The Associated Press and the Prescott Daily Courier are reporting that the Arizona version of the federal Occupational Health and Safety Administration will disclose their version of an investigation into the deaths of 19 members of the Granite Mountain Hotshots on Wednesday. The firefighters were entrapped and killed while suppressing the Yarnell Hill Fire in Arizona on June 30. Their requirements are that the report must be complete no later than six months after their investigation was announced, which would make it due no later than the first part of January, 2014.
The Arizona Division of Occupational Safety and Health will formally present their findings to the Industrial Commission of Arizona, their parent agency, at a 1 p.m. public meeting Wednesday, December 4, in the 1st Floor Auditorium, 800 West Washington, Phoenix, Arizona.
Both media organizations said the agency will recommend citations and penalties against state organizations. An agenda that has been released for the meeting said “Discussion & Action of OSHA Proposed Citations & Penalties. Arizona State Forestry Division, State of Arizona”, but does not mention the Yarnell Hill Fire.
The judgments and decisions of the incident management organizations managing this fire were reasonable. Firefighters performed within their scope of duty, as defined by their respective organizations. The Team found no indication of negligence, reckless actions, or violations of policy or protocol.
The objective as stated in the document was to “understand the rationale for the actions/decisions involved in the incident and then, if possible, to learn from them”.
Frequently at Wildfire Today we will write a summary and then our analysis of serious accident reports, but this particular document is very different from the traditional report. It adopts the new paradigm of leaving out conclusions and recommendations, a process that began to be etched into stone in August when the Serious Accident Investigation Guide was revised. This Learning Review claims that “conclusions can sometimes close the door on learning”. I would say on the other hand that they can more frequently open the door to an enhanced safety environment for firefighters. People can sometimes be hit by meteorites, but not often.
And like virtually every research paper, most of the recommendations are for additional studies, ensuring continued employment for academics and researchers.
Call me old school, but this document appears to be more useful for human behavior researchers than firefighters. How did we get to the point where language such as this is used repeatedly in a U.S. Forest Service funded official report about a wildland fire?
“Typical mission flow”
“Synthesis, analysis and sensemaking”
“Margin of maneuver”
“Sensemaking team”
“Single Loop vs. Double Loop Learning”
“Hoberman Sphere”
“Pressures and filters”
“Mind maps”
“Auditory signal”
“Signal detection”
The Learning Review does suggest that two additional products be prepared, one for “the field” and another for “the organization”. Maybe the field document, if produced, will be more useful for firefighters. And presumably the organization version will have conclusions and recommendations that will remain secret if the guidelines revised in August are followed.
I am not sure why the U.S. Forest Service paid the 22 people, plus multiple focus groups, to produce this study if they did not receive for their investment products usable by the field or the organization.
But I am old school when it comes to opportunities for learning lessons.
Little Bear Fire, burning operation on 532 Road, June 13, 2012, Photo by Kari Greer/USFS
There can be a variety of narrative reports written about a wildfire, including 24-hour and 72-hour, After Action Review, Individual Fire Review, Fire and Aviation Safety Team Review, and Lessons Learned Review. But a type that was new to us has been released about the 2012 Little Bear Fire in New Mexico. It is titled “Little Bear Fire Summary Report” which is a vague title for a report that analyzed perceptions — how the fire was viewed by fire managers and local residents.
It could be categorized more as research than a conventional report on a fire. A team of seven social scientists from North Carolina State University, the U.S. Forest Service, University of Colorado, and Ohio State University conducted interviews of stakeholders, with a focus on perceptions of the event itself — communication, evacuation, and wildfire preparedness. They talked with community members, local organizations, and federal agency personnel.
The Little Bear Fire started on June 4, 2012 northwest of Ruidoso, New Mexico and was contained at four acres with a fireline around it during the first five days. On the afternoon of the fifth day a wind event blew embers from a torching tree outside the fireline causing the fire to eventually burn 242 houses and 44,330 acres.
The management of the fire has been a magnet for criticism from politicians, residents, and others. But this new report does not explore in detail the tactics, strategy, or suppression decisions that were made — it concentrates on how the fire was perceived.
“Gordie”, a Wildfire Today reader, in commenting on how the U.S. Forest Service expends time and energy on designating “Honorary Forest Rangers” such as Arnold Schwarzenner and Betty White, wrote in part:
…A public official in Washington state once said (paraphrased): “What we are perceived to do may be more important in our customer’s eyes than our actual accomplishments.” A horrible truth, but for the great unknowing masses, looking good is more important [to] taxpayers than actual functionality.
Applying Gordie’s analogy, the USFS ordered research to determine if they are “looking good”.
