Lower North Fork Fire. Photo provided by Jefferson County Sheriff’s Office
A special commission created by the Colorado General Assembly to investigate the Lower North Fork fire has released their report. The fire originated from an escaped prescribed fire southwest of Denver on March 26, 2012. It burned 4,140 acres and killed three local residents at their homes. The report offers a number of recommendations but did not place blame.
This is the second report about the fire. The first, released in April, 2012, was conducted by Colorado’s Department of Natural Resources. That 152-page report (a very large 11.8 MB file) only addressed the management of the prescribed fire, and did not cover the suppression of the wildfire, the three fatalities, or the controversial evacuation procedures during the wildfire.
The charter of the commission which produced the second report was to investigate the following:
causes of the wildfire;
the impact of the wildfire on the affected community;
the loss of life and financial devastation incurred by the community;
the loss of confidence by the community in the response to the emergency by
governmental bodies at all levels; and
measures to prevent the occurrence of a similar tragedy
Their recommendations were on the following topics:
Coordination among fire districts
Raising the liability cap
Wildland-urban interface and local land use egulations
Funding for the federal FLAME Act (which is not fully funded by Congress)
911 capabilities
A consistent revenue source for wildfire suppression
Air emission permits
Funding for the SWIFT Program
The Commission also recommends that four bills be introduced in the Colorado General Assembly:
Prescribed Burn Program in the Division of Fire Prevention and Control
Wildfire Matters Review Committee
Extend Wildfire Mitigation Financial Incentives
All-hazards Resource Mobilization and Reimbursement
Waldo Canyon Fire, June 26, 2012, the day hundreds of homes burned in Colorado Springs. Credit: Keystoneridin
The Colorado Springs Independent conducted an exhaustive study into the management of the Waldo Canyon Fire, which in June, 2012 killed two people, destroyed 346 homes, and burned 18,247 acres — with some of those acres and most of the homes being within the city limits of Colorado Springs. The results of their investigation, published in a lengthy article on December 12, are extremely interesting. More about that later.
On October 23, the City of Colorado Springs released what they called an “Initial After Action Report”, but in the document they admitted the AAR was not the final, comprehensive report on the fire, but was considered preliminary. An in-depth analysis, they said, would occur over the next several months to fully explore Colorado Spring’s management of the fire.
The report, as we wrote then, was unusual. It listed some strengths and recommendations, but omitted information about the issues that caused the recommendations. Therefore, it was not always clear WHY the recommendations were made, forcing an observer to read between the lines. This limited the opportunities for lessons learned and may not in all cases have the desired result of preventing mistakes. There was no indication that they consulted experts outside the city for unbiased opinions or recommendations.
In reviewing the recommendations in the ARR, it appeared that many of the issues would be mitigated with adequate training and experience in the Incident Command System.
After reading the article in yesterday’s Colorado Springs Independent, I am left stunned. Regarding the management of the fire within the city of Colorado Springs, I have never heard of a wildland fire with such a huge impact that was so utterly, catastrophically mismanaged.
[Colorado Springs FD Fire Chief Rich] Brown said he specified in the city’s delegation of authority that the city, and no one else, would have control if the fire crossed into Colorado Springs.
The newspaper examined hundreds of documents including reports written by firefighters working on the fire. The article is astounding. If it is correct, and I have no reason to believe it is not, it exposes complete failures in pre-incident planning, qualification and training of fire department personnel, evacuation planning and execution, logistics, daily incident planning, strategy, and tactics. Apparently this large, modern city with an extensive, very vulnerable wildland-urban interface was completely unprepared to manage a large wildland fire or evacuations.
The article does not criticize firefighters. It points out the failures in preparedness and management of the fire by upper level officials, before, during, and after the incident. Some mid-level and upper level firefighters were forced into positions of great responsibility on the fire without having been provided the necessary training and experience. That was not their fault, it was just the way it was done in Colorado Springs.
You should read the article. It’s long, but worth it from a lessons learned perspective. The comments at the bottom of the article are interesting as well.
Here are a few excerpts from the article, copied and assembled into bullets:
When the fire swept into Mountain Shadows, the city had a mere four firefighting vehicles, or apparatus, assigned to that subdivision and all other land north to the Air Force Academy.
The evacuation plan had been drafted only that morning, and was enacted minutes before the first homes burned.
Local firefighters found themselves outgunned, and much of the help from other fire departments was nowhere close, because leaders sought those resources only after flames came into the city. Their chief staging area wasn’t set up and equipped until houses were ablaze, and they didn’t have a mobile command post until eight hours into Tuesday’s firefight [when most of the homes burned].
