Report released for fire shelter deployment on Bridger Foothills Fire in Montana

Three firefighters — only two fire shelters

Bridger Foothills Fire entrapment
From the Facilitated Learning Analysis for the Bridger Foothills Fire entrapment.

The report released Friday about the burnover of three firefighters on the Bridger Foothills Fire is jaw-dropping — and not only because there were three firefighters with only two fire shelters to protect them as the flames swept over. It is a well written and thorough report but lists few lessons to be learned, leaving it up to us to read between the lines.

The incident occurred about three miles northeast of Bozeman, Montana on September 5, 2020 when there were 115 active large wildfires burning in the United States which at that time had consumed 3,000,000 acres. Over 22,550 wildland firefighters and forestry technicians were committed across the nation. The August Complex of fires in Northern California had burned 305,000 acres which would be less than one third of its total size when it finally slowed down in the Fall after blackening over one million acres. In August and September there was a serious shortage of personnel to staff the fires. Few if any areas had an adequate number of firefighting resources to initial attack new fires or contain those that had been growing for weeks.

The initial attack on the Bridger Foothills Fire on September 4 included four smokejumpers, “several engines,” plus helicopters and air tankers. According to statistics on the national Situation Report at the end of the day on September 5, the second day of the fire, there were a total of 99 personnel on the fire. Five structures had been confirmed as destroyed and it was on its way to ultimately burning 28 homes and growing to 8,224 acres.

The 37-page report can’t be fairly summarized in a few paragraphs here. I suggest you check it out yourself, then leave a comment below with your impressions.

But briefly, three members of a Montana state helitack crew attacked the fire on September 4, spent the night on the fire, then during the afternoon of the next day were overrun by the fire in the meadow that served as their helispot. They attempted to set an “escape fire”, as used on the Mann Gulch Fire in 1949, to burn off the grass and sage before the fire reached them, but the grass was too green to easily ignite. As the fire approached them two men deployed their aluminized and insulated fire shelters designed to reflect radiant heat, but the third had failed to replace the shelter in his pack he had removed days earlier to lighten his load while on physical training hikes. Two of the men, both large individuals, crammed into one shelter that was made to accommodate one person. The three of them only suffered fairly minor injuries and walked away to a point where they could be transported to a hospital.

From the report:

The firefighters involved in this deployment came to decisions that made sense to them at the time. To learn from this unintended outcome, it is important that you read this without the assumption that this could never happen to you. Instead, please consider that you read this with the luxury of hindsight bias. Our intent is that you find the lessons that you can apply to your program to hopefully avoid experiencing what these folks went through.

Looking back with 20/20 hindsight, there were many things that contributed to the entrapment. If only one of them had occurred, the three helitack crewmen probably would not have been burned over. But the cumulative effect of numerous issues led to this near-fatal event.

Firefighters are familiar with the Swiss Cheese Model of Accident Causation.

Swiss Cheese model
Swiss cheese model by James Reason published in 2000.

The New York Times published on December 5 a version of the model adapted for the current pandemic:

James T. Reason's Swiss Cheese Model
James T. Reason’s Swiss Cheese Model as applied to the COVID-19 pandemic.

Many of our readers could study the report and substitute events that happened on the Bridger Foothills Fire for the layers in the Swiss Cheese Model.

Let us know in a comment below what you’re thinking. I’ll get it started with a few:

  • Very few firefighting resources initially attacked the fire.
  • Communication issues were mentioned many times in the report. Almost every very serious incident within an incident has communication problems.
  • Air tankers dropped retardant on the west side of the fire but not the east side that day. A person who was on the fire told Wildfire Today that if retardant had been applied to secure the east side it may have prevented the blowup. With the national fire situation at the time, air tankers may not have been available to continue dropping retardant that afternoon. (Would it have made a difference if the air tanker base 73 air miles away at West Yellowstone had not recently been closed and converted to a call when needed base?)
  • At times there was confusion about the location of the three entrapped firefighters. If a safety officer or Division Supervisor had known the exact location of the firefighters and the real time location of the fire, it may have made a difference — there might have been enough time to extract them by helicopter before the smoke and the flaming front made it impossible. THIS RECURRING ISSUE COULD BE SOLVED WITH OFF THE SHELF LOCATION TRACKING SYSTEMS for personnel and the fire! Federal and state wildfire organizations need to make this an urgent priority! This is a life-safety issue and the tools should have been deployed years ago by the federal and state agencies. Funding is not an acceptable excuse. Neither is apathy. Dig deep to find the motivation and the money.