We will get to the report’s findings, but first there was one fact about the management of the fire that was new to us. On June 9, the day after the four-acre fire blew up, the New Mexico Governor ordered a second Type 1 Incident Management Team. This decision was made without consulting the existing Type 1 team, which learned of the order hours after it had taken command of the fire. When this was discovered, the second team was assigned to stage at Albuquerque, rather than continue to the fire.
We wrote on September 27 that the media might find it difficult to develop story lines or come up with coherent, introspective, meaningful coverage about yesterday’s release of the Yarnell Hill Fire report if it did not include causes and recommendations. The report provided more information about the deaths near Yarnell, Arizona on June 30 of 19 firefighters, members of the Granite Mountain Hotshots.
The document did not identify causes or contributing factors like we have seen in other fatality reports. It had some conclusions and recommendations, but they were fairly mild and did little toward pointing fingers at specific acts or omissions that caused the accident.
This made it difficult for reporters who in most cases know little about wildland fire to summarize the report in a short news article. Facts about outflow winds, rate of spread, and staying in the black, meant little.
Many of them looked for something that was easy to understand or was measurable, like “radio problems” which was in the headline of some stories, or the number of air tankers. A radio programming mistake, leaving out the tone guard on frequencies, at first made it impossible to use those channels for communication. Some radio systems require not only that the correct frequency be programmed, but that a brief audible tone be added. If the tone is not included when transmitting, the receiving radio will ignore the transmission. The report said crews developed “workarounds so they could communicate using their radios”. Apparently this problem was solved or at least partially mitigated. The report did not elaborate on the “workaround”.
Here are some of the headlines and the first points mentioned about the causes, in articles we found about the release of the report:
Washington Post: In the first paragraph mentions an “unpredictable desert thunderstorm” and “confusing radio communications”.
Huffington Post’s headline: “Yarnell Fire Radio Problems Cited In Deaths Of 19 Firefighters, According To New Investigation”.
Associated Press headline at Firehouse.com: “Video: Yarnell Hill Fire Report Indicates Radio Issues”.
AZCentral.com, at the top of the article is a short video of lead investigator Jim Karels mentioning the radio programming issue.
LA Times cites “problems with radio communication”.
Associated Press at ABC15.com, in the first paragraph, said the report “…cites poor communication between the men and support staff, and reveals that an airtanker carrying flame retardant was hovering overhead as the men died.” (I would like to see a video of that “hovering” air tanker, which was a DC-10.)
NPR Blog cited “weather reports that may have been misunderstood [and] radio communications that the investigators deem ‘challenging.’ “
ABC7 news in Denver: “…poor communication between the men and support staff, and reveals that an airtanker carrying flame retardant was hovering overhead as the men died.”
New York Times: “…it outlined several problems, like radios that sometimes did not work properly, updates that did not give a precise sense of the crew’s movements, and the 33-minute period of radio silence.”
BBC: “…inadequate communication played a role in their fate…The report authors describe radio communications as ‘challenging throughout the incident’.”
In most of these articles citing radio issues, they are referring to the programming mistake, but some go on to discuss a failure of people to adequately communicate their thoughts to one another, which at times was an issue and led to confusion about the location of the Granite Mountain Hotshots. Other related problems were too much radio traffic on some frequencies and the workload of the Aerial Supervision Module which resulted in them missing some incoming radio calls from the 19 trapped firefighters.
(Originally published at 11:19 MDT, September 28, 2013; updated at 6 p.m. September 28, 2013. Observations after reading the report are at the bottom of this article.)
The Arizona State Forestry Division has released the Serious Accident Investigation report of the Yarnell Hill Fire, which on June 30, 2013, killed 19 members of the Granite Mountain Hotshots. It was produced by a very large cast of characters, 18 core Team Members, 17 Support Team Members, and 19 Subject Matter Experts, for a total of 54 people.
The report found:
The judgments and decisions of the incident management organizations managing this fire were reasonable. Firefighters performed within their scope of duty, as defined by their respective organizations. The Team found no indication of negligence, reckless actions, or violations of policy or protocol.
Air Attack’s photo of the Yarnell Hill fire at 7:24 p.m. June 29, 2013
A news conference about the report was live-streamed by at least two Phoenix area television stations. In the question and answer period several national news organizations as well as local media asked questions of the five-person panel which consisted of the Arizona State Forester, two people from the investigation team, and two officers from the Prescott Fire Department.
Below is a 21-minute video released by the investigation team today, which they described as a “A brief overview of the Yarnell Hill Fire Investigation report.” Much of it comes word for word from the report but it makes effective use of Google Earth to provide an overview of the geography of the fire.
Granite Mountain Hotshot Christopher MacKenzie shot the two video clips below shortly after 4:00 p.m. on June 30, 2013. These are the last images of the hotshots before they died. The video was unexpectedly made available today for the first time by the Prescott Daily Courier, which has an article about how the video and other photos of the fire were found.
