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State analysis of Yarnell Hill Fire fatalities proposes $559,000 fine for Arizona State Forestry Division

Bill GabbertDecember 4, 2013November 19, 2017UncategorizedArizona, Incident Response Pocket Guide, report, Yarnell Fire107 Comments

Yarnell Hill Fire at 1549 June 30, 2013. Photo by Chris MacKenzie of the Granite Mountain Hotshots. The arrow represents the location where the lookout had been positioned earlier.

(Originally published at 2:46 p.m. MT December 4, 2013; updated at 8:30 p.m., December 4, 2013)

Today the Arizona Division of Occupational Safety and Health (ADOSH) proposed fines totaling $559,000 to be imposed on the Arizona State Forestry Division as a result of the fatalities on the Yarnell Hill Fire near Yarnell, Arizona. Their findings were presented to the Industrial Commission of Arizona during a 1:00 p.m. public meeting in Phoenix. The documents can be found HERE.

On June 30, 19 members of the Granite Mountain Hotshots were entrapped by rapidly spread flames from a brush fire and were killed. One member of the crew who was in a different location serving as a lookout was not injured.

Two citations were proposed, one “willful serious” with a tine of $545,000, and another that was “serious” with a fine of $14,000.

[UPDATE at 6:46 p.m. MT December 4, 2013; The commission approved the fines. The Arizona State Forestry Division has 15 days to appeal the decision.]

The willful serious citation included the following (paraphrased):

Failure to furnish a place of employment which was free from recognized hazards that were causing or likely to cause death or serious physical harm.
Implementation of suppression strategies that prioritized protection of non-defensible structures and pastureland over firefighter safety.
The employer knew the suppression was ineffective, and that the wind would push the fire toward non-defensible structures, but firefighters were not promptly removed from exposure to smoke inhalation, burns, and death.
Thirty-one members of a structure protection group charged with protecting non-defensible structures were exposed to possible smoke inhalation, burns, and death.
A lookout was exposed to the same dangers.
Approximately 30 firefighters working on an indirect fireline in Division Z were exposed to the same dangers.
The Granite Mountain Hotshots continued with suppression activities until 1642 hours on June 30 when they were entrapped by a rapidly progressing wind driven wildland fire.

The serious citation, totaling $14,000:

The employer failed to implement appropriate fire suppression plans in a timely fashion during a life-threatening transition between initial attack and extended attack.
When the fire escaped initial attack none of the following analysis procedures were implemented: Incident Complexity Analysis, Escaped Fire Situational Analysis, Wildland Fire Situation Analysis, Wildland Fire Decision Support System, or Operational Needs Assessment.
On June 29 an Incident Action Plan was not completed for the next operational period prior to transitioning to a more complex management team.
The positions of Safety Officer and Planning Section Chief were not filled on June 30.
On June 30 the Division Z Supervisor (adjacent to the Granite Mountain Hotshots’ Division) departed from his assigned position which left Division Z without supervision during ongoing fire suppression operations.

Today, in addition to the citation information, the following documents were released by the Industrial Commission of Arizona:

Incident narrative and timeline.
Maps, photos, and diagrams.
The “Entrapment and Burnover Investigation” report prepared by Wildland Fire Associates.

We will add to this article later with more details about the investigation report, but below are the conclusions reached by Wildland Fire Associates, the consultants hired by the Arizona Division of Occupational Safety and Health:

Fire behavior was extreme and exacerbated by the outflow boundary associated with the thunderstorm. The Yarnell Hill Fire continually exceeded the expectations of fire and incident managers, as well as the firefighters.
Arizona State Forestry Division failed to implement their own extended attack guidelines and procedures including an extended attack safety checklist and wildland fire decision support system with a complexity analysis.
The incident management decision process failed to recognize that the available resources and chosen administrative strategy of full suppression and associated operational tactics could not succeed. This also remained the case when the strategy changed from full suppression to a combination of point protection and full suppression.
Risk management weighs the risk associated with success against the probability and severity of failure. ASFD failed to adequately update their risk assessment when the fire escaped initial attack leading to the failure of their strategies and tactics that resulted in a life-threatening event.

****

UPDATE at 8:30 p.m. MT, December 4, 2013

We just finished reading the “Inspection Narrative” compiled by AZ OSHA, and the “Granite Mountain IHC Entrapment and Burnover Investigation” report written by Wildland Fire Associates (WFA).

The Inspection Narrative

We noticed a couple of interesting tidbits in the Inspection Narrative that we don’t remember being pointed out in the previous Serious Accident Investigation Team report which was released on September 28.