Below is the section of the report that describes the deployment itself, but does not include what led up to it. The names have been changed.

The Deployment
“What do you mean you don’t have your shelter?”

Charlie frantically worked to light off the sage with his fusee. Hands shaking, the sage was lighting better than the grass had before. But it didn’t matter – there was no more time to burn – the fire was coming up fast on him and his crew from both the south and the east.

Charlie turned around to his crewmembers and noticed that one of them, Sam, was already in his shelter. The spot fire that had cut-off their last possible escape route was now well established on the slope below them, and the trees were crowning out with flame lengths of over 100 feet. The wind was blowing so hard that his helmet went flying off his head. Next thing Charlie realized, he was back at the small oval that they had cleared of ground fuels, looking down on his other crewmember Casey, who was laying in the fetal position with his chaps slung over his back and gear bags piled up around him.

“Get in your f**king shelter!” Charlie screamed to Casey.

“I don’t have it – share with me!” Casey shouted back.

“What do you mean you don’t have your shelter?! Did it blow away?!”

It hadn’t blown away, although that would have been easy in the “hurricane-like” winds that were whipping across the hillside in all directions. Casey had taken it out of his pack a few weeks earlier for PT hikes, and never put it back in.

But ultimately, why the shelter wasn’t on the hill did not matter. At this moment, Charlie realized how dire of a situation they were in. Casey was roughly 6’2” and weighed in at around 225 lbs, and Charlie was around 6’ and 190 lbs. And if they were both going to survive this flame front, they would have to squeeze into his one shelter as best as they could.

They could both feel the heat now, and the fire was “cooking.” Charlie ripped out his shelter and struggled to open it. Unlike Sam’s shelter, which Sam later described as “shaking out just like a practice shelter, [or] better,” opening Charlie’s shelter felt like trying to open a ball of tin foil. With Charlie and Casey each pulling at it, they fought to get it open, and valuable moments were lost as they furiously tried to shake it out. The moment they opened the shelter, Casey and Charlie locked eyes, then glanced up at the flames towering above them before they dropped to the ground. The updraft winds at that point were so strong, they had to fight to reach the dirt.

The last-minute nature of their deployment meant that neither Casey nor Charlie were completely in the shelter. Casey had dropped to get his head facing to the north and lined up with the hole he had dug and filled with water, with his legs largely sticking out of the shelter. Charlie was facing nearly the opposite direction, in a crouching position. In this arrangement, neither firefighter could get a seal on the shelter, and embers were blowing in just as fast as Charlie could sweep them out. Casey screamed over the radio that they had deployed, a transmission that was copied by air attack. Charlie then took the radio and remembers transmitting that there were three of them who had deployed, with only two shelters. Air attack, who confirmed that three people had deployed, did not recall hearing that there were only two shelters.

Post-deployment fire shelter Bridger Foothills Fire

Charlie later described how, in their initial arrangement, “I couldn’t take it anymore, I couldn’t get air, and it felt like I was in a microwave.” In this moment of desperation, Charlie stood up, thinking nothing could be worse than being crammed into the shelter, in the heat, without any way to breathe. Charlie immediately realized how much worse it could get with the fire burning all around and was forced to dive back into the shelter. This time, Charlie was shoulder to shoulder with Casey, which allowed them to get a slightly better seal.

The experience, however, was still far from comfortable. Unable to breathe and battling through the extreme heat, Charlie “was certain we were gonna die. [I thought] every second was our last second.” Casey described the sensation of trying to breathe as like “if anyone has ever been cleaning around you and it’s extremely potent – it’s like that but it’s on fire.” To try to alleviate the heat, he began splashing plastic water bottles on himself and Charlie, squeezing 4-5 bottles out along their backs.

Sam was equally certain that they were not going to survive. “100%, I thought we were dead. No doubt … I couldn’t breathe.” To try to get a breath, he wet down his shirt and started digging a hole into the ground. Although opening the shelter had been easy, Sam struggled in the wind to create a strong seal. For the fifteen or so minutes that Sam remained in the shelter, he was absolutely terrified for his life.

Casey and Charlie emerged from their shared shelter around 8 minutes after they first got in, after the initial flame front had passed. Their surroundings, however, still resembled a hellscape. Casey’s line gear, which he had been unable to throw very far away from the deployment site, was on fire and burning Charlie’s leg, so Charlie kicked it farther away. Outside of the circle, the cans of bug spray and sunscreen in the bag exploded. Combined with the combustion from the remaining fusees, the explosions caused the gear to burn down to nothing.

