Report released for tree strike fatality on the 2018 Ferguson Fire

Captain Brian Hughes
Captain Brian Hughes. Photo courtesy of Brad Torchia.

The National Park Service has released the Serious Accident Investigation Factual Report for the accident in which Captain Brian Hughes of the Arrowhead Hotshots was killed last year. Captain Hughes died when a 105-foot tall Ponderosa Pine fell in an unexpected direction during a hazardous tree felling operation. It happened July 29, 2018 on the Ferguson Fire on the Sierra National Forest near Yosemite National Park in California.

Captain Hughes, number two in the chain of command on the crew, was in charge of the crew at the time since the Superintendent was at the Ferguson Fire Helibase at Mariposa Airport.

You can download the Factual Report and the Corrective Action Plan. Below are excerpts from both.


Excerpt from the Executive Summary:

…Brian returned to California in 2015 and became a captain of the Arrowhead Interagency Hotshot Crew. As a captain, Brian was a trusted leader and mentor who led by example, inspiring others to train hard and develop their skills. His crew looked up to him and loved him as a brother.

The Ferguson Fire was reported July 13.

[…]

The Arrowhead Hotshots arrived on scene July 16, having spent the previous month and a half working prescribed and wildland fires ranging from one to ten days long. The crew spent the next eight days working alongside other highly experienced hotshot crews to build and prepare a fire containment line for burnout operations designed to burn away the available fuel in a given area and keep the original fire from spreading.

By July 28, the day before the accident, the Ferguson Fire had grown to 53,657 acres and was burning across multiple jurisdictional boundaries. Hughes and IHC-1 Squad Leader were working along the edge of a spot fire on steep, rocky terrain in Division G and identified several hazard snags—dead trees that posed falling and fire risks. One stood out: a 57-inch wide, 105-foot tall ponderosa pine burning approximately 10 feet below its top and producing a steady stream of embers. With winds expected the next day, they agreed the snag posed a significant risk to keeping the fire contained and agreed it needed to come down.

The Arrowhead Hotshots lead sawyer started cutting the tree down on the morning of July 29 with help from Hughes, who temporarily stepped in for the sawyer’s less-experienced swamper. The rest of the crew staged in an area safely uphill.

Hughes and the sawyer intended for the tree to fall uphill into an opening between trees. Instead, the tree fell downhill, hitting the ground approximately 145 degrees from the intended lay. It grazed another standing dead snag as it fell and then rolled and/or bounced farther downhill, coming to rest against other snags and brush.

Hughes and the sawyer had discussed the felling operation in detail. Warnings were issued prior to cutting. They also identified two escape routes in case something went wrong.

As the tree began to fall, the sawyer saw which direction it was going and instinctively ran directly downhill, escaping injury.

Hughes however, had moved about 20 feet downhill before the tree fell and then ran into the primary escape route as the tree started falling and was fatally struck. He was found lying underneath the tree in a space between it and the ground.

Efforts to save Hughes’ life were made on scene by the sawyer, fellow firefighters, and paramedics on the ground and in the air. Despite these efforts, Hughes was pronounced dead as he was being flown to the Mariposa Helibase.


Excerpts (Actions) from the Corrective Action Plan: (The full plan includes responsible parties and due dates)

