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USFS to use new serious accident review system

Bill GabbertAugust 7, 2014October 27, 2016Uncategorizedhuman factors, report11 Comments

(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.

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The USFS’ description of the new policy: Coordinated Response Protocol Paper

Report released on USFS engine rollover in Wyoming

Bill GabbertFebruary 6, 2014December 1, 2021Uncategorizedreport, rollover, safety, Wyoming1 Comment

The U.S. Forest Service has released a report on the August 8, 2013 rollover of Engine 492 southwest of Newcastle, Wyoming. In August we provided some information from the 72-hour report.

Below is an excerpt from the summary — you can read the entire report HERE.

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“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…”

Report released on escaped prescribed fire at Devils Tower

Bill GabbertFebruary 5, 2014August 25, 2019Uncategorizedescaped prescribed fire, prescribed fire, report, Wyoming3 Comments

Above: Map, showing the approximate location of the planned prescribed fire at Devils Tower (300 acres in white) and the 56 acres (in red) that escaped beyond the planned perimeter. Image from Google Earth. Perimeters by Wildfire Today.

Yesterday after Wildfire Today made inquiries about reports that may have been completed regarding the escaped prescribed fire on May 8, 2013 at Devils Tower National Monument in Wyoming, the National Park Service released the official review of the incident.

The NPS ignited the 300-acre unit on May 7, 2013. Several spot fires occurred outside the planned perimeter that were contained the first day. But during mopup at 12:50 p.m. on May 8 fire became established again at one of the spot fire locations on the southwest side of the project. At that time the cooperating U.S. Forest Service resources present the day before had been released. Some of the remaining firefighters were concentrating on the previous day’s spot fires at another location, but most of the firefighters were attending an After Action Review of a non-injury tipover of a Utility Task Vehicle (UTV) that occurred the day before. The 56 acres burning outside the burn unit were mostly stopped at the Monument boundary, but a few acres crossed over onto private land leased by Wyoming state Senator Ogden Driskill, but no structures were damaged.

Devils Tower Rx fire, May 8, 2013 — Devils Tower Rx fire, May 7, 2013. NPS photo.

In the interest of full disclosure, Devils Tower was one of the seven National Parks for which I was the Area Fire Management Officer, from 1998 until 2003.

The review pointed out several times that one of the primary issues related to the escape was that in computing the fine dead fuel moisture, it was assumed that the fire would be shaded by the smoke column. However, some of the area was not shaded, and for two hours each day on May 7 and 8, at those locations the fine dead fuel moisture dropped below the 4 to 10 percent allowed in the prescription, down to 3 percent.

Other than how the weather affected the fuel moisture, the review barely mentioned the weather conditions and the forecast. Two spot weather forecasts were issued before the escape — one at 7:57 a.m. MDT on May 7 and another at 9:29 a.m. on May 8, the day of the escape. For May 8, both forecasts predicted fairly strong northeast winds, of 7 to 15 mph and 8 to 14 mph.

The Remote Automatic Weather Station at Devils Tower is very close to the location of the prescribed fire, in a low-lying area partially sheltered by trees from winds from all directions (see map above). Northwest, north, and northeast winds are additionally partially blocked by higher ground and the Devils Tower itself. Below are the weather observations from the weather station between 17:23 on May 7 through 17:23 on May 8. They show mild sustained wind speeds, with gusts around mid-day to late afternoon on May 8 of 13 to 22 mph. If the weather station was in a more exposed location the recorded speeds would have been higher.

The NPS committed four people to the facilitated learning analysis of the non-injury slow tip over of the UTV, and three to the review of the escaped prescribed fire.

UTV at Devils Tower — Photo from the FLA for the UTV tip over, that presumably shows a UTV in the approximate location of the accident. NPS photo.

We initially covered the prescribed in 2013 fire HERE and HERE.

Weather cited as primary issue in escaped prescribed fire near Hettinger, ND

Bill GabbertFebruary 4, 2014November 17, 2017Uncategorizedescaped prescribed fire, Pautre Fire, prescribed fire, report, South Dakota7 Comments

A report issued by the U.S. Forest Service for a prescribed fire that escaped on the Dakota Prairie National Grasslands in northern South Dakota last year cited weather as being one of the primary factors in losing control of the fire.

The Pasture 3B prescribed fire was planned at 210 acres, 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.