Even without the flames, the heat, smoke, and winds were still so intense that Charlie and Casey reentered the shelter, where they remained for another eight or so minutes, getting continuously hammered by the wind. Eventually, while getting oxygen was still nearly impossible, it became clear that they were going to be miserable whether they were in the shelter or out. Knowing that everything was nuked around them, and the worst of the heat had passed, they emerged from the shelter again. But the beating afflicted by the fire was still far from over.

Sam’s experience: 

“I deployed my shelter and within probably a minute or two could hear, feel, and see the fire going over and around us. The inside of my shelter glowed red … there was no place to get a cool clean breath. Embers blew inside my shelter and I would push them out. I tried to dig in the ground to get a clean breath and was unsuccessful. At some point I remember Charlie asking how I was doing. I responded with ‘Not good man, I can’t f**king breathe.’ I thought about my wife and kids and knew with some certainty that I was dead.”


Notes on fire shelter use
Notes on fire shelter use from the report.

Holes in the Yarnell Hill Fire swiss cheese

In another thread there was a discussion about the Yarnell Hill Fire and the fact that when the 19 Granite Mountain Hotshots were killed there was only one aerial supervision aircraft over a very complex fire environment instead of two. Until recently it was more common to have both an Air Tactical Group Supervisor (ATGS) and a Lead Plane or Airtanker Coordinator over a fire that had advanced beyond initial attack.

The ATGS orbits the fire and coordinates, assigns, and evaluates the use of aerial resources, both helicopters and fixed wing. The Lead Plane directly supervises the air tankers, usually flying low and sometimes physically preceding the air tankers before they drop the retardant.

But now we sometimes see those two roles combined into one aircraft, called an Aerial Supervision Module. It can save money, but there is debate about how appropriate it is for a complex fire situation.

One of the recommendations in the first report issued about the fire, by the Arizona State Forestry Division last summer, was for the the State of Arizona to “request that the NWCG 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”. Other documents released by the state of Arizona last week revealed that members of the Blue Ridge Hotshots said that they witnessed “a near miss” with aircraft, who they described as sounding “overwhelmed” adding that “the air show seemed troublesome.”

The aerial supervision on the Yarnell Hill Fire was only one element, or one slice of James T. Reason’s Swiss Cheese model of accident causation, which is defined in Wikipedia:

In the Swiss Cheese model, an organization’s defenses against failure are modeled as a series of barriers, represented as slices of cheese. The holes in the slices represent weaknesses in individual parts of the system and are continually varying in size and position across the slices. The system produces failures when a hole in each slice momentarily aligns, permitting (in Reason’s words) “a trajectory of accident opportunity”, so that a hazard passes through holes in all of the slices, leading to a failure.

Having only one aerial supervision platform on a very complex fire gives you one slice with some holes. Below we list 18 other holes in the Swiss cheese.

Swiss Cheese modelAnother slice would be supervision of ground personnel. The holes in that slice were:

  • Transitioning that morning from a group of firefighters to only a partial Incident Management Team (all transitions can be tough, but when done hurriedly and to only part of a team, it can be dangerous);
  • Removing Supt. Marsh from the Hotshot crew and making him Division Supervisor. (A reporter who has seen the recently released documents told me that Marsh did not know he would be Div. Sup. until he got out on the fire line that day);
  • No Safety Officer;
  • No Division Supervisors arriving with the IMTeam;
  • No Division Supervisor on the Division adjacent to the accident;
  • An Incident Commander that took over the fire about six hours before the accident;
  • Decision-making was poor, such as failure to designate division breaks, or decide on and communicate a firefighting strategy likely to be successful.
  • Somebody, either Marsh, a Structure Protection Group Supervisor, or an Operations Section Chief (or all of the above), decided for the Granite Mountain Hotshots to leave the safe previously burned black area and walk through unburned brush, where they were entrapped by the fire and killed.

Holes in the planning slice were:

  • No maps given to firefighters that day;
  • No Incident Action Plan that day or the two previous days;
  • There was a poor briefing that morning;
  • Marsh did not attend the briefing because it was given in mid-morning after he and his crew departed the Incident Command Post and headed to their assignment (Marsh did receive some briefing info that morning).
  • There was no complexity analysis completed on day one or day two (the accident occurred on day three of the fire, June 30.) It was completed three hours before the accident.
  • The number of firefighting resources working on the fire for the first three days was inadequate to safely implement the strategy of fully suppressing the fire and protecting the structures and the people in the communities.