And, as readily admitted by city firefighters leading efforts on the ground that night, the fire could have charged further eastward for miles had it not been for the unanticipated arrival of U.S. Forest Service engines and their hot shot crews.
[A Colorado Springs FD Captain], a heavy rescue expert with no current wildland certification, was in charge of the city’s deployed resources on Tuesday [when most of the homes burned].
And because the department hadn’t made maps in advance for out-of-town engines, crew’s like Company Officer P.J. Langmaid’s were told to “split all our companies and place one member on each Denver Fire rig as a point of contact and communications/operations liaison.”
The next day, the city did sign its own delegation of authority — but apparently made it clear its fire personnel would remain separate from Harvey’s [Type 1 Incident Management] team, which arrived Sunday night. In a July 16 interview, [Colorado Springs FD Fire Chief Rich] Brown said he specified in the city’s delegation of authority that the city, and no one else, would have control if the fire crossed into Colorado Springs.
As adamant as the city was that its personnel operate independently during the fire, it is equally adamant that only its personnel examine the response. No third party has been engaged to review the city’s performance, which often is requested when a fire kills people.
The map below shows the progression of the Waldo Canyon Fire. Colorado Springs is on the eastern edge below the blue box that says “July 1-6”.
The Colorado Springs Independent, and the reporter, Pam Zubeck, deserve a great deal of praise for their investigation and the writing of this excellent article. Pulitzer Prize-worthy maybe?
The accident report on the fatal crash of the military C-130 MAFFS air tanker which was released yesterday illustrated one very important difference between accident investigations conducted by the military and the U.S. Forest Service. A notice on page two of the report points out that the findings of military aviation accident investigations are regulated by law, 10 U.S.C. 2254(d), which states:
Use of Information in Civil Proceedings.—For purposes of any civil or criminal proceeding arising from an aircraft accident, any opinion of the accident investigators as to the cause of, or the factors contributing to, the accident set forth in the accident investigation report may not be considered as evidence in such proceeding, nor may such information be considered an admission of liability by the United States or by any person referred to in those conclusions or statements.
C-130 MAFFS air tanker crash, July 1, 2012. US Air Force photo
For fatal wildfire burnovers or entrapments of U.S. Forest Service employees, a law provides for just the opposite, thanks to a bill that was sponsored by Senator Maria Cantwell and U.S. Representative Doc Hastings, which became Public Law 107-203 in 2002:
In the case of each fatality of an officer or employee of the Forest Service that occurs due to wildfire entrapment or burnover, the Inspector General of the Department of Agriculture shall conduct an investigation of the fatality. The investigation shall not rely on, and shall be completely independent of, any investigation of the fatality that is conducted by the Forest Service.
The Cantwell-Hastings bill that was signed into law in 2002 was a knee-jerk reaction to the fatalities on the Thirtymile fire the previous year. The Department of Agriculture’s Inspector General’s office had no experience or training in the suppression or investigation of wildland fires. They are much more likely to be investigating violations at a chicken ranch than evaluating fire behavior and tactical decisions at a wildfire. The goal of the Inspector General investigation would be to determine if any crimes were committed, so that a firefighter could be charged and possibly sent to prison.
After the trainee wildland fire investigator for the OIG finished looking at the Thirtymile fire, on January 30, 2007 the crew boss of the four firefighters that died was charged with 11 felonies, including four counts of manslaughter. The charges were later reduced to two counts of making false statements to which the crew boss pleaded guilty on August 20, 2008. He was sentenced to three years of probation and 90 days of work release.
The criminal charges brought against the firefighter who may or may not have made some mistakes on the fire had a serious, chilling effect on wildland firefighters. Not only does it make them reluctant to speak to anyone about what happened on an accident, some even had second thoughts about their willingness to continue working in a professional they loved because potential criminal charges or convictions could ruin their lives and the livelihood of their families.
In addition, firefighters lawyering-up after an accident makes it difficult to discover the causes of an accident and to learn lessons which could save lives by preventing similar fatalities.
The four-fatality MAFFS accident was a complex chain of events involving many individuals and firefighting resources. But in spite of the complexity, the report was released to the public only four months after the accident, making it possible for lessons to be learned while reducing the chances of a similar accident taking more lives.
This short turnaround is unheard of in the wildland fire agencies in part due to the potential civil and criminal implications down the road.
