A preliminary report has been released for an accident that involved a firefighter who sustained a broken leg on July 20 and was extracted by short-haul the next day. This occurred on the Gregg Creek Fire in the Willamette National Forest east of Corvallis, Oregon. Earlier, the Linn County Sheriff’s Office issued a press release with some basic information, but on July 26 the Willamette National Forest, over the signature of Forest Supervisor Tracy Beck, filed a “72-Hour Preliminary Report” approximately 144 hours after the extraction.
Below is the narrative and a photo from the report:
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“On July 20th, at approximately 2100 hours a Type Two IA crew was hiking off of the Gregg Creek Fire when a crewmember fell and sustained a lower leg injury. Crew EMT’s assessed the patient using the Medical Incident Report in the IRPG indicating “Priority-YELLOW (serious injury)”. The IC of the fire requested aerial extraction of the injured person though Eugene Interagency Dispatch (EICC). An additional 20 person hand crew, paramedics and overhead were dispatched to the incident to support medical evacuation operations while EICC pursued night time aerial extraction options. Both Oregon Air National Guard and United States Coast Guard were contacted for possible night time aerial extraction.
At 0303 hours on July 21st aerial extraction was attempted by the US Coast Guard without success due to excessive rotor wash creating additional hazards (ember showers and snags falling). Local cooperator Paramedics hiked in and were able to assist with patient care. A short-haul mission was ordered for first light.
At approximately 0830 hours short-haul operations were completed by a National Park Service short-haul capable helicopter which was prepositioned in the area due to fire activity. The patient was transported to a hospital and treated for a broken fibula and associated ankle injuries requiring surgery.”
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On July 21, 2015 at Corvallis, Oregon a helicopter would have been permitted to begin flying at 5:18 a.m. PT, which was 30 minutes before sunrise.
“At approximately 7:35 a.m. on July 12, a Stanislaus NF Type 3 engine was involved in a two vehicle collision which resulted in both vehicles rolling several times. The engine, on a cover assignment to the Sierra NF for lightning activity, was travelling east on Hwy 168, enroute to Prather Work Center for a briefing.
Responders from other Forest Service engines in the strike team, as well as CALFIRE, CHP and local EMS, were able to extricate the crew members and transport them to local hospitals. Three crew members sustained minor injuries, two of which were treated and released, while one crew member was held for observation overnight. The two more seriously injured crew members remain hospitalized in stable condition.
Hospital liaisons and patient advocates are in place supporting the firefighters and their families. A Peer Support Team as well as a Learning Review Team is in place. Upon completion, the final Facilitated Learning Review will be released thru the Wildland Lessons Learned center.
/s/ Kevin B. Elliott
Kevin B. Elliott
FLA Team Leader”
USFS photo from the report on the escaped prescribed fire, the Pautre Fire, in North Dakota and South Dakota.
The Associated Press is reporting that the Department of Agriculture, in a letter signed by Department Secretary Tom Vilsack, is denying $50 million in claims filed by sixteen ranchers and landowners over a prescribed fire that escaped and burned 10,679 acres in North Dakota and South Dakota.
The “Pasture 3B” prescribed fire was planned to be 210 acres on the Dakota Prairie National Grasslands, but strong winds on April 3, 2013 caused by the predicted passage of a cold front pushed the fire across a mowed fire line into tall grass and ultimately burned 10,679 acres, (3,519 acres federal and 7,160 acres private). The wildfire, named Pautre Fire, was stopped at 11 p.m. that night.
In explaining the denial, Secretary Vilsack said the Forest Service relied on forecasts from the National Weather Service in Rapid City, South Dakota, that ultimately proved inaccurate.
In February, 2014 the US Forest Service released a report about the fire, called a “Facilitated Learning Analysis. The issues listed by the document included:
Improved weather forecasts are needed.
Consider additional research on methods to predict effects of drought on fire behavior in grass fuel models.
The nearest remote automated weather station (RAWS) is more than 90 miles away.
The project was conducted at the critical edge of the prescription.
Consider gaming out worst case scenario “what ifs” during the planning process, and discuss with participants during the on-site briefing.
There were problems with radio communications [note from Bill: I don’t remember EVER seeing a report like this that did not cite radio communications as being an issue].