Holes in the communication slice:

  • Incorrect radio programming information was given to firefighters that morning which made radio communication difficult;
  • The overhead, such as it was, did not maintain adequate communication with field personnel, which led to inadequate accountability of personnel who were in harms way;
  • Marsh and Granite Mountain did not clearly tell the Operations Section Chief where they were and where they were going when they left the secure black en route to the box canyon;
  • The ASM had difficulty communicating with Marsh and Granite Mountain as they became entrapped, possibly due to him being “overwhelmed” (as described by the Blue Ridge firefighters).

These slices have 19 holes, and when you place the slices next to each other, all it takes is one more hazard that then passes through holes in all of the slices, leading to an unfortunate outcome. Perhaps if one or more of the holes had been plugged by better management of the fire, there would have been a more favorable result.


Followup: three fatalities on 2011 prescribed fire in Nebraska

Casey, one of the people who commented on our article about the most significant stories of 2011, pointed out to us that in addition to the one person that was killed April 28 on the prescribed fire near Trenton in southwest Nebraska, two others also died weeks and months later. Theresa Schnoor, 46, passed away at the scene, but Robert Seybold, 40, died May 18, 2011, and 37-year-old Anthony Meguire died at a burn center in Lincoln, Nebraska September 18, 2011. The three of them along with five others were conducting the prescribed fire on privately owned land.

May they all rest in peace.

Casey also pointed out to us an article written by David Hendee of the Omaha World-Herald that summarizes an investigation of the incident conducted by the Nebraska Fire Marshal’s office. The article is quite disturbing to read. Not because of any gore or graphic details, but because it points out many factors that might have resulted in a more favorable outcome if they had been handled differently. The issues included planning, organization, briefing, fire departments that were asked but did not assist, equipment, personal protective equipment, alcohol, and weather and how it related to the prescription.

Reason swiss cheeze model

This multiple fatality incident could be an example of the “swiss cheese” model developed by James Reason. A single error or unsafe act may not result in an accident, but multiple unsafe acts may align, like holes in layers of swiss cheese, to produce an unfortunate outcome.

We were not able to find a copy of the original Fire Marshal’s investigation report over the weekend, but if anyone has access to it, please let us know.


UPDATE: January 10, 2012:

We found out more about Nebraska’s policy which makes it difficult to learn lessons from accidents on fires.


Thanks go out to Casey

Osprey makes precautionary landing, starts fire

U.S. Marines jump from an Osprey

A MV-22 Osprey tiltrotor aircraft made an unscheduled landing Wednesday night in North Carolina after one of its engines ran low on fuel. The aircraft, based out of the Marine Corps Air Station in New River, N.C., was conducting low altitude training when it made a precautionary landing at 7 p.m. in Holly Shelter Game Land south of the air station. The crew of four was not hurt.

Marines refueled the Osprey but according to, upon taking off it “smashed into swamp mud, nose first”.  During that takeoff attempt, heat from the engine exhaust started a vegetation fire which did some damage to the exterior of the aircraft.

A news release from the Marine Corp claims…

The grass fire was quickly extinguished by the crew chief, but caused an undetermined amount of heat damage to the aircraft exterior.

But Emergency Management Director Eddie King said the local fire department had to work through the night to extinguish a 5-acre fire, in an area infested with snakes and alligators, that was caused by the incident.

On Thursday afternoon the Osprey was flown back to the New River Air Station.

It is interesting that the Marine Corps said the precautionary landing was caused by an engine running low on fuel. The aircraft has a drive shaft through the wings that connects the two engines, making it possible for one engine to power both prop-rotors. This feature may have prevented it from completely losing control and crashing.

There have been at least four crashes involving Ospreys:

  • June 1991– a nacelle struck the ground while the aircraft was hovering, causing it to bounce and catch fire.
  • July 1992– An Osprey caught fire and crashed into the Potomac River at Quantico before an audience of Congressmen, killing all seven crewmen.
  • April 2000– At Marana airport in Arizona an Osprey descended too quickly and crashed, killing all 19 on board.
  • December 2000– A series of problems and design flaws, a swiss cheese effect, caused a crash into a forest near Jacksonville, North Carolina, killing all four on board.

The development budget of the Osprey, first estimated at $2.5 billion in 1986, will cost at least $54 billion before the program is complete according to Wikipedia. About two percent of that would have paid for an entire fleet of new purpose-built air tankers.