  • Propose to NWCG that beginning in Fiscal Year 19 the Hazard Tree and Tree Felling Subcommittee (HTTFSC) conduct an evaluation of the “Forest Service Chainsaw, Crosscut Saw and Axe Training-Developing a Thinking Sawyer” course for applicability within the interagency community as an updated NWCG S-212, Wildfire Chain Saws, course. Based on the evaluation NWCG could adopt the course as is or with modifications for S-212 and individual agencies could adopt and use as appropriate.
  • Propose to NWCG that beginning in Fiscal Year 19 the Hazard Tree and Tree Felling Subcommittee conduct an evaluation and gap analysis of tree falling options, felling procedures, training and current best practices and update applicable supervisory operations position training and position task books as appropriate, i.e. Single Resource Boss, Strike Team and Task Force Leader, and Division Supervisor.
  • Propose to NWCG the development of an Advanced Wildland Fire Chain Saws training course beginning in Fiscal Year 19 unless need negated by adoption of “Forest Service Chainsaw, Crosscut Saw, and Axe Training-Developing a Thinking Sawyer” course on interagency basis.
  • Propose to NWCG a Fiscal Year 19 review and revision, if necessary, to FAL3, FAL2, and FAL1 competency and currency evaluation processes managed by NWCG.
  • Propose USDA Forest Service National Technology and Development, in collaboration with the Western States Division of the National Institute For Occupational Safety and Health (NIOSH), conduct a study on effects of acute and cumulative fatigue on wildland firefighters and Incident Management personnel to include fatigue mitigation recommendations.
  • Complete assessment of effects of fatigue, stress, and sleep management on wildland firefighters and incident management personnel to include methods to prepare for and mitigate the effects of fatigue, cumulative stress, and traumatic stress.
  • Propose all wildland fire tree and chainsaw related accident reports since 2004 be reviewed, associated recommendations evaluated for redundancy or conflict, and the current implementation status of recommendations to assist in setting priority actions to reduce similar incidents.
  • Evaluate how changing environmental conditions, such as extensive tree mortality in the west, and more extreme wildfires, are being factored into procedural practices and implementation of wildland fire policy, strategies, and tactics by agency administrators and Incident Management Teams.
  • Assess and consider adoption of USDA, Forest Service Risk Informed Trade Off Analysis process incorporating geographically specific information on topography, fuels, and expected weather to inform decision makers during initial response and extended attack of wildfires.

CHP report: Redding Hotshots’ truck was hit head-on

A Lexus drifted over the yellow line into oncoming traffic

The California Highway Patrol reports that the Redding Hotshots’ crew carrier (or “buggy”) was hit head-on in the accident that sent all 10 occupants of the truck to hospitals on April 30.

The accident was reported by the crew via radio. Members of the 20-person crew trained in first aid began treatment of their injured colleagues immediately.

The other vehicle, a 1996 Lexus, was driven by Linda L. Corr, 66. The report indicates that the Lexus drifted across the yellow line into oncoming traffic and collided with the crew carrier. Ms. Coor was transported by helicopter complaining of pain in her chest.

One of the firefighters was transported by CHP helicopter to Shasta Regional Medial Center. Another was taken by ground ambulance and the other eight were transported by U.S. Forest Service vehicles to local hospitals.

As of May 1 two firefighters were still in the hospital.

Redding Hotshots' Crew Carrier
The Redding Hotshots’ Crew Carrier. Screengrab from @KRCR Photog video.

The crew had been engaged in chain saw training and were returning to their Redding, California base when the accident occurred on SR-299 west of Burney at 5:10 p.m. As is typical of a Type 1 crew, they were traveling in three vehicles — two crew carriers and a superintendent’s truck.

The Forest Service has released very little information about the incident.

After Action Review released for the Carr Fire

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

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

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

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

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

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

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

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

All articles on Wildfire Today tagged “Carr Fire”.

21 issues frequently identified in firefighter entrapment reports

Can lessons actually be learned?

Horse Park Fire
The Horse Park Fire in Colorado, May 31, 2018. Screenshot from the Hotchkiss Fire District video.

The 43-page facilitated learning analysis about the entrapment on the Mendocino Complex of Fires was well-researched and skillfully written. Six firefighters received burns and other injuries when they had to escape from the fire by running through unburned vegetation.

The intent of the analysis and hundreds of others like it is for firefighters to gain knowledge from the dozens of identified lessons learned that were meticulously documented, hoping that they will not be repeated by those who read the report.

That sounds very straight forward and simple.

But will reading about something that occurred on a fire months or years ago and hundreds or thousands of miles away actually influence someone’s behavior, performance, or decision making ability? Intuitively, we may say, “Yes. Of course. Learning about something that went wrong on an incident will keep us from making similar bad decisions later.”