Our observations after reading the report and viewing the press conference and the question and answer session.
The official report commissioned by the Arizona State Forestry Division, a case of them investigating themselves, did not break much new ground. There was little of a negative nature written about the crew or their employer, the Prescott Fire Department, which was barely mentioned. The Granite Mountain Hotshots were fully qualified, staffed, and trained and they were on day 13 of a permitted 14 days in a row of fighting fire. And, there was “no indication of negligence, recklessness actions, or violations of policy or protocol”.
Why did the Granite Mountain 19 leave the “black”?
The investigators emphasized that they were unable to answer one of the most-asked questions about the fatalities — why the crew left the safety of the already burned area, the black, to attempt to walk 1.6 miles mostly through unburned brush to another safety zone, the Boulder Springs Ranch. They came to within 0.38 miles of their destination when they encountered one of the heads of the fire that had wrapped around the ridge to their left in the box canyon and was headed toward them, cutting off their path probably much to their surprise. Click the map below to see a larger version of the wind at the deployment site.
No one knew where the crew was in relation to the fire
There was confusion about the location of the crew. Other firefighters thought they had either remained safely in the black where they had been for a while, or they had headed north to another safety zone. But instead, they traveled south. When they reported that they were entrapped and were deploying their fire shelters, no one knew where they were. Finally they told Air Attack they were on the “south side”, but even though a DC-10 air tanker was orbiting and ready to drop on them, airborne personnel could not find them, either due to heavy smoke or because they were looking in the wrong place. But under the extreme wind and fire conditions, it is unlikely that air support would have helped the firefighters very much.
Improving situational awareness
This is another fire, like the Esperanza Fire, where if the fire overhead, such as a Division Supervisor, Operations Section Chief, or Safety Officer, had known the location of the personnel on the fire in relation to the real-time spread of the fire, it could have saved lives — 24 on these two fires alone.
It is irresponsible for the wildland fire agencies to continue to do nothing to improve the situational awareness of firefighters, which has proved fatal to too many of them.
We have written about this several times before. Many local fire departments, EMS divisions, and police units have the ability to send location data to dispatchers. If the analog or digital ground-based radio systems being used today can’t handle this task in remote areas, then use a satellite-based system. The U.S. Forest Service asked for proposals to purchase thousands of little location devices last year, and adding high tech video systems to air attack ships could help. We have also written about a device we called a Firefighter’s Emergency Situational Awareness Device, a FESAD.
One of the recommendations in the report was to “review current technology that could increase resource tracking, communications, real time weather, etc.” The Q&A panel today said, in response to a question, that the surviving family members of the 19 Hotshots strongly suggested while being briefed this morning that tracking systems for firefighters be utilized.
Very Large Air Tanker not ordered because of “steep terrain”
The information that the state of Arizona released on July 16 about the resources deployed on the fire said a DC-10 Very Large Air Tanker (VLAT) was in Albuquerque and available on June 29, but was not ordered due to Air Attack’s concern about its effectiveness in steep terrain and inability to deliver retardant before cut-off time. The way this was addressed in today’s report was “ICT4 declines the VLAT offer at 1750 [June 29] based on fire conditions.” There was nothing about “steep terrain”, which didn’t exist on the fire to the extent that it would severely limit the effectiveness of a DC-10 VLAT. In fact, the next day, June 30, they used the hell out of both DC-10s, dropping over 88,000 gallons in 8 flights. A recommendation in today’s report was to “…develop a brief technical tip for fire supervisors/agency administrators on the effective use of VLATs.”
Air tanker drops on Yarnell Hill Fire, June 29 and 30, 2013.
The DC-10s may have been effective on June 29 when the fire was still small, but by the time they both arrived on June 30, the day of the entrapment, the wind event was making it difficult for anything dropped from the air to slow down the fire — too much heat, and too much wind blowing the retardant away before it hit the target.
Aerial Supervision Module taking on too many roles?
During the time of the entrapment the roles of Air Attack and Lead Plane were filled by a single aircraft called an Aerial Supervision Module (ASM), coordinating all of the aerial firefighting, directing air traffic, preventing aircraft from bumping into each other, developing tactics, AND serving as Lead Plane, physically leading the air tankers into their targets about 200 feet above the ground. The Lead Plane duties limited their ability to perform full Air Attack responsibilities over the fire at the same time. The report said, “ASM was too busy handling multiple duties to communicate with the crew just prior to the deployment”.
One of the recommendations in the report is to request the National Wildfire Coordinating Group to develop guidance to identify at what point is it necessary to separate the ASM and Air Attack roles to carry out required responsibilities for each platform.