One was found on page 18. At approximately 1545 hours, one of the the Type 2 Operations Section Chiefs called the Granite Mountain Hotshots and asked if they could spare resources to assist in Yarnell. Either Marsh or GMIHC Captain Steed responded that they were committed to the black and he should contact the Blue Ridge Hotshots.

While the GMIHC said they were not available for the change in assignment, the request from the Ops Chief informed them that they were needed in Yarnell. This may have influenced their decision to move toward the ranch, perhaps with the ultimate goal of assisting in the town. We could not find a mention of this in the WFA report.

One other item in the Narrative (on page 17) we noticed was a disagreement and/or confusion about the break between Divisions A and Z. The Division Z Supervisor didn’t arrive on the fire line until 1 p.m. on June 30. I in addition to the Division break fiasco, he was not clear at all about what tactics in the area could be successful. He left the fire line to head to the Incident Command Post and did not return. Parts of this were also mentioned in the WFA report. The problem with filling the Division Z position was mentioned in the citation.

Below are some quotes from the WFA report:

P. 15: At 1558, ATGS abruptly leaves the fire and goes to Deer Valley. He turned air tactical operations over to ASM2 who was busy dealing with lead plane duties at the time. ASM2 got a very brief update from ATGS that did not include division breaks locations and the location of the on-the-ground firefighters. ASM2 had been ordered as a lead plane because ATGS functions were covered.
Continue reading “State analysis of Yarnell Hill Fire fatalities proposes $559,000 fine for Arizona State Forestry Division”

Arizona State OSHA to release findings on Yarnell Hill Fire fatalities Wednesday, December 4

Bill GabbertDecember 3, 2013August 25, 2019UncategorizedArizona, report, Yarnell Fire

The Associated Press and the Prescott Daily Courier are reporting that the Arizona version of the federal Occupational Health and Safety Administration will disclose their version of an investigation into the deaths of 19 members of the Granite Mountain Hotshots on Wednesday. The firefighters were entrapped and killed while suppressing the Yarnell Hill Fire in Arizona on June 30. Their requirements are that the report must be complete no later than six months after their investigation was announced, which would make it due no later than the first part of January, 2014.

The Arizona Division of Occupational Safety and Health will formally present their findings to the Industrial Commission of Arizona, their parent agency, at a 1 p.m. public meeting Wednesday, December 4, in the 1st Floor Auditorium, 800 West Washington, Phoenix, Arizona.

Both media organizations said the agency will recommend citations and penalties against state organizations. An agenda that has been released for the meeting said “Discussion & Action of OSHA Proposed Citations & Penalties. Arizona State Forestry Division, State of Arizona”, but does not mention the Yarnell Hill Fire.

The Arizona State Forestry Division, responsible for the management of the fire, released a Serious Accident Investigation report on September 28, 2013. That report, produced by an army of 54 people, found:

The judgments and decisions of the incident management organizations managing this fire were reasonable. Firefighters performed within their scope of duty, as defined by their respective organizations. The Team found no indication of negligence, reckless actions, or violations of policy or protocol.

Yarnell Fire lead investigator talks about the report and tracking firefighters

Bill GabbertNovember 30, 2013August 25, 2019UncategorizedHoly Grail, Jim Karels, tracking, Yarnell Fire29 Comments

Jim Karels, Florida State Forester, Yarnell Hill Fire — Jim Karels

The person who led the 54-person team that investigated the June 30 deaths of 19 members of the Granite Mountain Hotshots talked to a reporter for the Florida Current about the results of their investigation and how they track firefighters in his agency.

Previously, Florida State Forester Jim Karels’ team wrote in their report about the Yarnell Hill Fire which was released in September:

The judgments and decisions of the incident management organizations managing this fire were reasonable. Firefighters performed within their scope of duty, as defined by their respective organizations. The Team found no indication of negligence, reckless actions, or violations of policy or protocol.

The Yarnell Hill Fire report also said:

… [it] does not identify causes in the traditional sense of pointing out errors, mistakes, and violations…

Many of us criticized the report for whitewashing the tragedy and failing firefighters who deserve to increase their knowledge of how to avoid similar disasters in the future. A lessons learned opportunity was missed.

It will be interesting to see if the report about the fire that is being written by the Arizona Division of Occupational Safety and Health provides better information about what happened, why, and how to avoid similar deaths.

Below is an excerpt from the article in the Florida Current:

Karels, though, said a second section of the report asks questions about the decision-making process that will help develop lessons to be learned. He said the fact that all 19 firefighters died together while making decisions on their own and separately made the investigation different from other investigations.

“It would be real easy to say, ‘This is exactly what happened and these are why decisions were made and this is something to blame,'” Karels said. “But all 19 are gone. So we reconstructed an event based on the best knowledge we had.”

