John Segar, FWS Chief Branch of Fire Management, presents Kaili McCray with Citation for Exemplary Action.
The U.S. Fish and Wildlife Service (FWS) at the National Interagency Fire Center (NIFC) in Boise, Idaho presented a Citation for Exemplary Action to Larry (Kaili) McCray, Wildland Fire Medical Standards Program Manager with the U.S. Department of the Interior (DOI). McCray, a FWS employee serving at NIFC in the position co-funded by other DOI bureaus, was awarded the Departmental honor for heroic acts at the 2013 Beaver Creek Fire on the Sawtooth National Forest northwest of Hailey, Idaho.
The Exemplary Act Award recognizes McCray’s prompt action and decisions that contributed to saving a life on August 13, 2013. McCray administered chest compressions, applied an automated external defibrillator (AED), and ordered oxygen in response to a fire camp crew member who suffered a cardiac arrest. He coordinated his efforts with two other trained employees assigned to the fire from the U.S. Forest Service and the State of Maryland. The emergency room physician who later cared for the victim credited the responders’ actions and use of the AED on site with saving the patient’s life.
McCray was assigned to the Beaver Creek fire as a Medical Unit Leader trainee when the incident occurred, and has also been qualified as a wildland firefighter since 2010.
The Citation, signed by FWS Director Dan Ashe, was presented to McCray by his supervisor, FWS Chief, Branch of Fire Management, John Segar.
“The victim’s heart had stopped. Kaili’s quick thinking, decisive action, and leadership were directly responsible for preventing a death,” said Segar. “He joins a small and select group within the fire community ever to receive this award.”
In 2013, there were nine cardiac cases reported on wildland fires, with six of them fatal. The three saves resulted from AED and other life support equipment being available and properly used by trained personnel responding immediately. Since 1990, cardiac arrest has been the third-leading cause of wildland firefighter deaths. Aircraft and vehicle accidents are the first and second leading causes respectively of wildland firefighter fatalities.
The Wildland Fire Lessons Learned Center posted a standard incident review, which is available online.
Shawna Legarza, a former Hotshot who is now the Director of Fire and Aviation for the U.S. Forest Service’s California Region was interviewed for the CBS evening News.
The subject came up of tracking the location of firefighters. We have written often about what we call the Holy Grail of Wildland Firefighter Safety, a system that could track in real time the location of firefighters on the ground AND the location of the fire, all displayed on one screen — anything from a cell phone or seven-inch tablet to a laptop computer at the Incident Command post. This data should be available in real time to ground and aviation personnel on fires, as well as key supervisors and decision makers in the Operations and Planning Sections. Knowing the positions of personnel relative to the fire would be a massive step in improved situational awareness and could reduce the number of firefighters killed on fires. This information could have saved 24 lives in recent years — 19 on the Yarnell Hill Fire and 5 on the Esperanza Fire. In both cases the firefighters and their supervisors did not know where the firefighters were relative to the location of the fire.
The technology is available right now. The military has been using it for years. Our leaders in wildfire suppression need to make the decision to get it done.
Granite Mountain Hotshots hiking to their assignment, June 30, 2013. Photo by Joy Collura.
It has been almost a year since 19 firefighters were killed on the Yarnell Hill Fire, June 30, 2013. The dust has settled near Yarnell, Arizona and many claims have been filed against various government agencies. One of those was converted into a lawsuit Monday when it was filed in Maricopa County Superior Court in Phoenix. It lists 162 property owners who name the state and the Arizona State Forestry Division as defendants. From the suit:
If the Arizona State Forestry Division had competently managed, contained and suppressed the Yarnell Hill Fire, no member of the Granite Mountain Interagency Hotshot Crew would have died. And Yarnell and its people would have escaped devastation.
That was the first of several lawsuits that will probably be filed. The second was issued Wednesday by 12 of the families of the firefighters killed in the fire.