No overwhelming force
The ordering and use of ground and aerial firefighting resources was less than aggressive on June 29, the day before the tragedy when the fire was still small. The only air tankers used that day were two single engine air tankers, and for only part of the day, dropping a total of 7,626 gallons. After being released, they were requested again by Air Attack, but dispatch only allowed one to respond to the fire, wanting to keep one in reserve in case there were other fires. General Norman Schwarzkopf’s philosophy when confronting the enemy was to use “overwhelming force”. This strategy also is effective when confronting a wildfire. Overwhelming force for a short amount of time can prevent megafires burning for weeks, consuming many acres, dollars, and sometimes homes and lives.
New guide for wildfire accident reports requires conclusions and recommendations to be kept secret, intended for internal agency use only.
On Friday we wrote about some of the controversial issues that have surfaced in recent weeks related to the deaths of the 19 members of the Granite Mountain Hotshots on the June 30 Yarnell Hill Fire. One of them, covered by the USA Today, concerned the reports prepared by the Serious Accident Investigation team.
The latest Serious Accident Investigation Guide, revised just last month, was written by representatives of the five federal land management agencies and recommends that two reports be prepared. One, the Factual Report, would be made public, and the other, the Management Evaluation Report, would be confidential, and intended for internal agency use only.
According to the new guide released last month, “Only the facts go into the Factual Report— no inferences, conclusions, or recommendations.”
The confidential Management Evaluation Report would include:
Findings identified in the Factual Report
Cause(s) of the accident
Conclusions and observations
Confidential information (no witness statements or autopsy reports)
Recommendations for corrective measures
Other findings—findings not related to the accident which if left uncorrected could lead to future accidents/organizational failures (follow specific agency policy regarding other findings)
If conclusions and recommendations are kept secret, only to be seen by a few people, this would severely limit the opportunities to learn any lessons that could prevent similar tragedies.
These recommendations released in August, if followed by the teams writing the reports for the Arizona state government and others in the future, would result in public reports that are much different from those we have seen in recent years. Some that come to mind that include causes, contributing factors, or recommendations are the CR 337 Fire Fatality, the Steep Corner Fire Fatality, the Dutch Creek Fire fatality (huge 21Mb file), and the Sadler Fire entrapment.
The five people who wrote the new guide may be fearful of lawsuits and criminal charges which began after the 2001 Thirtymile Fire. Senator Maria Cantwell and Representative Doc Hastings, in a knee-jerk reaction to that fire, wrote the Cantwell-Hastings bill which was approved by Congress, signed by the President, and became Public Law 107-203 in 2002. It requires that in the case of a fatality of a U.S. Forest Service employee “due to wildfire entrapment or burnover, the Inspector General of the Department of Agriculture shall conduct an investigation of the fatality” which would be independent of any investigation conducted by the USFS.
Before the Thirtymile Fire 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 food stamp fraud or violations at a chicken ranch than evaluating fire behavior and tactical decisions at a wildfire. The goal of the Inspector General investigation is 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 he pleaded guilty on August 20, 2008. He was sentenced to three years of probation and 90 days of work release.
This had a chilling effect on firefighters who are required to make split-second decisions that later may be second guessed by a jury with no clue of what it is like to be faced with a life and death situation on a rapidly spreading wildfire.
Since those felony charges were filed against a firefighter who may or may not have made an error in judgement while fighting a fire, most wildland firefighters with any connection at all to a serious accident have had reservations about talking to investigators. They are being advised behind the scenes to “lawyer up” and to say little if anything about what they know or observed. Many have purchased professional liability insurance which would help to defray the cost of hiring attorneys which otherwise could ruin the financial lives of underpaid government employees and their families.
The unintended consequences of Senator Maria Cantwell and Representative Doc Hastings’ legislation has changed fire investigations. If firefighters can’t feel free to discuss what happened on a fire, finding any lessons to be learned is going to be difficult. This could result in the same mistakes costing more lives.
…not absolute rules. They require judgment in application.
Accident investigators, including the amateurs from the Office of Inspector General’s office, have found it easy to use the Orders and Situations as a checklist, saying “x” number of them were violated. That later becomes fodder for attorneys in civil suits and prosecutors seeking to put firefighters in prison.
It appears that the writers of the new investigation guide placed more emphasis on preventing criminal charges and civil lawsuits than learning lessons when they decided to keep secret the conclusions and recommendations following serious accidents. They may feel they were forced into this very uncomfortable position because of the current lawsuit and criminal prosecution atmosphere.
How do we fix this?
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).
The Associated Press and the Prescott Daily Courier are reporting that the Arizona version of the federal Occupational Health and Safety Administration will disclose their version of an investigation into the deaths of 19 members of the Granite Mountain Hotshots on Wednesday. The firefighters were entrapped and killed while suppressing the Yarnell Hill Fire in Arizona on June 30. Their requirements are that the report must be complete no later than six months after their investigation was announced, which would make it due no later than the first part of January, 2014.
