consideration should be given to ordering fire behavior analysts (FBAN), long-term analysts (LTAN), and strategic operational planners (SOPL) to help supplement the planning section within any IMT. These positions need to be well integrated with the IMT, and can assist with communicating the long-term plan for an incident to stakeholders and the public alike. The SOPL position, in particular, can be a highly effective position in bridging any gaps or inconsistencies between the agency administrator leader’s intent and operations on the fire.
  • Continue to use the right IMT for the job based on the primary responsibility area, relative risk, and anticipated complexity of an incident. The Organizational Assessment and Relative Risk modules within WFDSS and the Indicators of Incident Complexity located within the IRPG are standardized resources to help objectively determine incident complexity. Complexity and risk assessments, as well as any changes, should be documented by ICs. The CWCG should further address the issue of IMT utilization in complex multi-jurisdictional areas to help ensure efficiency of wildfire engagement statewide.
  • The NPS All-Hazard team and CAL FIRE providing employee support services (ESS) were both considered successes and other units being severely impacted by an event of this magnitude should consider doing the same. Ensure that any IMTs operating within proximity of each other are in strong communication through daily IC calls or meetings to avoid any duplication of effort or confusion to the extent possible in an already chaotic environment.
  • Expectations of the reassignment of resources needs to be communicated to the GACC early on to decrease administrative paperwork and the chasing down of resources out in the field. Local government fire engines that already have some agreement with a federal agency should be mobilized on that agreement first in preference over the secondary mobilization option provided by the Farm Bill. A mechanism for states to pay for Farm Bill engines would represent an efficiency gain.
  • There is an opportunity for the CWCG to include direction on fatality response in the CFMA during the next revision. The California Fire Assistance Agreement (CFAA) covers California local government fire response and also needs to include adequate direction on incident fatality response.
  • Efficiencies need to be built into the dispatch system in regards to contract resources that allow for contract resources to be reassigned by the GACC based upon location, availability, and incident need, and to not cycle back into the Virtual Incident Procurement (VIPR) system for reassignment.
  • In lieu of an established lend-lease program, GACCs, ICs, unit fire program managers, and duty officers, are encouraged to continue strong daily communication to solve short-term resource shortage issues and address immediate life safety threats posed by rapidly escalating incidents. Resource accountability is especially challenging in these situations and must be stressed among the coordinating entities.
  • Agencies need to continue to recognize they have differing policies and objectives. Long-term planning tools, including those available in WFDSS, should be utilized by SOPLs and LTANs and communicated to the unified IC for the respective agency. This unified IC would advocate to incorporate WFDSS and PACE modeling into the long-term strategic decision making process during the incident.
  • A pre-season SOP be developed that articulates that only one incident number be generated corresponding to the jurisdiction of the point of origin of the fire. This is would be incorporated into the LOP/Local AOP which is tiered under the CFMA.
  • It was agreed that the standard procedure should continue having PIO representation from each participating agency. The need for a joint information center should be evaluated on a case-by-case basis on all complex, multi-jurisdictional incidents.
  • Expanded discussions with FIRESCOPE and the county sheriffs within California to address consistency of evacuation procedures and communications between the 58 county law enforcement entities across California.
  • A standard SOP should be implemented, whereby only one incident number is generated according to the ownership of the origin point of the fire. This standard would be incorporated into the LOP/Local AOP which is tiered under the CFMA. This will result in clearer communication and understanding of resources ordered by the fire and from a single dispatch ordering point. In cases where a secondary incident must be created for any reason it must be correctly nested under the parent incident in ROSS and IROC to ensure proper resource statusing and accountability. Incident ownership can be transferred within these systems and should be done as early as possible if need be. Additionally, evaluate and determine best fire management dispatching practices and options for the WHIS program in light of the incident (state vs. federal). Include scenarios revolving around complex DPA and jurisdictional boundary issues in pre-season preparedness planning. Practice how this might look in terms of incident number, accounting information, single ordering point, agency administrator roles, unified command, cost share, and resource statusing and accountability.
  • Continue early engagement with partners when cost share is anticipated to efficiently come to consensus about cost apportionment early in the incident.
  • Move forward with the NPS hiring of positions to implement the interagency BAER plan.
  • Start contracting process early and coordinate use of equipment and resources.

All articles on Wildfire Today tagged “Carr Fire”.

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.

Report released on fatality of Oklahoma grader operator

grader Jack Osben wildfire fatality
The grader that Jack Osben was operating. Photo taken two days after the burnover. From the FLA.

The Wildland fire Lessons Learned Center has released a Facilitated Learning Analysis on the fatality of Jack Osben, the grader operator who was burned over while working on the Shaw Fire in Western Oklahoma April 12, 2018. The tragedy occurred during extreme conditions — extended drought, 100 degrees, 5 percent relative humidity, 45 mph winds, and the fire was burning in thick grass that had not been grazed or hayed in seven to eight years.

The executive summary is below. The entire document can be downloaded (4 MB file).


*Except for Jack Osben, all names are pseudonyms

On April 12th, 2018, 61-year-old Jack Osben, a motor grader operator for Roger Mills County in Oklahoma and volunteer firefighter died as a result of thermal burns while providing initial attack to the Shaw Fire. The wildfire grew to approximately 3,500 acres in a mixture of grass and shrubs during a Red Flag Warning day. The employees of Roger Mills County were in a state of readiness due to a mixture of prolonged drought, extreme heat, and gusting winds that had created extremely dangerous wildfire conditions.

Shaw Fire grader fatality
The Shaw Fire, as seen from a grader approaching the fire. From the FLA.

Jack was performing progressive line construction using a motor grader on the Shaw Fire. While he had been working as a grader operator for a few years, he had limited experience using the grader related to fire suppression activities. Between 1400-1430 hours Jack met up and began working with Alex, a fellow grader operator who had more than two decades of experience fighting fire.

Although they entered the field at different locations, they converged almost immediately. Alex instructed Jack to fall in line behind him to improve the initial grader line. After working together to establish line for about 4,000 feet, Alex lost sight of Jack’s grader in the smoke and flames, which had grown significantly and shifted directions quickly.

Due to the fire’s shift in direction, Alex was forced to abandon his grader. He began to walk toward a nearby road when he spotted Jack, who was also on foot emerging from the smoke. They spoke briefly when they met. Alex observed that Jack had visible burns to his arms and was possibly suffering from smoke inhalation. The reality was that Jack’s injuries were much worse than they appeared. He died as a result of thermal burns either during transit in the ambulance or right after arriving at the hospital.

This accident took place in Western Oklahoma where the tactical use of motor graders for wildland fire line construction is common. Additionally, there is different emphasis on values at risk, namely that firefighters in Western Oklahoma commonly protect grass for cattle grazing. Other regions may rank grass as a low value-at-risk but it is absolutely a consideration for how people in this region fight fire and manage land1.

This is the first Facilitated Learning Analysis (FLA) to emerge from the State of Oklahoma. In brief, the FLA process is meant to facilitate learning from unintended outcomes by interviewing people who were involved in the event, and sharing a collective story of their experiences. We also offer lessons learned from those involved and with their help, generate recommendations that may be useful for people within and outside of the region.

For many readers, this analysis will serve as an introduction to a different way of fighting fire with some of these methods appearing unconventional. But, in the words of one of the grader operators, “you make do with what you have.” Even if the methods and context are different, this statement ties together the ethos of wildland firefighters everywhere. It is also important to note that the men and women of Roger Mills County are exceptional at what they do and have an impressive record of doing it safely.