He said lessons learned from the fire include the need for more prescribed burning and mitigation nationwide to reduce the potential for deadly wildfires.

In the interview Mr. Karels also talked about tracking the location of firefighters, since no one on the Yarnell Hill Fire knew where the Granite Mountain Hotshots were at the time of the fatal entrapment or previously that they were hiking through unburned vegetation near the fire which changed direction and burned over their location due to a passing thunderstorm.

Florida had to figure out the lessons from its own wildfire deaths in 2011 when two firefighters in Hamilton County were killed while battling a blaze.

He said [the] “Blue Ribbon Fire” led to recommendations on improving communication, asset tracking and providing enough helicopters to battle fires.

[Agriculture Commissioner Adam] Putnam is requesting $5 million for new vehicles in fiscal year 2014-15 in addition to $4 million received last year for upgrading technology and equipment…

The Hamilton County fire and the Arizona fire both led to recommendations to improve the tracking of firefighters and equipment during a rapidly expanding fire, Karels said.

After the 2011 fire, Florida began installing a tracking system on computers in supervisory vehicles that map firefighters and machinery with the locations of the fire and terrain, Karels said.

Where do we go from here?

We have written previously 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.

On the 2006 Esperanza Fire in southern California, Branch II and the Captain of Engine 57 had an understanding that the Engine crew would not remain at the Octagon house, where they eventually died (see page 9 of the USDA OIG report). The crew was supposed to go to an area identified as a safety zone and not try to defend the house, according to information provided by Branch II. For some reason the crew decided to defend the house, setting up hose lays and a portable pump. The fire entrapped them at that location, killing all five members of the crew.

If Branch II, an Operations Section Chief, or a Safety Officer had access to real time information about the location of their resources on the fire, it is likely that the engine crew would have been directed to go to the safety zone as instructed earlier by Branch II.

Granite Mountain Hotshots hike to the Yanrell Hill fire — Granite Mountain Hotshots hike to the Yarnell Hill fire on June 30. Photo by Joy Collura.

The person that was supervising the 19 firefighters that died on the Yarnell Hill Fire was the Operations Section Chief. In the report on page 22, he tells the crew, Granite Mountain Hotshots, to “hunker and be safe”, which usually means find a nearby safe spot and stay there. On page 27 Operations tells the airborne Aerial Supervision Module about the crew, “They’re in a good place. They’re safe…”

The Blue Ridge Hotshots thought Granite Mountain was walking north to a ranch house safety zone north of their location. OPS thought the crew was safely in the black. He did not know the 19 firefighters were walking in the unburned area toward a ranch south of their location. If Ops or a Safety Officer with access to the location of all fire resources had known the crew’s location as they first began their fatal trek, it is likely the entrapment could have been prevented.

The Holy Grail of Firefighter Safety, as I envision it, 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.

Cell phone-based location systems will not work on many fires due to incomplete coverage. What might work are temporary cell sites or dedicated repeaters on aircraft or mountain tops, or a geosynchronous satellite that is always overhead and could receive data from almost everywhere except in the deepest, steep canyons or heaviest tree canopy. The same satellite could host the proposed system that would survey the entire western United States every two minutes or less, mapping fires and detecting new fires as small as 10 feet in diameter.

If Congress and the American people were presented with this proposal, even though it would cost hundreds of millions of dollars, they just might vote to save firefighters’ lives.

Luddites who oppose technology and want everything to remain the same will never be in favor of this concept. I understand that, and recognize that everyone is entitled to their own opinion

Evacuation and planning during Yarnell Hill Fire criticized

Bill GabbertNovember 18, 2013November 18, 2013UncategorizedArizona, Yarnell Fire8 Comments

There are reports that residents said they were not notified about evacuation before the Yarnell Hill Fire burned into their town and fled only after they saw the nearby wind-driven fire approaching their house.

Yarnell Hill Fire burns into Yarnell, Arizona, June 30, 2013. Photo by Joy Collura.

An article written by reporters for the Arizona Republic which also appeared in the USA Today provides details about the evacuation of Yarnell and Glen Ilah, Arizona when the Yarnell Hill Fire burned into the town destroying 127 homes. The article reports that some residents said they were not notified and fled only after they saw the nearby wind-driven fire approaching their house.

The fire burned into the towns on Sunday, June 30, the third day of the fire, the same day that 19 members of the Granite Mountain Hotshots were entrapped and killed. The plans the fire organization had in their heads called for short time frames to notify residents and for them to get out of the community. Below is an excerpt from the article:

On that Sunday, residents watched the fire and smoke plumes grow. The wind was blowing the fire toward Peeples Valley, about 3 miles to the north.

That morning, automated emergency alerts went out by phone, text and e-mail to Yarnell residents: Be prepared to evacuate. You will have an hour to get out if evacuation is ordered. You will get another notice beforehand.