Bernardo Fire. Screen grab from live video from NBC7 at about 4 p.m. PDT, May 13, 2014.
The Bernardo Fire that started May 13, 2014 was one of the first in a series of 12 large wildfires that occurred in San Diego County during a 10-day period in mid-May. No homes were destroyed, in spite of the fact that it burned through and adjacent to dense housing developments. This was a testament to the community planning and preparedness that is evident in many areas in California.
A 72-page report has been released on the 1,548-acre fire which identified lessons learned and recommendations for change. Examples include:
Outfit five Type 1 engines for immediate deployment during high risk wildland fire days. The engines would have all radios, pagers, MDC, EMS equipment (short narcotics) on board. Storage could possibly be within the Repair Facility.
Purchase and make available additional radios and batteries to meet the needs of large-scale incidents.
Direct Division/Group Supervisors to identify supply Drop Points and Staging Areas within their geographic divisions and/or functional groups.
Increase the number of City fire/rescue medium-lift helicopters to three (3) to insure SDFD’s ability to provide aerial fire suppression and rescue.
Request funding to hire additional brush management inspectors. A total of 22 positions are required to conduct annual inspections of the 42,505 private parcels in the wildland/urban interface within the City of San Diego. The Department currently has 6 positions dedicated to these inspections.
Train additional Department personnel to fill all IMT, DOC, and EOC positions to a minimum three-deep roster. Consideration should be given to using non-uniformed staff for incident support positions to free uniformed staff for key skills or fire line assignments.
Ensure that only one ICP is being utilized. One of the benefits may be that angled drafting tables, large-scale maps, and overlays would be made available by one of the other agencies in UC. Purchase and make available the drafting tables, large scale maps, printers and plotters and install in the CIMU vehicles.
Consider including redlines and foam pro systems in future fire engine specifications.
Consider assigning water tenders to each strike team and task force.
Issue each individual SDPD officer their own vegetation fire PPE so that they are equipped with the necessary safety equipment upon arrival at a vegetation fire.
Provide display processing equipment at the ICP to include hardware and tools necessary to provide a large format, bright, clear picture for collaboration should be determined and purchased. Provide command vehicles both paper backup large format topographical or satellite maps and a digital map display solution. Ideally, a “Google Earth-like” solution on a large format touch screen monitor should be run. NICS provides the basis for this type of map display collaboration and markup. Properly paired with the correct hardware either in command vehicles or support vehicles will allow incident managers better awareness.
Consider extending capability to track additional support vehicles (and staff) utilizing existing GPS technology tracking hardware/services.
The El Paso County Sheriff’s Office has released a summary report on the investigation of the Black Forest Fire which started June 11, 2013 near Colorado Springs, Colorado. The fire killed two people and burned 489 houses and 14,280 acres, resulting in $420 million in insured losses.
The investigators eliminated natural causes, such as lightning. That left human-related ignitions.
Below are excerpts from the report:
…Given the known devastation of the fire at that point, an Investigation Team was formed consisting of recognized experts in the area of Wildland fire investigation from agencies including the USDA Forest Service, the Aurora Fire Department, the US Bureau of Alcohol, Tobacco, Firearms and Explosives (ATFE), the 4th Judicial District Attorney’s Office and others. This team was assisted by surveyors from the El Paso County Public Services Department.
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The only clearly established fact was that no natural causes existed and thus the fire was human caused. A potential cause associated with the metal particles can not be ruled out, or positively identified. A potential cause associated with an intentional ignition is not supported by the evidence or circumstances, but can not be completely ruled out. The origin of the fire is in an area that is not readily accessible from a roadway, allowing an easy escape, as is typical in intentionally set Wildland fires. There was no evidence of any other miscellaneous cause such as blasting, fireworks, welding, target shooting, etc.
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Upon the completion of the investigation, the entire case was reviewed by the Sheriff’s Office Investigations Division and the District Attorney’s Office to determine if any additional leads remained. It was the determination of the El Paso County Sheriff’s Office and the District Attorney’s Office that there was not sufficient evidence to warrant criminal prosecution at this time. None of the investigation or forensic examination supported any one possibility to the extent needed to pursue criminal charges. Additionally, no additional recommended follow-up work could be identified at this time.