A comment left by Paul regarding the article about the facilitated learning analysis was interesting:

Nothing “new” in the “Lessons Learned”. After decades in the fire service, makes me wonder if Lessons can be really be learned (and applied) at an organizational level. Seems they are constantly learned at the personal level.

Paul makes a good point. Those of us who have read numerous after action reports have seen almost all of the identified lessons many times before. Below are 21 issues mentioned in the Mendocino Complex report that were identified on the August 19, 2018 incident-within-an-incident.

  1. Interpersonal communications
  2. Communications system (radios & repeaters)
  3. Organizational structure
  4. Inadequate briefings
  5. Span of control way out of whack
  6. Inadequate knowledge about the real-time location of the fire
  7. Crew resource management
  8. See something say something
  9. Play the what-if game
  10. Turn down assignment
  11. Interagency rivalry
  12. Inadequate lookout ability due to terrain
  13. Metro firefighters and those from a different fuel type thrown into a complex wildfire situation
  14. Escape routes
  15. Safety zones
  16. Not knowing the real-time location of firefighting resources
  17. Holy Grail of Wildland Firefighting
  18. Burn victims not being sent to a burn center
  19. Very long travel times to fireline assignments
  20. Personnel shortages on Incident Management Teams and Unable To Fill resource orders on fires affecting tactics and safety
  21. Failure to declare an Incident-Within-An-Incident

Will identifying these issues still another time in a well-written document help prevent them from recurring? We have always assumed it will. But if so, why do the well-intentioned reports continue to list many of the same items?

In a perfect world an important lesson to be learned would be described once in a report. It would then become global knowledge in the firefighting world and the issue would never again have to show up in an after action review.

If these documents and formal classroom training is what Paul refers to as the “organizational level”, does he have a point that the most frequent way firefighters learn is from personal experience?

How do we increase the effectiveness of lessons learned reports?

Is there a different, or innovative method that could transplant these lessons into the personal mental “slide shows” that experienced firefighters consult and refer to when they are faced with a tough decision in the field?

Without doubt, someone will say all we have to do is abide by the 10 Standard Firefighting Orders and 18 Watch Out Situations. The Orders have been around for 62 years. Someone else just saying “follow them” will not magically make it happen. That has been said millions of times in the last six decades and still, between 1990 and 2015, an average of 17 wildland firefighters were killed each year. Continuing to do the same thing while expecting different results is not realistic.

Lessons learned after the entrapment on Mendocino Complex of Fires

Six firefighters received burns and other injuries when they had to escape from the fire by running through unburned vegetation

fire wildfires crew carrier damaged burned injuries
Crew carrier that was damaged during burnout operations on the Mendocino Complex of Fires August 19, 2018. Photo from the report.

A facilitated learning analysis (FLA) with dozens of valuable lessons learned was just released about an incident where six firefighters were entrapped on a wildfire and had to run to safety through unburned vegetation. The incident within an incident occurred August 19, 2018 on the Mendocino Complex of Fires east of Ukiah, California. Six firefighters received burns and other injuries when the fire crossed a dozer line in multiple locations during burnout operations and cut them off from their planned egress. Some of the firefighters refused treatment, while others were transported to hospitals where they were treated and released.

You can download the entire report here: (large 7MB file).

One thing to keep in mind when you read the lessons learned is that the organizational structure on the fire, which ultimately burned more than 459,000 acres, was very unusual. Two complete Type 1 incident management teams were ordered for the fire due to its enormous size. Normally when there are two teams on a very large fire they divide it into two geographical zones, with each team assuming responsibility for one. Logistically, in this case, there were not enough logistical resources available to support two large incident command posts, so everyone worked out of one base. The two teams were merged into one, which produced duplicates in some overhead positions.

The report was very skillfully designed and written and could be a valuable resource for wildland firefighters.

Below we have a very brief summary from the report of the entrapment, and following that, all of the lessons learned attributed to the personnel who were on the fire, in their own words. We did not include another section from the report that contains analysis from the FLA team.