On April 3, 2013 we wrote about the wildfire:

An article in The Rapid City Journal has more information about the impacts of the fire on the ranchers. Privately owned grazing, hay stacks, and miles of fencing were damaged or destroyed during the ranchers’ calving season. Here is an excerpt:

“Laurie Casper, 36, said the fire destroyed 95 percent of her family’s farmland, which is more than 1,000 acres.

‘We lost all of our calving pasture, we lost our summer grazing, we lost our fall grazing, we lost 100 percent of our alfalfa— which we cut for hay bales in order to feed the cattle this oncoming winter— all that’s completely gone,’ she said. ‘And there’s just just miles and miles of fences that are completely gone.’ “

The prescription in the project’s burn plan for the maximum wind speed at eye level was 15 mph and the maximum wind speed at the 20-foot level was 20 mph. One of the spot weather forecasts for the morning of the prescribed fire predicted the passage of the cold front, with winds shifting from the south at 5 to 11 mph in the morning, to northwest at 25 mph with gusts to 30 mph in the afternoon. The actual weather that day was very similar to the forecast.

About a month later, another prescribed fire not too far away, at Devils Tower National Memorial in western Wyoming, also escaped, due partially to strong winds. That report still has not been posted on the Wildland Fire Lessons Learned Center website. We were told today that was due to a glitch, and it will appear there very soon, possibly as early as today, February 4. (UPDATE, February 5, 2014: the National Park Service arranged to have the Devils Tower report posted late in the day on February 4. We wrote about it here.)

The report said firefighters concluded they would not do much different next time (page 12):

Firefighters did an excellent job of planning, organizing and executing this prescribed fire and adhering to the prescribed fire plan. Following the control of the escaped fire some firefighters had difficulty thinking of anything they would do differently next time. While it is true that we work in a dangerous environment with unexpected changes in weather, we strive to be a learning culture and continuously improve our ability to make decisions that evaluate risk and get work done on the ground.

Some of the issues listed by the Facilitated Learning Analysis team 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].

The commendations section included this:

The personnel involved in all levels of the Pasture 3B prescribed fire were motivated, worked well as a team, were adequately trained, and appropriately briefed. They had a keen awareness that this was the first burn of the year, and took numerous precautions to ensure successful completion of the prescribed fire.

We did not see any mention in the report of damaged fences, hay, or pastures.

Some ranchers in western North Dakota donated hay to the South Dakota ranchers who lost theirs in the escaped prescribed fire.

Forest Service’s explanation for their refusal to fully cooperate with Yarnell Hill Fire investigations

Bill GabbertDecember 9, 2013August 25, 2019UncategorizedCantwell-Hastings, report, Yarnell Fire34 Comments

Yarnell Hill Fire at 7:30 p.m. MST, June 29, 2013, approximately 21 hours before the 19 fatalities. Photo by ATGS Rory Collins, Oregon Department of Forestry.

During the two investigations by teams of people working for the Arizona Division of Occupational Safety and Health (ADOSH) trying to document what happened and why during the Yarnell Hill Fire that killed 19 firefighters on June 30, the U.S. Forest Service provided so little information that it was described as “useless” by one of the teams.

The ADOSH “Inspection Narrative” said the USFS provided redacted copies of documents produced by members of the Blue Ridge Interagency Hotshot Crew, which was working nearby during the accident. However, the documents were redacted to the point where they were “useless in ADOSH’s investigation”. The removed portions included not only the names of the Blue Ridge personnel, but all names, as well as information the USFS stated “was of a sensitive nature”.

The other report released simultaneously last week was written by Wildland Fire Associates working under contract for ADOSH. Referring to information they hoped would be available from the USFS, it stated:

…we were given access to all information and personnel that we requested with the exception of the employees of the USDA Forest Service. The USDA Forest Service declined the request to allow their employees to be interviewed for this investigation.

To my knowledge, this is the first time that the USFS has refused categorically to allow their employees to be interviewed following a serious accident that occurred on a fire.

We reached out to the U.S. Forest Service to ask why they provided no meaningful cooperation to the investigations. Their logic is difficult to follow and involved the Privacy Act and a distinction they tried to make between the recent ADOSH reports and the Serious Accident Investigation Team report which was released September 28. They explained that the ADOSH is a compliance and regulatory agency, while the SAIT report was a safety and accident investigation. The entire USFS statement is below:

USDA Forest Service employees are subject to a variety of laws, such as the Privacy Act of 1974, as amended, 5 USC 55a, designed to protect personal and confidential information. We are legally required to withhold certain information due to the requirements of federal law to protect privacy and confidentiality of our employees. At their request, the Forest Service did provide ADOSH some documents for their investigation and offered to provide written response to remaining questions.