Three other reports have previously been released about the Black Forest Fire:
A 2,000 page, 345 megabyte report, released March 14, 2014, commissioned by the Black Forest Fire District which evaluated how the fire was managed, including the performance of Fire Chief Bob Harvey during the first hours of the fire. Sheriff Terry Maketa had been extremely critical of the Chief in numerous interviews with the media. The complete report can no longer be found on the District’s web site.
During the initial attack phase on the Bureau of Land Management Fire, a Type 4 engine from the Richfield, Idaho Rural Fire Department responded. The two people on the engine attempted to make a frontal attack on the head of the fire.
The engine got stuck, or high-centered, on a rock and could not be moved. The two people on the engine, a city employee and a “part-time” volunteer, in an attempt to protect the truck from the approaching fire used two small booster hoses, one-half inch in diameter with a flow rate of 10 gallons per minute. They had to abandon the engine as the fire got closer, and it was destroyed. There were no injuries to the personnel.
Below is an excerpt from the report. “ENG3” is the apparatus that was destroyed by the fire:
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“…ENG3 proceeded south on the two track toward the head of the fire with FF2 riding on the top of the engine. The engine left the two track road and drove off-road toward a lava blister trying to access the active fire perimeter. Near the base of thelava blister, ENG3 struck a rock cluster high centering the rear axle of the vehicle and rendering ENG3 immobile. FF1 utilized four-wheel drive in an attempt to dislodge the vehicle, but sandy conditions caused ENG3’s side tires to sink. The rear axle of the apparatus pivoted on the rear differential, listing the vehicle to its right side. The driver’s rear tire was raised off the ground by 8-12 inches.
WT1 operator, FMO, and AFMO hiked west from the highway over the lava blister and observed ENG3 high centered on a rock in unburned fuel north of the active fire perimeter. The AFMO notified the IC at approximately 1215 of the immobilized engine. ENG3 crew deployed booster hose off both sides of the truck. FF2 worked from the right hose reel in front of the truck and south about 50 feet up the lava blister into sparser fuels. FF1 stayed near the front of the truck wetting a heavier pocket of unburned grass and brush.
ENG1 left the west flank and drove to the location of ENG3 to help remove ENG3 from the rock. ENG1 determined that an attempt to dislodge ENG3 would be unsuccessful. ENG1 then drove southwest and established an anchor point at the lava blister, approximately 200 yards from ENG3. ENG1 resumed mobile attack working back towards the disabled engine.
Between 1220 and 1225, wind direction changed from west to south. Fire behavior increasedand the fire made a rapid run toward the disabled engine. The FMO and AFMO made verbal contact with the two individuals on ENG3. The FMO and FF1 retreated to a safety zone in the black on top of the lava blister approximately 25 yards east of the disabled engine. The AFMO urged FF2, still by ENG3, to immediately retreat toward him into the safety zone. FF2 delayed until he felt excessive heat from the fire, closed the nozzle, and retreated to the safety zone.
At 1227, ENG3 was engulfed by the fire and completely destroyed…”
Engine rollover, Warm Springs, Oregon, July 18, 2014.
*The Wildland Fire Lessons Learned Center has published a report on a BIA engine that rolled over near Warm Springs, Oregon, July 18, 2014. Two people were injured, one seriously. The LLC says more than 50 fire vehicles have rolled over in the last 10 years.
*Fire officials in Washington state suspect an arsonist is responsible for igniting 23 fires in less than two weeks. Most of them have been vegetation fires.
*In other news from Australia, a Senator gave a speech, titled, Thank you For Smoking, praising nicotine fiends for their $8 billion a year contribution to the economy. He said he did the math: Last year smokers cost the health care system $320 million and another $150 million in bushfire control.
*Researchers have found that “recent (2001–2010) beetle outbreak severity was unrelated to most field measures of subsequent fire severity, which was instead driven primarily by extreme burning conditions (weather) and topography.” Unfortunately, to read the article, researched and published by government employees, it will cost you $10 for two days of access. If the researchers, Brian J. Harvey, Daniel C. Donato, and Monica G. Turner, are going to hide the results of their taxpayer-funded research behind a pay wall, what’s the point in hiring researchers? Support Open Access.