BRIEF SUMMARY FROM THE REPORT

During burnout operations, a sudden wind shift and explosive fire growth happened and personnel were cut off from their escape routes. Most of the firefighters were able to move back to their vehicles to exit the area. However, six individuals farther down the dozer line were forced to run in front of the advancing flame front, through unburned fuels to a nearby dirt road for approximately one mile before they were picked up and transported for treatment. Five Los Angeles Fire Department firefighters and one CAL FIRE firefighter were injured. Two unoccupied CAL FIRE emergency crew transports parked in the vicinity sustained damage from the fire when it jumped containment lines.


LESSONS LEARNED BY THE PARTICIPANTS

Interviews were conducted with key personnel involved in the entrapment on the Ranch Fire. At the conclusion of each interview, each person was asked what they learned for themselves from this event and what they believe the greater wildland fire community could learn. The following are the subsequent lessons the participants shared with the FLA Team that they believe could benefit others. When possible, these lessons were written in the words of those interviewed, though a few places lesson were edited for clarity. These lessons were broken into four categories: Aviation, Inter- Crew, Fireline, and Overhead.

AVIATION

  • I’m not sure what lessons I learned could apply to the ground. It is not my job to second guess what folks are doing on the ground. My job is to support them and give them our perspective to help them to succeed. They use our input as another tool.
  • Let incoming aircraft know what type of response they are being requested. This is what it would sound like, “Declare an IWI and have them report to Mendo IP (initial point – aviation) for an IWI.”
  • We had an awareness of not taking risks that would incur potential damage or injuries or add more complexity. There is a balance when you are dealing with a life threatening situation that we didn’t make things worse, i.e. compromise ourselves in poor visibility. We ordered additional support to maintain span of control. We immediately ordered up additional support and didn’t try to tackle it ourselves. Didn’t want to be a liability.
  • Declare an IWI when injuries are discovered and follow IWI protocols so communication is clearer. Not declaring this an IWI created a lot of confusion because others did not understand the extent of the injuries or people involved.
  • I knew the voice on the ground so I did not provide decision points or trigger points. I just gave him the facts based upon what he was seeing. If it was someone else, I might have said no to the operation (in reference to when Dep. Branch II was asking about location of the fire for the burnout operation).

INTER-CREW

  • Everybody has a responsibility to run a risk management profile and use Crew Resource Management.
  • Ask questions when something does not make sense to you.
  • Ensure you and your resources are briefed thoroughly and information is flowing. People need to understand the assignment and have buy in.
  • Maintain transparent communication between resources and within your crew.
  • Speak your mind if something does not feel right. Make sure your voice is heard and understood when doing so. Validate subordinates concerns by passing them up the chain of command. If you are asked a question and don’t have an answer, re-evaluate.
  • Trust but verify. You will receive intel from other resources, but validate that information for yourself. Gather your situational awareness.
  • Rely on your experienced personnel within the group, no matter what position they hold.
  • Do not let urgency influence your actions.

FIRELINE

  • Remain vigilant and consider the worst-case scenario. Play the “What if?” in your mind.
  • Take the time to assess the situation and determine if it fits an IWI circumstance. ”I was mad at myself for not following the IWI in the 206.”
  • Good communications are critical. Validate the information you are given. Take time to scout the line. The best thing to do is ask questions for the things that are unknown and communicate with your people frequently.
  • Have the courage to turn down an assignment.
  • Vulnerability and approachability are key traits of a strong leader.
  • There was a perception that refusing an assignment could get you less desirable jobs or reassigned on the fire.
  • Rank adds to the confusion and tension around speaking up.
  • I think the dysfunction and disconnect between commanders intent and what was happening in division and branches was a contributing factor to the very rushed firing operation.
  • The CAL FIRE/Fed rivalry was evident on this fire and I believe it was a detriment to the operational tempo and production.
  • Help your supervisors and use humble inquiry to have a discussion about tactics. Do things make sense? What is the end state?
  • There was no good vantage point for the lookout. Our perception is that a lookout can see the fire but is maybe in a less than desirable location.
  • If you don’t get a good briefing, ask for it. Make sure to receive a thorough briefing from supervisors.
  • I think we need to encourage a culture of voicing concerns in a professional manner. Leadership needs to be approachable. I’ve been a metro firefighter for more than 30 years.
  • I’ve only been in wildland for 6 years, and I’m like born again after doing some structure protection just a few weeks before on another fire (burning out around six homes, we saved five of them). I really believe in that – this highly influenced my decision to accept the assignment. Huge mistake.
  • PPE. We have it for a reason. Wear it all appropriately, in particular shrouds and gloves.