This is literally a life and death issue — Senator Maria Cantwell’s and Representative Doc Hastings’ hastily conceived Public Law 107-203 must be repealed and replaced by one similar to 10 U.S.C. 2254(d), which serves the military very well. The Cantwell-Hastings law serves no useful purpose. Accidents are investigated, with or without the ridiculous law. It had unintended consequences and needs to be fixed.
It takes a while to digest the 49-page report on the July 1 crash of MAFFS #7, the military C-130 air tanker, in which four crew members were killed. Earlier we posted a summary of the report, but here are some additional thoughts.
MAFFS crash, radar at 1733, five minutes before the crash.
The radar image above, 5 minutes before MAFFS #7 impacted the ground at 1738 local time, recorded a very large thunderstorm cell southwest of the crash site. The middle of the concentric circles is the location of the crash. The circles indicate 5, 10, and 15 nautical miles from the impact site. The light green areas may have been virga, rain that was not reaching the ground. The red, light brown, dark green, and possibly the yellow areas were most likely rain, accompanied by strong winds. The longest east-west line is the South Dakota/Nebraska state line. The longest north-south line is the boundary between Wyoming and the states of South Dakota and Nebraska.
In addition to the C-130 working on the fire, there was also a Bureau of Land Management Air Supervision Module aircraft which was flown by a lead plane pilot and also carried an Air Tactical Group Supervisor. It was acting as the lead plane at the time of the accident.
The ASM/Lead experienced a severe downdraft while approaching the intended retardant drop zone with the C130 in trail. This is being investigated by the US Forest Service as a separate Incident With Potential.
The third fixed wing aircraft to arrive at the White Draw fire that was mentioned in the report served as Air Attack. It was piloted from the left seat by Air Attack 3 (AA3 in the report), and in the right seat was the Air Tactical Group Supervisor. Both were employed by the State of South Dakota.
Before the crash, the air attack aircraft encountered sudden updrafts and downdrafts with airspeed fluctuations between 20 to 40 knots, which forced the aircraft into bank angles of approximately 90 degrees.
Here are some interesting passages from the report that discuss the weather conditions:
At 17:38:18L, MP1 ordered an e-dump of the retardant, which was immediately conducted. At the same time, Firefighter 1 (FF1) a ground firefighter, was located approximately 1.5 miles west-southwest of the future mishap site. FF1 witnessed the MA [mishap aircraft] jettison their retardant load, at which time she experienced variable surface winds with estimated gusts up to 50 miles per hour. At the same time, in Air Attack, ATGS observed the smoke lying down and “sheeting” of the fire, indicating to him “hellacious” surface winds. ATGS and AA3 lost altitude, experienced updrafts and downdrafts with airspeed fluctuations of 20 to 40 KIAS and severe turbulence. Air Attack lost an estimated 1,000 ft due to the weather conditions. ATGS did not see the MA jettison the retardant load.
Between 1730L and 1745L, Incident Commander 1 (IC1), a member of the Army National Guard, was traveling on a motorcycle, southbound on Highway 18 approximately seven miles north of Edgemont attempting to get to an 1800L meeting at the White Draw Fire incident command center in Edgemont, South Dakota. While heading towards Edgemont, IC1 witnessed the MA flying to his right, approximately one mile away, making a bank as the MA prepared for their approach to the drop area. IC1 lost sight of the MA while going down the hill towards Edgemont, at that same instant, IC1 was “hit with this extreme, fierce wind”. IC1 described it as side wind because it “pushed me over to the other side of the highway”.
The MAFFS crew received a briefing on the weather for the Arapahoe fire they dropped on earlier in Wyoming, but they did not have any specific weather information on the weather for the White Draw fire in southwest South Dakota and no update was requested when they were diverted to that fire.
From the report:
On 1 July 2012 at 1650L, the National Weather Service issued a severe thunderstorm watch for northeast Wyoming and western South Dakota encompassing the area surrounding Edgemont, South Dakota and the White Draw Fire. The severe thunderstorm watch, valid from 1650L to 2300L, was issued for potential hail up to two inches in diameter and wind gusts up to 70 miles per hour. However, there was no evidence the MC requested or received forecast weather information for South Dakota or the White Draw Fire area at any time on 1 July 2012.
After dropping on the Arapahoe fire in Wyoming, the MAFFS was dispatched to the Highlands fire west of Custer, South Dakota. But en route they were diverted to the White Draw Fire which was 24 miles southeast of the Highlands Fire.
At that time I was taking photos at the Highlands Fire and the Oil Creek Fire, the latter being farther west across the state line near Newcastle, Wyoming. Between 1730 and 1830 I remember seeing massive, very dark thunderstorm clouds to my southeast. The photo below taken at 1715 is looking south toward the Highlands Fire. In the background the dark clouds farther south can be seen.