*Firefighters are on lessened alert in the Black Hills after the area received two to five inches of rain over the last few days.
(Updated on August 9, 2014 to include a link to details about the new USFS policy, and on August 11 to correct information about the distribution of the version of the report prepared for “organizational leadership”.)
The U.S. Forest Service has created a new review process for serious incidents involving a fatality or three or more hospitalizations, called the Coordinated Response Protocol (CRP). According to the agency:
The CRP is a process now being used to ensure we learn everything possible from serious incidents so we can prevent recurrence while reducing the painful effects on those closest to the incident or accident by coordinating the investigations and reviews that are required when fatalities have occurred. The CRP uses pre-trained and designated response teams. This provides a basis for coordination and communication before any team is dispatched to an incident. This new process minimizes traumatic impacts on witnesses, coworkers and others close to the tragedy while improving our ability to gather information and learn. The CRP replaces the Serious Accident Investigation with a new process called the Learning Review. The Learning Review is designed to create learning products for multiple audiences.
A new Interagency Serious Accident Investigation Guide was used for the first report on the Yarnell Hill Fire on which 19 members of the Granite Mountain Hotshots were killed. The process prohibited causes, conclusions, and observations from being included in the public report; they were reserved for a second version of the report that would be for internal agency use only.
That process was a total failure and set a new low bar for learning opportunities following serious accidents. The USFS prohibited their employees that had specific knowledge about the fire from being interviewed.
The new protocol just introduced by the USFS also specifies that two reports be produced; one for the public and another for organizational leadership.
Ivan Pupulidy called us to say that he was the author of the new protocol. Presently he is the Acting Program Manager for Human Factors Risk Management Research Development and Application for the USFS’ Rocky Mountain Research Station. In September he will be the Director of the USFS’ new Office of Learning. Mr. Pupulidy said the agency no longer subscribes to the one-year old Interagency guide and explained that under the new system both versions of the reports will be published on the Wildland Fire Lessons Learned Center website. When asked if the causes, conclusions, and observations would be included in the reports, he said they “will not include traditional nonsense”.
Mr. Pupulidy said the information will be broken up into two reports, rather than just having one, because a single document became “lengthy and troublesome”.
Our view:
Some firefighters would argue that causes, conclusions, and observations are not “nonsense”, but are some of the more important and useful features of an accident report, and that banning them reduces the opportunities for learning and preventing similar accidents. Having subject matter experts review an accident and provide information about how and why it happened can be crucial information for those in the early stages of their career.
Any effective accident review must collect all of the information, and without censoring or overtly protecting agency officials, distribute findings that can reduce the chance of a future similar accident. As we found out, anything short of that is a waste of time and money. More than 50 people worked on the Yarnell Hill report, and could not pull it off. It sounds simple, but to get a politically sensitive agency to carry it out, apparently is very, very difficult.
In addition, innocent bystanders and witnesses with information about the accident must be protected from civil lawsuits and criminal charges.
The National Interagency Fire Center has released their annual summary of wildfire activity in 2013. In the aviation section one of the stats we always find interesting is the number of requests for large air tankers that are unable to be filled (UTF). That is, when firefighters officially submit a request for an air tanker but there are none available because all of them are committed to fires, they are on their day off, or they have a mechanical problem.
An air tanker having a day off is ridiculous, especially when the fleet size has atrophied from 44 at the beginning of 2002 down to nine when the 2013 fire season began. But that is the way the U.S. Forest Service writes their contracts for large air tankers.
During the 2002 fire season the wings literally fell off two air tankers, killing five aviators, causing the USFS to begin grounding the older museum pieces that summer, continuing the process into 2004. Since then the UTF rate has been climbing. Much of the time when firefighters need air tankers there are none available, reaching a high of 48 percent in 2012.
After 2004 when the groundings settled down and the fleet size ranged from 9 to 21, the average UTF rate was 26 percent. In 2013 it was 21 percent. Before the two wing failures, with 40 air tankers on contract the average UTF rate was 7 percent for 2000 through 2001.
