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
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.