Report released on Schoolhouse Fire ATV fatality

position of ATV after accident

The U.S. Forest Service has released a “Learning Review Report” for the All Terrain Vehicle (ATV) accident on the Schoolhouse Fire in New Mexico that killed firefighter Token Adams. You may have followed the search for Mr. Adams, who was missing for a week before his body was found on September 6, 2013.

The report is very well written and appears to discuss in detail numerous issues directly and indirectly related to the accident. It does not use, like the first Yarnell Hill Fire report, dozens of the latest in-vogue buzz words that are in fashion this week in the human behavior community. (It only uses a few.) The report covers real issues that firefighters, and especially firefighters who operate ATVs, can relate to.

It does not place blame on anyone, and from the evidence presented, this seems appropriate, in that no one really made any serious mistakes that would normally have been avoided. All of the required personal protective equipment, training, and qualifications were in place.

The accident occurred as Mr. Token was searching for a reported fire on an ATV, as he attempted to go up a short 30 percent grade, a slope easily traversed on an ATV. A tire slipped on a rock that may have been partially hidden by pine needles, causing the center of gravity to shift. The ATV began to roll, causing Mr. Token to either jump or fall off. The ATV rolled over Mr. Token, hit a tree and then settled back on him. The rear cargo rack landed on his neck, impacting just below his full-face helmet, and he died instantly.

The video below uses some surprising techniques to illustrate how the accident occurred.

Two items listed in the lessons learned analysis generated further discussion in the report:

ATV safety culture

In the course of the search, line officers spent a lot of time in the field with employees talking about the use of ATVs in the Forest Service. The employees shared their experiences concerning close calls and minor accidents involving ATVs which had not been reported. Several of these instances were shocking to the line officers. who had no experience on ATVs. The employees thought that if these numerous incidents had been reported the agency would have banned ATVs, which were thought to be extremely useful in accomplishing their jobs. After these revelations, the line officers were stunned, and not sure what the Lesson should be. They didn’t want to make an uninformed knee-jerk decision, and felt the need to obtain a deeper understanding of ATV risks.

I can understand this culture completely. While scouting a very large planned prescribed fire on an ATV, it rolled 90 degrees. I stepped off, uninjured, as it ended up on its side. I pushed the undamaged ATV back onto its tires, started it up and continued evaluating the prescribed fire. Of course I did not report it to anyone, including the other person traveling ahead of me on another ATV.

There are probably hundreds of similar non-injury unreported ATV mishaps that occur every year in land management agencies.

Location reporting devices

SPOT
Example of a Satellite Emergency Notification Device. Photo by Bill Gabbert

While radios and cell phones can be very useful in most cases to call for help in the case of an accident, there are times when an employee is in an area where there is no reception. Or, as in the case of this ATV accident, the victim is incapacitated and can’t make a call. While a real-time automatic location tracking device would not have saved Mr. Adams, since he died instantly, it would have made a difference to the 200+ searchers and his family who spent a week looking for him.

In 2012 we wrote about the USFS’ solicitation to buy $1.2 million worth of Satellite Emergency Notification Devices (SEND). The agency purchased 6,000 of them. This is not enough for every employee, and one was not used by Mr. Token that day. These hand-held consumer-quality devices are better than nothing, but it is a very unprofessional attempt to enhance the safety of field personnel. We can do better.

I have written before about how the inability of fire supervisors to always be situationally aware of the location of firefighters has contributed to at least 24 deaths in recent years — 19 on the Yarnell Hill Fire and 5 on the Esperanza fire.

The Holy Grail of Firefighter Safety, as I envision it, would enable firefighters’ radios 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 or desktop computer) that would be monitored by a dispatcher, Safety Officer, Branch Director, Operations Section Chief, Branch Director, 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.

New protocol for accident reports?