In articles like this pointing out how the air tanker fleet has decreased by 75% over the last 11 years, we usually mention that air tankers don’t put out fires. Under ideal conditions of moderate burning conditions without a strong wind, they can sometimes slow down a fire making it easier for firefighters on the ground to make better progress and actually stop the fire. It is one tool in the toolbox. But an *aggressive, prompt, initial attack with overwhelming force both on the ground and from the air is more likely to keep a new fire small than what we have seen in recent years with reductions in the number of firefighters and aircraft. An aggressive attack can prevent a small fire from becoming a megafire that can cost over $100 million.
In 2013 there were nine fires with suppression costs exceeding $10 million. The Rim Fire in and near Yosemite National Park ran up bills amounting to $127 million.. And those dollar figures do not include the damage to privately owned property or the lives lost. Information provided by the USFS shows that 11,625 homes burned in wildfires over the last three years; and they don’t have records for ALL structures that burn in wildfires across the nation. If those houses had an average value of $100,000, we are looking at a monetary value of $1.1 trillion. During that three year period 60 people were killed in wildfires, including firefighters and local residents.
While the number of acres burned in wildfires in the United States in 2013 (minus Alaska) was lower than the recent trend, the number of air tanker requests that were filled (1,017) was four times higher than the average between 2002 and 2012, which was 252 per year. The year with the second highest number of filled requests since 2002 was 2011 when large air tankers were requested 407 times.
We are at a loss to come up with a reason for the unprecedented increase in the number of filled requests, in a year that had the fourth lowest number of acres burned in the lower 49 states in the last 10 years. The number of requests for large air tankers was 1,343, compared to an average of 434 per year.
The information in this report might be 100 percent right and truthful. But, sadly, we are now forced to look at these and other statistics coming out of Boise and the Interagency Fire Center and consider that they may or may not be accurate. We learned a lesson after the U.S. Forest Service issued their “FY 2013 Aviation Safety Summary” last month which claimed there were no USFS aircraft accidents in the last three years. At least four accidents since 2008 with a total of nine fatalities, including the 2012 crash of the MAFFS air tanker on a USFS fire which killed four aviators, do not show up in their stats. Nor are they even mentioned anywhere in the report. Their use of imaginative criteria for leaving out certain accidents made it appear that they had a pretty good accident record, when the opposite is true.
That lesson learned means we now have to look at these Boise reports and question their accuracy. This is really unfortunate. It casts doubt on reports and statistics that might have the potential for us to learn other lessons that could enhance the safety of firefighters at the point of the spear — busting their asses out on hot, steep, dusty, smoky, rocky slopes in the middle of nowhere for weeks at a time.
“On Thursday, August 8, 2013 Medicine Bow-Routt National Forest and Thunder Basin National Grasslands Engine 492, a 2013 KME Type 4 engine was involved in a rollover accident along Wyoming State Highway 450. The accident occurred around noon, as Engine 492 was responding to the Osage Fire, in mutual aid assistance to Weston County, Wyoming. The accident occurred near mile marker 40, or approximately 10 miles east of the Thunder Basin Work Center.
The engine left the highway, veered slightly to the right side of the road hitting a paved apron to a side gate, with the driver seeking to decelerate and regain control of the engine. The engine returned to the road, with the engine brakes being heavily applied, then redirected back to the highway, which resulted in crossing the center line and going to the opposite road edge. Engine 492 rolled over a few times before coming to rest on its wheels (up-right).
At the time of the accident all three members of Engine 492 were wearing their seatbelts. Use of seatbelts and the integrity of the engine cab are likely the principal reasons for the survivability of this accident. All three crew members were hurt in the accident and the Type 4 engine was a total loss. Two of the crew members were transported by ambulance to Newcastle, Wyoming and the third member was transported by ambulance to the high school practice field in Wright, Wyoming where he was transferred to, and then transported by helicopter to the hospital in Casper, Wyoming. The two crewmembers that were transported to Newcastle, Wyoming were released later the same day. However, the injuries sustained by the third member resulted in a longer stay in Casper and release from the hospital on Saturday, August 10th…”
The IC of the fire requested aerial extraction of the injured person though Eugene Interagency Dispatch (EICC). An additional 20 person hand crew, paramedics and overhead were dispatched to the incident to support medical evacuation operations while EICC pursued night time aerial extraction options. Both Oregon Air National Guard and United States Coast Guard were contacted for possible night time aerial extraction.