Highlands Fire, 1715 MT, July 1, 2012. Photo by Bill Gabbert
From 1630 until 1645 a Canadian “Bird Dog” and a CV-540 were over the Highlands fire. They were asked to drop, but refused, saying there were too many people on the ground in the intended drop area. It would be interesting to know where they went after being released from that fire, or if the weather affected the decision about their destination.
CV-540, T44, over Highlands Fire, at 1708 MT, July 1, 2012. Photo by Bill Gabbert
The MAFFS has a capacity of 3,000 gallons, but each time MAFFS #7 reloaded that day they refilled with less retardant. At the White Draw fire it was only carrying 2,346 gallons which it split into two drops on the fire.
Crew rest or fatigue were not issues, according to the report.
Regarding the radio transmissions from the lead plane pilot saying “I got to go around” after encountering the downdraft and coming within 10 feet of the ground, and a few seconds later calmly advising the MAFFS to “drop your load when you can”, (meaning an emergency release of retardant to lighten the load, enabling the aircraft to more easily maneuver) the report said:
MAFFS aircrew members attested that a call for a go around is most commonly heard regarding misalignments for drops rather than urgent situations. It is possible that [the lead plane’s] call for a go around while meant to abort the mishap drop, was not interpreted by the [MAFFS Crew] as significantly urgent, based on their prior experience.
According to the report the overall flying experience of the MAFFS crew was high.
However [the pilot, the aircraft commander] had limited experience as a MAFFS aircraft commander and [the navigator] was participating in his first MAFFS mission. [The pilot] was a current and qualified Senior Pilot with over 1,900 total C-130 hours, however prior to the day of the mishap he had accomplished only seven drops as a MAFFS copilot and zero drops as a MAFFS aircraft commander.
The second pilot was more experienced with MAFFS and served as a MAFFS instructor pilot for this sortie.
The emergency locator transmitter (ELT) failed to activate when the C-130 crashed. One of the survivors called 911 on his cell phone and reported the crash but he said he didn’t know where he was.
The flight data recorder for the C-130 was found and shipped to the Air Force Safety Center for data retrieval and analysis. The report said the last 12.8 hours of data on the device were corrupt and unusable for investigation purposes.
There was no evidence that aircraft weight or the MAFFS unit in the cargo hold were factors in the crash. “Prior to the mishap, the MAFFS unit was operating at 100 percent capability and an emergency dump was successfully completed.”
About 34 minutes after the crash, firefighting helicopter crews assigned to the fire that were on the ground at the nearby Edgemont Municipal Airport were notified about the crash. But they were unable to fly at that time due to heavy rain, gusty winds, and a low ceiling. While waiting, an EMT loaded medical equipment on N935CH, call sign 5CH.
At the time of the crash the air attack ship was at 1,500 feet above the ground and following the MAFFS aircraft, observing the drop. On that pass the air attack ship had their hands full, experiencing extreme turbulence which resulted in bank angles of approximately 90 degrees. After the crash it had to leave the area due to the strong turbulence and the approaching thunderstorm. It loitered at a safe distance for about 30 minutes before it was able to access the area again, after which it led one of the fire’s helicopters, H-535, to the site.
During the last pass, the lead plane over-temped (or “smoked”) the aircraft engines while attempting to recover from being pushed down to within 10 feet of the ground and had to go to the Rapid City Airport.
When the weather improved, the two helicopters, N911FS, call sign H-535 (from the San Bernardino National Forest in southern California), and 5CH, departed and proceeded toward the mishap site. When they landed at the site at approximately 1850, the EMT on 5CH met the survivor who was still talking to the 911 operator on his cell phone. The EMT assessed and began treating him while the other helicopter crewmembers searched for other survivors, eventually finding the second survivor “wandering near the mishap site”. Helicopter 5CH transported both survivors to the Custer Airport, about 10 minutes away. One of them was then flown by an emergency medical helicopter to Rapid City while the other went by ground ambulance to a hospital.
As Wildfire Today reported on September 17, the pilot and at least two crewmembers of H-535 were given awards for their actions related to the crash. It is possible that others involved in the emergency response to the incident also received awards.
Firefighters Daniel Diaz (center), Kevin Walters (left), and pilot Chuck MacFarland (right) receive their awards for their actions following the crash of MAFFS 7. Photo credit: San Bernardino National Forestx
Today the US Air Force released the full report on the crash of MAFFS #7, the C-130 air tanker operated by the North Carolina National Guard. The accident occurred July 1, 2012 as the aircraft was attempting to drop retardant on the White Draw Fire near Edgemont, South Dakota. There were four fatalities. The two crewmen in the rear of the aircraft were seriously injured but survived. Those two were operating the Modular Airborne FireFighting System (MAFFS) in the cargo hold which enables the C-130 to function as an air tanker, capable of dropping up to 3,000 gallons of fire retardant.