The report was “the product of the Coordinated Response Protocol (CRP) Team convened by the Chief of the U. S. Forest Service”, and referred to the “Draft CRP Guide (9/19/2013)”. That date is two weeks after Mr. Token was found, and is 10 days before the first report on the Yarnell Hill Fire was released. This process, the report says, attempts to “minimize bias in the way we approach data gathering, synthesis, analysis and sensemaking”. And, it “integrates the accident investigation process with employee health and wellness, law enforcement investigations and other actions taken in response to a serous accident”.

We asked Jennifer Jones, a Public Affairs Specialist for the U.S. Forest Service in Boise, if we could get a copy of the new protocol. She replied:

According to Steve Schlientz, Director of the Office of Safety and Occupational Health, Washington Office, U.S. Forest Service, the guide has undergone extensive revision and is still under development. It is not expected to be completed until late spring/early summer this year and we can’t release the guidebook until it is completed and approved.

72-hour report for the Token Adams fatality

Token Adams
Token Adams, USFS photo

The 72-hour Preliminary Information Report for the fatality of Engine Captain Token Adams has been released. If you followed the search for Mr. Adams, who was missing for a week before his body was found on September 6, there is not much new in the report except for the mechanism of injury.

Preliminary analysis indicates Captain Adams was thrown from his ATV as he negotiated over a slight rise and then the ATV flipped onto Captain Adams resulting in fatal injuries.

When the search began, he was last seen on an all terrain vehicle attempting to find a reported fire.

The report below was issued by the Washington office of the U.S. Forest Service.

****

Date: September 13, 2013

Subject: 72 Hour Preliminary Information Report, Schoolhouse Mesa Fire Accident

Number and Type of Injuries: One fatality              Name: Token Adams

On the afternoon of August 30th, 41 year old US Forest Service Engine Captain Token Adams was killed in an all-terrain vehicle (ATV) accident while searching for a lightning caused fire. A Learning Review Team has been assigned to the incident and the review is underway.

Narrative:

Late in the afternoon of August 29th a crew member aboard a military aircraft reported a possible wildland fire. The location of the reported fire was estimated to be in Cebolitta Canyon on the Jemez Ranger district, Santa Fe National Forest, in the vicinity of an older fire that crews had believed to be no longer active.

At approximately 0900 on August 30th, three firefighters (Token Adams among them) responded to the general location of the reported smoke. Each of the firefighters brought an ATV. After a briefing concerning the search strategy they each separately began scouting the area. Their first mission was to confirm that the older fire was no longer active and a possible source of the smoke report. This mission was completed and the three met back at their trucks around 1030. Their second mission was to broaden their search area to locate the new fire. They discussed the broader search area and each left separately on their ATVs. Each communicated with each other periodically by two way radio to coordinate the search. Communications were also made with a lookout who was working on a nearby lookout tower and the Santa Fe Interagency Dispatch office.

At 1344, Captain Adams communicated by radio with other firefighters concerning the status of the search. After this time, calls to Captain Adams went unanswered. At about 1500 the new fire was located by one of the firefighters and he called, via radio, to Captain Adams and the third firefighter to respond to the new fire. With no response from Captain Adams, suppression on the new fire was halted and all efforts were then directed towards contacting and locating Captain Adams. Within three hours a formal Search and Rescue operation was ordered which involved numerous, volunteers, state, federal and local government personnel. His body and the ATV were found on September 6th.

Preliminary analysis indicates Captain Adams was thrown from his ATV as he negotiated over a slight rise and then the ATV flipped onto Captain Adams resulting in fatal injuries. Captain Adams was known to be a skilled ATV rider, he was properly trained and certified as an ATV operator, and he was wearing all appropriate personal protective equipment.

/s/ Liz Agpaoa,
Learning Review Team Leader”

Body of missing firefighter discovered in New Mexico

(UPDATE at 9:50 a.m. MDT, September 11, 2013)

The memorial service for Captain Token Adams will be Thursday September 12th, 2013 at 10:00 am at:

Calvary of Albuquerque
4001 Osuna Rd. NE
Albuquerque NM 87109

To get further information about the service please go to www.danielsfuneral.com.