OVERHEAD

  • Who can call for a “Roll Call” to ensure everyone is accounted for? Should it be done at the division or with the Team?
  • Command channel was never cleared. Weather was read over Command during the incident.
  • It was a difficult unified command. We typically go unified with an IC and maybe OPS, but not unified with two whole teams.
  • Trying to meld two Type 1 teams is not advantageous. There are too many voices and it muddies the water. That was happening on this incident. Having Deputy Branches was a side effect of blending two teams together. We had different operational mindsets and they weren’t communicating clearly enough. If we ever have two Type 1 teams again we need to address this more clearly.
  • Don’t get down into the weeds. This is very difficult when there is a Branch and a Deputy Branch. They need to stay up and out of weeds.
  • Don’t use deputy branches. I will fight tooth and nail not to have a Deputy Branch again. Next time I can isolate branches, make them smaller or broken apart.
  • Regardless of how good the plan is, timing is a critical element of the development of the plan. Sometimes we get wrapped up in the plan and fail to reassess the plan. When conditions changed, we needed to reevaluate.
  • I should have spoken up sooner. When I drove up, I should have voiced more that this was not a viable plan.
  • Put too much time in trying to salvage a line that was already lost.
  • I need to ask more questions to get a clearer picture.
  • Make sure everyone has a clear plan. The basics. LCES. Where are we going? Who is in charge? Leaders Intent, even if briefing has to be hasty.
  • Drop points are not safety zones. TRAs are not safety zones or deployment zones.
  • When you have two teams there can be difficulties like one team pushing for one thing and the other team pushing for another. You have to be more vocal. If we make deputy branches, they have to ride in the same vehicle. They cannot divide and conquer tasks because there is confusion about who is in charge.
  • We created a hybrid of the ICS system. The two ICs got along great. Below OPS is where it got muddled. Both teams had some failures when it came to how we were organized and communicated below us. Once we got feedback from the field, we cleaned up and it went better. There are definitely ways to make it work better.
  • I should have come up on Command and at least notified the medical unit there was an IWI. I should have forced myself to help Branch check those boxes. I’ve been thinking how I could have helped. “At all costs you have to address what you feel isn’t safe.”
  • I’m not blaming CAL FIRE or the Forest Service, I’m blaming human nature. We have to let go of what’s on your shoulder [referring to the organization/agency patches].
  • Talk to each other. We have qualifications for a reason. At the end of the day, we have to work together and realize there are good people out there in all agencies. Talk with people to determine their experience levels and comfort in different fuel types, conditions, etc. If someone is a qualified division, they are qualified. Base actions on the complexity of what the fire is going to do instead of I don’t know this guy or trust him so I’m going to just take this on myself.
  • It took too long for the FLA team to get here. Quite honestly, we were talking to you seven days later. Guys were barely at the hospital when I requested a team. Bring someone in to look at this objectively. I’m a little frustrated that it took a while to get here.
  • When we decided to meld the teams, we asked for Agency Administrators and Incident Commanders to get together and have a frank discussion behind closed doors. I believe that should happen more.
  • Letter of delegation is not real. You need closed-door discussions and talk about it. This settled things down a bit. It might be a best practice.
  • I believe that CAL FIRE and Forest Service are going to work together in the future. Anytime we are going to do that we need to work out HOW beforehand. Every time we have worked out something it’s been during a fire and that’s not the time to do that. We need to look at how both sides operate and drill down how it works and whose going to do what, before the fire bell rings. On the dirt, we fight fire, and it shouldn’t be that different on the teams.
  • For me personally, as Operations when I am in the field I try not to be overly involved in tactics so I don’t know all the details of what has already being looked at. If you get too involved you can get things messed up. I should have spoken up sooner. When I drove up I should have voiced more that this was not a viable plan. Looking back, we should have just fired out to protect people. I took for granted that was what was going on.
  • Branch was calm when the separation happened. He handled it well. It was textbook on how to help folks that are cut off and running. He asked for resources and kept his voice calm. Once the message was passed to all resources that we would shelter in place in the saddle we realized it was not the best place for a safety zone. People stayed calm, folks understood what they needed to do, and it allowed Branch to deal with separated folks.
  • Peer support is important. Having CISM there was awesome. They had a couple of therapy dogs. We now want to have a permanent CISM and dog on our team.
  • OPS leadership out there at the time helped people. They had their heads down on the mission and OPS being there may have helped them survive.
  • We recognized radiant burns can be misdiagnosed or dismissed as minor or superficial. Blisters and swelling can occur many hours later. The burns need to be looked at by a specialist and we had to convince the doctor to get referral to a specialist. We also had firefighters refusing treatment. One firefighter that went in had red ears the night before and the next day they looked like cauliflower. We need a universal protocol.