The investigation was led by Brigadier General Randall C. Guthrie, USAFR. Also participating were the following board members: Legal Advisor, Medical Member, Pilot Member, Maintenance Member, Flight Engineer Member, Weather Member, Loadmaster Member, Recorder and two Court Reporters.
The report does not list who the investigation board may have interviewed. Most likely they talked with the crews of the lead plane and air attack and probably other personnel assigned to the fire in various positions, but it would seem to be important to have someone on the board who lives and breathes aerial firefighting. Maybe the “Pilot Member” was MAFFS qualified at least.
We will be writing more about this report in the coming days, but for now, here is the “Opinion Summary” from the report:
I find by clear and convincing evidence the cause of the mishap was Mishap Pilot 1 (MP1), Mishap Pilot 2 (MP2), Mishap Navigator (MN) and Mishap Flight Engineer’s (ME) inadequate assessment of operational conditions, resulting in the MA impacting the ground after flying into a microburst. Additionally, I find by the preponderance of evidence, the failure of the White Draw Fire Lead Plane aircrew and Air Attack aircrew to communicate critical operational information; and conflicting operational guidance concerning thunderstorm avoidance, substantially contributed to the mishap.
On 1 July 2012, at approximately 1738 Local time (L), a C-130H3, T/N 93-1458, assigned to the 145th Airlift Wing, North Carolina Air National Guard, Charlotte Douglas International Airport (KCLT), Charlotte, North Carolina, crashed on public land controlled by the United States Forest Service (USFS), while conducting wildland firefighting operations near Edgemont, South Dakota.
At the time of the mishap all members of the Mishap Crew (MC) were assigned or attached to the 156th Airlift Squadron, based at KCLT. The MC consisted of MP1, MP2, MN, ME, Mishap Loadmaster 1 (ML1) and Mishap Loadmaster 2 (ML2). For the mishap sortie, MP1 was the aircraft commander and pilot flying in the left seat. MP2 was in the right seat as the instructor pilot. MN occupied the navigator station on the right side of the flight deck behind MP2. ME was seated in the flight engineer seat located between MP1 and MP2, immediately aft of the center flight console. ML1 and ML2 were seated on the MAFFS unit, near the right paratroop door. ML1 occupied the aft Modular Airborne Fire Fighting System (MAFFS) control station seat and ML2 occupied the forward MAFFS observer station seat.
After three uneventful sorties, the Mishap Aircraft (MA) entered the White Draw Fire Traffic Area (FTA) in South Dakota. The lead plane for the MA was Lead B-5. Lead planes are responsible for the safe, effective and efficient use of air tanker operations within an FTA. A lead plane is also responsible for leading air tankers to a low-level, where fire retardant can be safely dispensed. Air Tactical Pilot (ATP) piloted Lead B-5 from the left seat and Air Tactical Supervisor (ATS) occupied the right seat. ATS initially acted as the airspace manager for the White Draw FTA. However, prior to conducting the retardant drops a third aircraft, Air Attack, entered the White Draw FTA and took over airspace management duties. Air Attack 3 (AA3) piloted Air Attack from the left seat and Air Tactical Group Supervisor (ATGS) was in the right seat.
Upon entering the FTA, the MC noticed a thunderstorm and witnessed lightning between 10 and 20 nautical miles away. ATP determined two retardant drops were needed. Lead B-5 and the MA performed the first drop precisely on target, but the MA’s airspeed was 10 knots slower than planned. As the MA positioned for the second drop, ME and MN noticed an increase in fire activity and surface winds changing in both velocity and direction. Lead B-5 then experienced a rapid “sinker” and ATP stated, “I got to go around.” ATP struggled to keep Lead B-5 under control. In response, MP2 commanded a go-around “out of this” and MP1 pushed the throttles up. Twelve seconds later, ATP advised the MC to dump their load and the MC complied. Despite MA engines at maximum power, airspeed and altitude continued to deteriorate, ultimately resulting in the mishap. The MA impacted lightly-wooded, rolling terrain and slid through a tree-lined ravine which was approximately eight feet deep, before stopping roughly 410 feet (ft) from the initial point of ground impact. MP1, MP2, MN and ME died in the mishap. ML1 and ML2 survived, but suffered significant injuries.