While the sudden deaths of 19 people is horrific, it would ease our pain somewhat if we thought that something, anything, could come out of this that resembled lessons learned. If a few tidbits could be found in the ashes of the fire that could help others avoid a similar fate, maybe we could move forward with a glimmer of hope.
An experienced firefighter can analyze the two official reports about the fatalities, and combined with reading between the lines and drawing conclusions based on their knowledge, they can nit pic using 20-20 hindsight like a Monday morning quarterback. We succumbed to what we saw as inevitable and after the second report came out in December wrote a piece listing 19 issues, or holes in the slices of Swiss cheese, that when combined, the holes align, permitting (in James T. Reason’s words) “a trajectory of accident opportunity”, so that a hazard passes through holes in all of the slices, leading to a failure.
We put the 19 issues into four categories: supervision of aerial resources, supervision of ground personnel, planning, and communication. This was not the first time these issues, or deficiencies have been seen on wildland fires. Communication, for example, is listed in almost every investigation report for a fatality on a fire. And it was not the first time that firefighters took on an assignment without an adequate briefing, without a current map of the fire, had incorrectly programmed radios, no safety officer, no written incident action plan, or that an incident management team arrived on the third day of a fire without any Division Supervisors.
When you combine all of the slices of the Swiss cheese and their 19 holes, failure is not inevitable, but it becomes more difficult to avoid. When a sleepy fire awakens and becomes complex all within the space of a few hours, it taxes the infrastructure that has been put in place. A robust organization can be resilient in the face of adversity, recovering quickly from difficult conditions, possibly even compensating for 19 holes. But if the organization and decision making, affected in some cases by little sleep over the previous 48 hours, is stressed and tested beyond its limits, undesirable results are more likely to occur.
It is conceivable that if one or more of the issues, or holes, had not occurred, we would not be mourning the 19 members of the Granite Mountain Hotshots.
One thing we don’t know about the fatalities on the Yarnell Hill Fire is why, exactly, the 19 firefighters walked into what became a lethal firetrap in a canyon. Nothing in the reports shed much light on how that decision was made, or by whom. It seems counter-intuitive that experienced firefighters would leave the safety of a previously burned area and expose themselves to the fire as they walked through unburned, very flammable vegetation, especially after a warning had been issued over the radio about an approaching thunderstorm cell with strong winds.
As the lawsuits work their way through the court system, the discovery process may yield information the government agencies that commissioned the reports preferred to be kept out of the public eye. Questions may be answered.
We can label them mistakes or unfortunate decisions, but what was done on the fire has been done before. Most of the time firefighters are lucky and get away with it, returning to their families when the fire is out. Other times they become documented in fatality reports.
While there may be few cultural changes coming out of this fire, other than perhaps being more aggressive and attacking new fires with overwhelming force, many firefighters and managers will move some basic safety principles closer to the surface of their ongoing evaluation of conditions on a fire. Supervisors may double and triple-check the location of their fire resources, and confirm through active listening techniques that orders and assignments are absolutely clear and understood. And that works both ways, up and down the chain of command. Fire managers could evaluate the supervision of aerial resources more often to ensure that the workload and span of control are within reasonable limits. Agency administrators could be certain that the management structure on a fire is appropriate for the complexity, and that “short” incident management teams are rarely if ever used. Transitions from one incident management organization to another may be watched more carefully.
Based on what we know about the fire, there is no earth-shaking revelation that can become a lesson learned. They have already been taught. Firefighters have been making the same mistakes for decades. They end up in reports that sit on shelves or hard drives. Unfortunately, another firefighter will repeat them. And they might be lucky, or resilient, and go home to their family when the fire is out.
A group of five retired wildland firefighters has formed an organization called “Safety Matters”. Their goal is to “call attention to deficiencies in wildand firefighter safety presented by current wildland fire management systems.”