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Token Adams
Token Adams, USFS photo

The body of U.S. Forest Service Engine Captain Token Adams was found today. Missing since Friday, August 30, he was last seen when he boarded an ATV to attempt to locate a smoke that had been reported on the Santa Fe National Forest in northern New Mexico. His crew of three split up when they arrived at the general location of a smoke report but he did not return to the agreed upon meeting place. For the last eight days hundreds of people have been searching for him over dozens of square miles of the National Forest.

At 11:45 a.m. today searchers discovered his remains about one-quarter mile from the nearest road. In a video about this development at KRQE, the reporter said there was an apparent crash of the ATV and that Captain Adams had been wearing full protective gear, but the exact cause of death has not been determined.

Below is an announcement issued Friday afternoon by the Incident Management Team managing the search organization:

Friday September 6 2013 – 4:45 pm

We are sad to announce that the body of Jemez Ranger District Engine Captain Token Adams has been located. Token was dispatched to locate a smoke reported on Friday August 30 2013. Search efforts began late Friday afternoon and continued through this morning when his body was discovered.

Token was an Engine Captain working in Jemez Springs NM. He was 41 years old and had been an Engine Captain on the Jemez Ranger District for 1 ½ years. He was a wildland firefighter for 10 years including previous experience as a hotshot. Before coming to the Forest Service Token served in the U.S. Navy. Token grew up in the community of Coarsegold California and was a 1990 graduate of Yosemite High School in Oakhurst California.

Token is survived by his wife Heidi a 3 year old son Tristan his mother a brother and sister. Token’s wife Heidi is expecting their second child.

All public and media are asked to please respect the privacy of the firefighter’s family during this time of mourning. We will release all details of this tragedy when more information becomes available.

Wildfire Today had been publishing daily updates on the search since it became public on September 2, 2013.

Our sincere condolences go out to the family and co-workers of Captain Adams.

Firefighter missing in New Mexico

(UPDATED at 6:18 p.m. MDT, September 6, 2013)

The body of Engine Captain Token Adams was found today. At 11:45 a.m. searchers discovered his remains about one-quarter mile from the nearest road. In a video about this development at KRQE, the reporter said there was an apparent crash of the ATV and that Captain Adams had been wearing full protective gear, but the exact cause of death has not been determined.

Below is an announcement issued Friday afternoon by the Incident Management Team managing the search organization:

Friday September 6 2013 – 4:45 pm

We are sad to announce that the body of Jemez Ranger District Engine Captain Token Adams has been located. Token was dispatched to locate a smoke reported on Friday August 30 2013. Search efforts began late Friday afternoon and continued through this morning when his body was discovered.

Token was an Engine Captain working in Jemez Springs NM. He was 41 years old and had been an Engine Captain on the Jemez Ranger District for 1 ½ years. He was a wildland firefighter for 10 years including previous experience as a hotshot. Before coming to the Forest Service Token served in the U.S. Navy. Token grew up in the community of Coarsegold California and was a 1990 graduate of Yosemite High School in Oakhurst California.

Token is survived by his wife Heidi a 3 year old son Tristan his mother a brother and sister. Token’s wife Heidi is expecting their second child.

All public and media are asked to please respect the privacy of the firefighter’s family during this time of mourning. We will release all details of this tragedy when more information becomes available.

Our sincere condolences go out to the family and co-workers of Capain Adams.

****

(UPDATED at 7:45 a.m. MDT, September 6, 2013)

There is not much new to report on the search for missing firefighter Token Adams. The incident management team has released a missing person’s flyer, which contains the following information:

MISSING PERSON
Santa Fe National Forest requests your assistance in locating this person.
Search Subject: Token Adams
PHYSICAL DESCRIPTION
Age: 41
Height: 5’ 11″
Weight: 165
Hair: Peppered
Eyes: Wearing black sunglasses
Last seen wearing long sleeve yellow nomex shirt, green nomex pants, and lace up brown leather wildland fire boots. Last seen in the area of Holiday Mesa off Forest Service road 608 on Friday, 8/30/13. Mr. Adams was seen riding a red Polaris 400 ATV while investigating a possible fire start when he disappeared.
If you were in the area of Holiday Mesa and Stable Mesa on or after August 30th and may have seen this individual, please contact the Forest Service at 505-438-5600.