The mishap aircraft (MA) and a USFS-owned MAFFS unit were destroyed. The monetary loss is valued at $43,453,295, which includes an estimated $150,000 in post aircraft removal and site environmental cleanup costs. There were no additional fatalities, injuries or damage to other government or civilian property.
An After Action Report (AAR) was released today about the Waldo Canyon Fire that burned into Colorado Springs June 26, destroying 345 homes and ultimately blackening over 18,000 acres. This AAR is not the final, comprehensive report on the fire, but is considered preliminary. An in-depth analysis will occur over the next several months to fully explore Colorado Spring’s management of the fire.
The organization of the report is a little unusual, listing strengths and recommendations, but omitting many of the issues that caused the recommendations. Therefore, it is not always clear WHY the recommendations were made, forcing an observer to read between the lines. This limits the opportunities for lessons learned and may not in all cases have the desired result of preventing mistakes. Maybe the final report will fill in these gaps.
The report listed several areas identified as “major strengths”, including interagency cooperation, dedicated personnel, pre-incident training and exercises, planning, and the fact that they saved 82 percent of the homes in the direct impact area.
Some of the recommendations:
A system needs to be designed to provide immediate notification to first responders and key agency representatives as decisions are made.
Real-time documentation. Use “scribes” to track real-time information for record keeping and serve as a communication link between locations when primary staff is busy with their duties.
Train staff and volunteers who can serve in the Emergency Operations Center to staff a more robust Logistics Section.
Provide additional training on the use of the Incident Command System (ICS).
A Communications Unit Leader should be assigned to ensure that an incident-wide Communications Plan is developed.
Exercise the numerous emergency management plans. The report listed seven of them.
For the Emergency Operations Center, develop an organization chart early in the incident, and train the personnel on their roles and how to interface with the Incident Command Post.
Develop a plan on how to provide adequate food to incident personnel.
Establish procedures for handling large quantities of donated food and water. Provide incident management training for non-profits and agency personnel to improve management of volunteers and donations.
Develop a plan to ensure incident personnel work consistent shifts and receive adequate rest, breaks, and rehabilitation (food and supplies).
Evaluate the need for post-incident critical stress debriefings.
Develop an ICS organization chart to ensure that a Safety Officer and Accountability Officer are assigned.
Ensure that span of control policies are followed.
Utilize Staging Areas to assist in accountability of personnel and resources.
Use street names rather than neighborhood names to define evacuation boundaries.
Provide maps of areas that are being evacuated to first responders.
In reviewing the recommendations in the ARR, it appears that many of them would be mitigated with adequate training and experience in the Incident Command System, NIMS, or NIIMS. A Type 1 Incident Management Team assumed command of the fire at the end of Day 2, June 24; most of the homes were destroyed on June 26. The team was no doubt very fluent in the use of ICS, but if they were interfacing with multiple agencies who had limited knowledge in the management system, there could have been some inefficiencies and a lack of adherence to ICS protocols.
The U.S. Forest Service has released two additional reports about last year’s Pagami Creek Fire which was managed, rather than suppressed, for 25 days, until it ran 16 miles on September 12, eventually consuming over 92,000 acres of the Boundary Waters Canoe Area Wilderness in Minnesota. We also remind you of the facilitated learning analysis of the eight USFS employees caught out in front of the fire in canoes.
Policy review
The objective of one of the reviews was to determine if the major decisions made by the incident management teams and the staff of the Superior National Forest were consistent with official USFS policy. The review was conducted by one person, Tom Zimmerman, a program manager for the USFS’ Wildland Fire Management Research, Development, and Application Program in Boise. Mr. Zimmerman analyzed the decisions and compared them with 21 policy statements, manuals, directives, and Forest level planning documents. He concluded that the decisions “appear consistent with all levels of policy and process direction”.
Decisions review
There was another review, “looking at decisions made by line officers and Incident Management teams based on the Delegation of Authority from the Forest Supervisor”. The individuals involved in this review were Jim Thomas, Fire and Emergency Operation Specialist for the Eastern Region of the USFS, and Jim Bertelsen, a Superior NF employee acting in his capacity as President of local NFFE Union 2138. This review also found no fault with how the fire was managed, saying no information was overlooked that would have predicted the unprecedented movement of the fire on September 12.
While we don’t dispute the qualifications of Mr. Zimmerman and Mr. Thomas, a person has to wonder if these internal reviews, each conducted basically by one person, would have reached different conclusions had they been completed by a panel of neutral subject matter experts.