Since they came out in January, they have been soliciting input from individuals interested in wildland fire, and have been studying fires that occurred between 1990 and 2013 where firefighters were killed. Their most significant product to date is a 16-page report released Monday, titled Safety Matters Forum Briefing. The document identifies some commonalities in the fatality fires and provides suggestions for improvements in the areas of fatality investigations, the role of the Agency Administrator, fire program leadership, emergency communications, and mapping. They did not take on the issue of fire supervisors knowing the real time location of their firefighters and the fire, what I call the Holy Grail of Firefighter Safety.
Monday morning they sent the report to all members of the National Wildfire Coordinating Group. Some of the best stuff in the report is in the Executive summary. Here is an excerpt (emphasis added):
…Safety Matters feels that the lack of participation by management in the fire management decision process is a major failing in providing for firefighter safety. A majority of firefighter fatalities in the last 20 years have occurred after a fire has escaped initial attack and before a full incident management team has assumed management responsibilities for a fire. Given this situation we do not feel it is ever the sole responsibility of firefighters to assess the values at risk and determine the appropriate action. Investigations of firefighter fatalities due to burnovers or entrapments seldom look at management involvement, but rather focus on decisions made by the affected firefighters. It is time to quit blaming firefighters for the lack of management involvement.
We further believe that the current system tasked with protecting firefighters is seriously flawed. There are several National Wildfire Coordinating Group (NWCG) committees that are tasked with addressing the issue of firefighter safety, but there is no clear or obvious path for an identified problem to be brought forward and be addressed through a change in policy or procedure. Additionally, the current system staunchly supports the idea that only those within the system are qualified and experienced enough to provide credible input.
Safety Matters believes that the current approach needs to change both procedurally and behaviorally in order to truly make firefighter safety the first priority. A comprehensive review by a diverse and impartial group of experts would help clearly identify the shortcomings of the current system, and help craft a revised system that would best ensure that firefighter safety is the first priority.
One of the more interesting recommendations is about the structure of fatality investigations:
….We believe that a National Transportation Safety Board (NTSB) model of accident investigation would better meet everyone’s needs in investigating wildland fire fatalities. This approach would allow a single independent investigation of the accident by an impartial group of specialists. The advantage is that this model is not constrained by time, agency agendas or associated politics, or public pressures.
Black Forest Fire, Colorado Springs, Colorado, June 15, 2013. Photo by Bill Gabbert.
One of the most dangerous things wildland firefighters do is simply being under trees. Frequently firefighters are injured or killed after being hit by limbs or entire trees that fall. And it is not just fallers cutting down trees that are exposed to the hazards. Just last week a visitor in Yellowstone National Park was killed by a falling tree that had been a standing, dead lodgepole pine, fire-killed 26 years earlier during the park’s 1988 fires.
When I was a chain saw operator and faller on the El Cariso Hot Shots, three limbs, all about four feet long and four inches in diameter, fell out of a 36-inch diameter snag I was falling. One hit me square on the top of my aluminum hard hat, putting a sizable dent in it as I was making the final cut. I was stunned for a couple of seconds, but after I collected myself I realized that the swamper had been hit on his back by two of the limbs as he was bent over. It turned out to be a serious injury that affected him for a long time. We were lucky that the limbs were not any larger; it could have been a lot worse.
Just to illustrate the point of the danger faced by firefighters from trees, burning or not, here are some accidents we found with a quick search on Wildfire Today. This is just a partial list.
The Defense Advanced Research Projects Agency (DARPA) has donated $225,000 worth of situational awareness equipment to the Prescott, Arizona Fire Department. The 19 firefighters that died on the Yarnell Hill Fire on June 30, 2013 were members of the department’s Granite Mountain Hotshots. It is likely that if the fire’s chain of command knew that the crew had left a safe area and decided to hike through unburned brush, they would not have been overrun by the fire.