****

(UPDATED at 10:35 a.m. MDT, September 5, 2013)

Searchers are still looking for U.S. Forest Service engine captain Token Adams who was last seen Friday, August 30, as he boarded an ATV to attempt to locate a smoke that had been reported on the Santa Fe National Forest in northern New Mexico.

The mother of Token Adams, Letake Anderson, visited the Incident Base Camp Thursday morning. She spoke to search crews and thanked them for their hard work.

A Firewatch Cobra helicopter is scheduled to arrive today to provide additional support for the search team. This specialized helicopter has cameras as well as infrared and low-light sensors and can transmit images to search crews up to 30 miles away.

Firewatch Cobra helicopter N107Z
Firewatch Cobra N107Z on Bar Complex. USFS photo.

More information about the Firewatch Cobra.

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(UPDATED at 11:40 a.m. MDT, September 4, 2013)

The search and rescue operation continues today, looking for Engine Captain Token Adams who disappeared Friday. Captain Adams has not been heard from since he departed on an ATV trying  to find a fire that had been reported in the Santa Fe National Forest in northern New Mexico.

Joe Reinarz’s Type 1 Incident Management Team assumed command of search efforts Wednesday morning as part of a unified command and will oversee the organization in coordination with the New Mexico State Police.

****

(UPDATED at 12:47 p.m. MDT, September 3, 2013)

Token Adams
Token Adams, USFS photo

Rain on Sunday and Monday hampered the search for Engine Captain Token Adams. The 250 personnel involved in the search are traversing topography described as extreme with sheer cliffs.

Despite the grid pattern being used by the professional and dedicated personnel on the incident, their efforts have not been successful. Searchers are using GPS as part of this grid pattern and are being asked to report their locations hourly. Searchers will focus Tuesday on determining that certain areas have been fully searched.

Weather predictions for today and tonight are for a 60% chance of showers and thunderstorms which will once again affect both air and ground operations.

HERE is a link to a map of the area being searched, but be advised it is a huge 19Mb file and will take a while to download.

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(UPDATED at 8:23 a.m. MDT September 3, 2013)

A Southwest Type 1 Incident Management Type, with Incident Commander Joe Reinarz, will assume command of the search efforts Wednesday morning at 6:00 a.m. for missing firefighter Token Adams. The team will begin in-briefing at noon Tuesday, September 3.

Mr. Adams is 41 years old and is an engine captain with the U.S. Forest Service and a former Hotshot. He is married with one son, and is expecting another child in less than a month.

****

(Originally published at 2:27 p.m. MDT Monday, September 2, 2013)

A wildland firefighter sent out to look for a fire has been missing since Friday August 30. Token Adams was one of three people that were dispatched to a report of a smoke in the Schoolhouse Mesa area on the Jemez Ranger District of the Santa Fe National Forest in northern New Mexico. When they arrived in the general area Mr. Adams went off by himself on an all terrain vehicle to attempt to locate the smoke. He did not return as expected to the meeting point.

John Helmich, a spokesperson for the Santa Fe National Forest, told us on Monday that when Mr. Adams was first outbound to look for the smoke late in the day on Friday he called his wife on his cell phone, and has not been heard from since, either by phone or via the radio he also carried.

At least 200 people from several land management agencies, search and rescue organizations, the National Guard, and law enforcement agencies are actively searching for him. The Civil Air Patrol has used infrared equipment from a fixed wing aircraft and the New Mexico State Police have made a helicopter available.

The fire the three firefighters were trying to locate was eventually found. It was named the Schoolhouse Fire and was fully contained at 25 acres.

The last time we heard of wildland firefighters missing was late in the afternoon on June 30 — the Granite Mountain Hotshots were missing on the Yarnell Hill Fire in Arizona. We hope this incident has a better outcome.