For clarification, Arizona Division of Occupational Safety & Health (ADOSH) is a compliance and regulatory agency.

The Interagency Serious Accident Investigation of the Yarnell Hill Fire was, in contrast, a SAFETY and Accident investigation. While the safety investigators also looked into rule compliance the focus was concentrated on understanding why the accident happened; which may or may not be related to rule compliance.

It is interesting that previous interpretations of the Privacy Act have not resulted in “useless” information from USFS employees in serious accident investigations, although there has been a recent trend to leave out names of people that were involved, which is not necessarily a bad thing.

Refusing to allow the federal government employees to be interviewed by the ADOSH teams is a very disturbing development.

The SAIT report did not include any names nor did it list the people they interviewed, so it is difficult to determine how much if any cooperation they received from the Forest Service. That report basically said no mistakes were made, while the ADOSH reports provided much, much more detail about what happened on the fire.

If this is going to be the policy of the USFS going forward, it can severely disrupt future lessons learned inquiries, and in some cases could make them “useless”. Interfering with the process of learning of how to prevent similar fatalities does a disservice to the dead firefighters.

Cantwell-Hastings law

This ridiculous action by the Forest Service may be one of the unintended consequences of the Cantwell-Hastings legislation which became Public Law 107-203 in 2002. It was sponsored by Senator Maria Cantwell and Representative Doc Hastings, in a knee-jerk reaction to the 2001 Thirtymile Fire. The law requires that in the case of a fatality of a U.S. Forest Service employee ”due to wildfire entrapment or burnover, the Office of Inspector General (OIG) of the Department of Agriculture shall conduct an investigation of the fatality” which would be independent of any investigation conducted by the USFS.

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 he pleaded guilty on August 20, 2008. He was sentenced to three years of probation and 90 days of work release.

This law may have made the USFS so fearful of criminal charges and lawsuits that they are refusing to cooperate with fire investigations.

Where do we go from here?

The military has the benefit of a law that is the opposite of the Cantwell-Hastings bill. They have the protection of 10 U.S.C. 2254(d), which states that in the case of an aircraft accident:

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.

Senator Maria Cantwell and Representative Doc Hastings need to suck it up and admit their knee-jerk reaction to the Thirtymile fire has caused a great deal of unintended harm. In 2001 they thought their ill advised idea might enhance the safety of firefighters, but it has accomplished the reverse. Lessons learned are becoming more difficult to uncover. Mistakes are more likely to be repeated because of their legislation which became Public Law 107-203. They wanted investigations, but investigations have always occurred following serious accidents. Their legislation had zero benefits, and had far-reaching negative consequences.

Senator Cantwell and Representative Hastings should feel a moral obligation to fix the problem they created. They need to craft legislation to protect firefighters, similar to that protecting the military in 10 U.S.C. 2254(d).

Contact your Senator and Representative if you have an opinion about the Cantwell-Hastings law.

State analysis of Yarnell Hill Fire fatalities proposes $559,000 fine for Arizona State Forestry Division

Bill GabbertDecember 4, 2013November 19, 2017UncategorizedArizona, Incident Response Pocket Guide, report, Yarnell Fire107 Comments

Yarnell Hill Fire at 1549 June 30, 2013. Photo by Chris MacKenzie of the Granite Mountain Hotshots. The arrow represents the location where the lookout had been positioned earlier.

(Originally published at 2:46 p.m. MT December 4, 2013; updated at 8:30 p.m., December 4, 2013)

Today the Arizona Division of Occupational Safety and Health (ADOSH) proposed fines totaling $559,000 to be imposed on the Arizona State Forestry Division as a result of the fatalities on the Yarnell Hill Fire near Yarnell, Arizona. Their findings were presented to the Industrial Commission of Arizona during a 1:00 p.m. public meeting in Phoenix. The documents can be found HERE.

On June 30, 19 members of the Granite Mountain Hotshots were entrapped by rapidly spread flames from a brush fire and were killed. One member of the crew who was in a different location serving as a lookout was not injured.

Two citations were proposed, one “willful serious” with a tine of $545,000, and another that was “serious” with a fine of $14,000.

[UPDATE at 6:46 p.m. MT December 4, 2013; The commission approved the fines. The Arizona State Forestry Division has 15 days to appeal the decision.]