Report released for rescue and extraction of water tender rollover victim

It happened on the Cougar Creek fire in Washington

water tender fire rollover wildfire
A total of 30 people—using a combination of standard carry and caterpillar carry, depending on the incline—transported Robert from the accident site down to the road via the pathway that the Type 2 Hand Crew constructed, where an ambulance was waiting. From the report.

A report has been released for what turned out to be a difficult and complex rescue after a water tender rolled 150-feet down a slope. It occurred August 18, 2018 on the Cougar Creek Fire outside of Leavenworth, Washington. The steepness and heavy vegetation slowed efforts to extract and transport the 300-pound truck driver but in spite of the challenges the person identified as “Robert” in the report arrived at a Life Flight helicopter about 2 hours and 20 minutes after the first 911 call.

water tender fire rollover wildfire
The pink flagging marks where Robert’s Water Tender slid off the road and rolled down the hill. From the report.

A system of ropes was necessary in order for personnel to access the victim from the top side, but the report heaps a great deal of praise on a Type 2 hand crew that from a lower road…

“…cut a highway through the forest in a matter of minutes.” In fact, the [Division Supervisor] later recalled that the crew was so fast and so efficient that they cleared the path in front of the Medics who were arriving from the bottom. These Medics coming up from the bottom were able to maintain a “comfortable walking pace” behind the crew as they worked.

The timber canopy virtually eliminated the possibility of extraction by a helicopter with hoist or short haul capabilities. Plus, there was a three-hour ETA for the helicopter.

The 30 people on scene carried the victim in a Stokes basket down the steep slope to a waiting ambulance below, using a standard carry and caterpillar (or conveyor belt) system depending on the incline.

water tender fire rollover wildfire

A section in the report section titled “Drills Work!” included this:

Last year, a Montana Incident Management Team put the Type 2 Crew (who cut the access line up to the accident site on this incident) through a drill that taught them how to use the caterpillar system and polished their cutting skills. This crew’s members said specifically that the reason they were so successful on this incident was because of this earlier drill that they had experienced in Montana.

NIFC produced a video about the management of a serious injury complicated by a helicopter incident that occurred on the Deer Park Fire on the Sawtooth National Forest in central Idaho in 2013. In the video, which can be seen in the Wildfire Today article about the incident, you can see a description of the conveyor belt technique for moving a stokes basket in rocky or steep terrain. It begins at 5:25 in the video.

The entire 11-page report about the August 18, 2018 accident on the Cougar Creek Fire can be downloaded HERE (1.4 MB).