Entrapment and near-miss facilitated learning analysis
Deployed fire shelters on the Pagami fire. USFS photo from the facilitated learning analysis.
In addition to those two reviews, released earlier was an excellent facilitated learning analysis (FLA) of the near misses and entrapments of eight USFS employees who were caught out in front of the rapidly spreading fire in canoes while they were trying to evacuate the recreating public from the area. At one point when they were fleeing the fire, the smoke was so thick they could not see the fronts of their canoes. Two people left a canoe and took refuge in the cold water, deploying a single fire shelter over their heads as they floated, suspended by their life jackets. Two others were flown out at the last minute by a float plane when it somehow found a hole in the smoke and was able to find them and land on the lake. Four people, after paddling furiously in the strong winds, dense smoke, and darkness, unable to find a fire shelter deployment site on the heavily forested islands, finally found a small, one-eighth acre barren island where they climbed inside their shelters as they were being pounded with burning embers.
The very well done FLA is a must read. Someone should make a movie about this.
Below is a guest post written by Mike DeGrosky, the CEO of Guidance Group, Inc.
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I want to thank Bill for allowing me to blog as a guest at Wildfire Today.
In 2010, my company, Guidance Group, Inc. coordinated the work of the Secretary of Agriculture’s Independent Large Cost Fire Review Panel, which reviewed the six fiscal year 2009 wildland fires whose suppression costs exceeded $10 million. The six fires included the Backbone, Big Meadow, Knight, La Brea, and Station fires in California and the Williams Creek fire in Oregon.
Phil Schaenman (of TriData Corporation) and I presented the Panel’s final report in a briefing to the U.S. Forest Service on August 13, 2010 followed by a briefing with the Secretary of Agriculture’s Chief of Staff later that week. Apparently, sometime after these briefings, but before the Departments of Agriculture and Interior had completed their review and transmitted the report to Congress, someone, who remains unknown, leaked the report. The report found its way to a group of Forest Service retirees as well as Los Angeles Times reporter Paul Pringle, both who were critics of the Angeles National Forest’s handling of the Station Fire.
When excerpts from the report began showing up in LA Times articles critical of the Forest Service and in Congressional panel hearings, a commenter on Wildfire Today accused me of leaking our own report. Not only was this accusation false, this person offered neither justification for their accusation or evidence to support it. In fact, it would not have been in our interest to leak the report and endanger our reputations and working relationship with the Forest Service, but you never know why people get the ideas they do. At the time, in deference to the Forest Service and their review process, I felt it best to say little. However, now that the report is out in the public domain, I would like to clear the air.
In reality, we first became aware that the report had found its way outside agency circles in early October, when I received a call from a member of the Forest Service retirees’ group challenging the Angeles Forest’s handling of the Station Fire. The caller complimented our work, commended the report, and asked me to verify its authenticity. When I enquired as to how he had come to be in possession of the report, he told me that the group had received the report “from a contractor’s association.” I can only speculate as to how it found its way to Paul Pringle at the LA Times.
It is interesting to note that Mr. Pringle never contacted either the panelists or I. I would have loved the opportunity to help him put his story in context. Interestingly, the members of Congress who conducted panel hearings on the Station Fire in October never contacted us either, nor have the various organizations investigating the Forest Service’s action regarding the Station Fire. That is, in part, my purpose for my entry on Bill’s blog. Those who want to understand how the 2009 Large Fire Cost Review does (and does not) relate to the Station Fire need to know a few things that have gotten lost as the controversy took on a life of its own..
First, having the report in the public sphere was not troubling to us. We are proud of our work and do not fear public scrutiny of it. However, a few people focused on a single paragraph taken from a six-page section discussing the Station Fire. Wanting it to support their point of view, they stretched a few phrases beyond their intended purpose and presented these passages outside the context in which the Panel made them. For example, the Panel’s findings included the following:
Incident Management – The Station fire represented a very large, complex incident, in rugged terrain, involving multiple jurisdictions at the edge of the City of Los Angeles. Fire personnel faced extraordinary challenges. However, the agency personnel, including agency administrators who were actively engaged, handled the situation as well as one might expect given the circumstances. The fact that the IMT came from southern California and had experience with this type of high profile fire proved advantageous” (p. 26).
and:
Initial Response – Controversy continues over whether Forest personnel could have stopped the fire on the morning of August 27 (day 2). Critics claim that if the Forest had airtankers and heavy helicopters on station over the incident at first light, they may have stopped the fire’s spread. If true, more than $90M in cost could have been avoided. However, the Forest Service, Los Angeles County, and CAL FIRE jointly reviewed the initial and extended attack. Their report, issued on November 13, 2009, found that the initial attack ICs acted appropriately and made prudent decisions regarding the safety of firefighters, including those involved in air operations. Further, the report determined that aggressive air operations in the early daylight hours of day 2, without necessary ground support, would not have been effective. The matter remains under investigation and, therefore, beyond the scope of this Panels’ review” (p. 26).