The willful serious citation included the following (paraphrased):

Failure to furnish a place of employment which was free from recognized hazards that were causing or likely to cause death or serious physical harm.
Implementation of suppression strategies that prioritized protection of non-defensible structures and pastureland over firefighter safety.
The employer knew the suppression was ineffective, and that the wind would push the fire toward non-defensible structures, but firefighters were not promptly removed from exposure to smoke inhalation, burns, and death.
Thirty-one members of a structure protection group charged with protecting non-defensible structures were exposed to possible smoke inhalation, burns, and death.
A lookout was exposed to the same dangers.
Approximately 30 firefighters working on an indirect fireline in Division Z were exposed to the same dangers.
The Granite Mountain Hotshots continued with suppression activities until 1642 hours on June 30 when they were entrapped by a rapidly progressing wind driven wildland fire.

The serious citation, totaling $14,000:

The employer failed to implement appropriate fire suppression plans in a timely fashion during a life-threatening transition between initial attack and extended attack.
When the fire escaped initial attack none of the following analysis procedures were implemented: Incident Complexity Analysis, Escaped Fire Situational Analysis, Wildland Fire Situation Analysis, Wildland Fire Decision Support System, or Operational Needs Assessment.
On June 29 an Incident Action Plan was not completed for the next operational period prior to transitioning to a more complex management team.
The positions of Safety Officer and Planning Section Chief were not filled on June 30.
On June 30 the Division Z Supervisor (adjacent to the Granite Mountain Hotshots’ Division) departed from his assigned position which left Division Z without supervision during ongoing fire suppression operations.

Today, in addition to the citation information, the following documents were released by the Industrial Commission of Arizona:

Incident narrative and timeline.
Maps, photos, and diagrams.
The “Entrapment and Burnover Investigation” report prepared by Wildland Fire Associates.

We will add to this article later with more details about the investigation report, but below are the conclusions reached by Wildland Fire Associates, the consultants hired by the Arizona Division of Occupational Safety and Health:

Fire behavior was extreme and exacerbated by the outflow boundary associated with the thunderstorm. The Yarnell Hill Fire continually exceeded the expectations of fire and incident managers, as well as the firefighters.
Arizona State Forestry Division failed to implement their own extended attack guidelines and procedures including an extended attack safety checklist and wildland fire decision support system with a complexity analysis.
The incident management decision process failed to recognize that the available resources and chosen administrative strategy of full suppression and associated operational tactics could not succeed. This also remained the case when the strategy changed from full suppression to a combination of point protection and full suppression.
Risk management weighs the risk associated with success against the probability and severity of failure. ASFD failed to adequately update their risk assessment when the fire escaped initial attack leading to the failure of their strategies and tactics that resulted in a life-threatening event.

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UPDATE at 8:30 p.m. MT, December 4, 2013

We just finished reading the “Inspection Narrative” compiled by AZ OSHA, and the “Granite Mountain IHC Entrapment and Burnover Investigation” report written by Wildland Fire Associates (WFA).

The Inspection Narrative

We noticed a couple of interesting tidbits in the Inspection Narrative that we don’t remember being pointed out in the previous Serious Accident Investigation Team report which was released on September 28.

One was found on page 18. At approximately 1545 hours, one of the the Type 2 Operations Section Chiefs called the Granite Mountain Hotshots and asked if they could spare resources to assist in Yarnell. Either Marsh or GMIHC Captain Steed responded that they were committed to the black and he should contact the Blue Ridge Hotshots.

While the GMIHC said they were not available for the change in assignment, the request from the Ops Chief informed them that they were needed in Yarnell. This may have influenced their decision to move toward the ranch, perhaps with the ultimate goal of assisting in the town. We could not find a mention of this in the WFA report.

One other item in the Narrative (on page 17) we noticed was a disagreement and/or confusion about the break between Divisions A and Z. The Division Z Supervisor didn’t arrive on the fire line until 1 p.m. on June 30. I in addition to the Division break fiasco, he was not clear at all about what tactics in the area could be successful. He left the fire line to head to the Incident Command Post and did not return. Parts of this were also mentioned in the WFA report. The problem with filling the Division Z position was mentioned in the citation.

Below are some quotes from the WFA report:

P. 15: At 1558, ATGS abruptly leaves the fire and goes to Deer Valley. He turned air tactical operations over to ASM2 who was busy dealing with lead plane duties at the time. ASM2 got a very brief update from ATGS that did not include division breaks locations and the location of the on-the-ground firefighters. ASM2 had been ordered as a lead plane because ATGS functions were covered.
Continue reading “State analysis of Yarnell Hill Fire fatalities proposes $559,000 fine for Arizona State Forestry Division”

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