DARPA, created in 1958, can claim credit for ARPANET (earliest predecessor of the Internet), the Global Positioning System, breakthroughs in driverless vehicles, and many other innovations. Currently they are working on technologies that would enable us to fly anywhere on the planet in a single hour, grow vaccines in plants to protect against pandemics, and build a robot that runs faster than a cheetah.
The Daily Courier has an article that spells out some of the features of the system donated to the Prescott FD. Here is an excerpt:
Several portable electronic networking devices can be placed on mountaintops or in planes to connect firefighters with a self-contained mobile 4G network in remote locations. The entire network is called MANET for Mobile Ad-hoc Network.
For example, he can use the tablet to calculate the distance to a safety zone and how long it might take to get there based on the terrain. While the time calculation doesn’t include vegetation, a firefighter still can look at real-time images of the vegetation and terrain.
One firefighter can hike an escape route and then transmit that route to other firefighters, Keith added.
Incident command officers can use the system’s video screens to display the exact locations of firefighters wearing the kits. And firefighters facing an emergency can override others on the radio system to announce their situation.
Firefighters on the ground access the same video feeds as the supervisors. They can zoom in on their location, then zoom out to gain situational awareness. They have access to the Internet and its weather information. Fire managers can add the locations of the fire perimeter, spot fires and safety zones on the maps for all to see. Map layers include terrain, roads and structures. The system can even tell when firefighters are about to go out of the range of communication.
“This is game-changing technology,” Kluckhuhn said. “What you are seeing now didn’t exist a year ago.”
DARPA may not have known that the Prescott Fire Department no longer has a hotshot crew and they have no plans to rebuild Granite Mountain, so we hope Prescott can find a use for the $225,000 worth of situational awareness equipment. Perhaps they will donate it to an organization that deploys wildland firefighters every day.
The software that runs the system, called Fireline Advanced Situational Awareness Handheld (FLASH) was designed specifically by DARPA for wildland firefighting. The government now owns the software.
The hardware is expensive, about $9,000 for each firefighter kit, so there’s little chance that anyone outside of the military will be purchasing the equipment. The United States places a higher priority on spending $1.57 trillion on adventures in Afghanistan and Iraq than in protecting our own homeland from wildfires.
But at least this demonstrates that the technology is available. Maybe a scaled-down version with fewer bell and whistles can be developed that the land management agencies will be willing to spend money on.
A step toward the Holy Grail of Firefighter Safety?
We have written several times about the Holy Grail of Firefighter Safety. As I envision it, the system would enable radios carried by firefighters and in their vehicles to transmit their location in real time which would then show up on a remote display (on anything from a cell phone or a 7″ tablet, up to a laptop computer) that would be monitored by a Safety Officer, Branch Director, Ops Chief, or Division Supervisor. The display would also show the real time location of the fire. Knowing either of these in real time would enhance the safety of firefighters. Knowing both is the Holy Grail.
Since 2006 at least 24 wildland firefighters have been killed whose deaths probably could have been prevented if their supervisors had known in real time the location of the firefighters and the fire. Those fatalities occurred on the Yarnell Hill and Esperanza Fires. If we go back through entrapments over the last several decades, we would probably find many others that fall into the same category.
How many more firefighters will we mourn before the Holy Grail of Firefighter Safety is available and deployed?
Next-generation Incident Command System
A system we wrote about in February has a great deal of potential to be a Holy Grail solution and is already being used by many emergency services organizations, including CAL FIRE. We were told in February by people closely associated with the project that the U.S. Forest Service has shown no interest in the system.
It has the unfortunate name “Next-Generation Incident Command System“ (NICS), but it is not a new Incident Command system; it is hardware and software. The developers describe it as “a mobile web-based command and control environment for dynamically escalating incidents from first alarm to extreme-scale that facilitates collaboration across [multiple] levels of preparedness, planning, response, and recovery for all-risk/all-hazard events.” It is a combination of tools, technologies, and an innovative concept of operations for emergency response.