In short, the Panel was largely complimentary of the Forest Service’s incident management under nightmare conditions and, more importantly, the Large Fire Cost Review for FY2009 purposefully avoided the initial or extended attack of the Station Fire. However, these facts remained largely unreported.
Unfortunately, the Panel’s report included an unintended choice of words, causing confusion. Citing factors that increased fire costs, in referencing troubles with ordering federal resources, the report described how, in early 2009, the Regional Forester issued a letter providing budget guidance for the region’s fire preparednessfunds. In the course of our fieldwork, it became obvious that field personnel interpreted the letter to mean that the Forests should order Forest Service personnel and equipment before ordering state or local resources; and that this interpretation had delayed, on occasion, the arrival of critical resources. As an example, the report recounted a situation in which the nearby Morris fire released a strike team of CAL FIRE engines who returned to San Diego while an order for a Federal strike team of engines for the Station fire remained unfilled.
Unfortunately, we inadvertently included the word “initially” in the description of events, leading some to believe that this example had bearing on the controversy concerning the extended attack of the Station Fire, despite the Panel’s statement that the initial attack of the Station Fire was beyond its scope. Some even called it the “smoking gun” that they had been seeking.
In reality, this strike team (and another that was reassigned) were released on August 29th, three days after the start of the Station Fire, not during initial attack. However, it is important to note that, way back in October, as the Paul Pringle referenced report passages in the LA times and the report came up in Congressional panel hearings, we acknowledged to the Forest Service that this section of text described resource orders made early in the fire, but not during initial or extended attack. I still contend that other text in the Station Fire section of the report made that context clear. Inclusion of the word “initially” was inadvertent, and the Panel was aware that the situation occurred days after the fire’s start.
I am pleased that the report is finally out in the public eye, where people can read it for themselves rather than speculating on its contents or allowing others to interpret it for them. I hope that these remarks clarify the relationship between the Large Fire Cost Review for FY2009 and the controversy surrounding the Station Fire.
The Orange County Fire Authority has released their after action review on the October, 2007 Santiago fire, southeast of Los Angeles. The document is 138 pages long and 7.3 Mb. The fire burned 28,517 acres and destroyed 42 structures, including 14 homes, 4 commercial buildings, and 24 out buildings.
On a quick review, I did not see any earth-shaking revelations. There were some challenges with communications (i.e. 800 Mh vs. VHF systems) but have you ever seen an AAR for a large incident that did not mention problems with communications?
Some of the recommendations:
“…aggressively pursue adoption of Very High, High, and Moderate Fire Severity Zones” on the CalFire maps.
Develop a Wildland-Urban Interface Program that includes enforcement provisions, and commit the necessary resources.
Accelerate the purchase of new helicopters, and acquire night vision capability.
Establish a full-time, year-round hand crew, a 2nd seasonal handcrew, and a seasonal fly crew.
Increase staffing on Type 3 wildland engines to include a 4th firefighter.
A sign installed in Harbison Canyon within the footprint of the 2003 Cedar Fire east of San Diego. The fire burned 273,246 acres and 2,232 homes. Photo by Bill Gabbert, 2004.
The second Blue Ribbon Commission Task Force in California since the fires of 2003 presented its report yesterday about how to deal with large wildland fires in the state. The recommendations include more engines, more aircraft, more firefighters, fire safe construction, and better systems for real time communications and intelligence. Many of these were in the report following the 2003 fires but were not implemented because of the state’s fiscal problems. Click here to download the 106-page report (788 KB).
Here is how the LA Times began their story on the report:
Three months after massive brush fires burned hundreds of homes across Southern California, a blue-ribbon task force on Friday made dozens of recommendations aimed at improving the response to large-scale blazes.
But many of the proposed measures are similar to those made after the devastating wildfires of 2003 — and many of those were never implemented because there was no money available.
And because the state is in a fiscal crisis, it remains unclear whether the new recommendations will fare any better. Several reports over the last decade have said California needs to increase the number of firefighting aircraft as well as boost the number of firefighters.
UPDATE: January 18, 2018. The links above no longer work, but found a copy of a 2004 Blue Ribbon Report about the 2003 fires. It is a huge 21 MB file.