State fire officials had established three geographic landmarks that would act as evacuation “trigger points” when the fire reached them. The first, fire officials thought, was far enough away to give residents an hour to get out, according to an investigative report on the fire. A second trigger was set to evacuate firefighters. The third was set for the edge of Yarnell. If flames got there, everyone would have to get out immediately.

[…]

According to the investigative report, a fire official who wasn’t named said the evacuation trigger points were off by more than 50%, meaning the fire reached key points much faster than expected. “The fire outperformed their expectations, even with many knowledgeable people there,” the report said.

The article appears to say that no written Incident Action Plan (IAP) was prepared until Monday, the fourth day of the fire, the day after the 19 fatalities and the loss of 127 homes:

No fire-action plan was written until Monday, the day after the evacuations.

Written plans, which include decision points for evacuations, are standard procedure early in a fire, said Will Spyrison, a 35-year wildfire veteran who has evaluated fire-commander candidates.

If that is true, that no written IAP was prepared until day four of the fire, that helps to explain some of the chaos, supervision problems, and poor decisions that were evident during the first three days.

We were not able to find any reference to a written IAP in the official investigation report on the fire. On page 15 it mentions that in a briefing on day three some of the attendees “review the area using Google Maps on an iPad”. It also said, “Incoming resources receive a communications plan”. If there was no written IAP, it is very odd that important fact was left out of the report. If there WAS one, that very important document would have been mentioned at least once in the 116-page report.

A written IAP does not have to be 40 pages of flowery language, but by the second day of any uncontained fire there should be a few pages passed out to the fire leaders that at least list the Command and General Staff, the Operations Section chain of command, what resources are available, their assignments, communications, evacuation plan if applicable, structure protection plan if applicable, and a map. To not have any of that in writing by day three is bush league and nonprofessional, and can lead to disorganization and safety issues. Firefighters deserve better.

****

UPDATE at 2:29 p.m. MST, November 18, 2013:

We confirmed that there were no Incident Action Plans written for any operational periods until the fourth day of the fire, July 1, 2013. Below is a list of IAPs and maps that the investigation team listed on a web site that has these and other documents related to the fire.

First claim filed for death on Yarnell Hill Fire

Bill GabbertNovember 15, 2013December 22, 2016UncategorizedYarnell Fire37 Comments

Yarnell Hill Fire near Yarnell, AZ, June 30, 2013. Photo by Joy Collura.

The first of what could be many claims has been filed for the death of one of the members of the Granite Mountain Hotshots. On June 30, 19 firefighters on the crew died when they were overrun by flames on the fire near Yarnell, Arizona.

According to Azcentral, Marcia McKee, the mother of firefighter Grant McKee, filed the $36 million action.

Below is an excerpt from Azcentral:

The 16-page claim alleges officials “carelessly” allowed the hotshots to move into a chaparral-choked area where escape from the fire was impossible, that officials lost track of the hotshots and that officials failed to understand the “extreme peril” that confronted the hotshots.

The claim names 13 entities or individuals, including Gov. Jan Brewer, Arizona State Forester Scott Hunt, Prescott Wildland Division Chief Darrell Willis, who oversaw the crew, Prescott Mayor Marlin Kuykendall, the Yavapai County Board of Supervisors, and Department of Public Safety.

Mural to be unveiled

In another story related to the fire, on Saturday, November 16 a mural will be unveiled in Prescott memorializing the fallen Granite Mountain Hotshots and all first responders, from 11 a.m. to 1 p.m. at Classic Gas, 1310 W. Iron Springs Road.

Hope for a better fire shelter

Bill GabbertNovember 11, 2013November 12, 2013Uncategorizedfire shelter, Yarnell Fire21 Comments

Yarnell Hill Fire shelter — From the Yarnell Hill Fire report: “The burned remnants of a fire shelter that was recovered from the Yarnell Hill Fire deployment site shows signs of extremely high heat. The photo was taken during equipment inspection.”

Wildland firefighters who carry pup tent-like aluminum foil fire shelters hope they never have to unfold and climb into them as a wildfire approaches. Quite a few firefighters have deployed and survived inside them, but too many have died using the limited protection it provides.

The investigation that followed the deaths of 19 members of the Granite Mountain Hotshots June 30 on the Yarnell Hill Fire in Arizona found that all of the fire shelters were very seriously damaged during the burnover. The outer foil shell was 95 to 100 percent burned away on 17 of the 19 shelters, while the foil on the other two was 80 percent burned away. The shelters are constructed of numerous panels of material that are sewn together with heat-resistant quartz and fiberglass thread which failed in some areas on most of the shelters, causing some of the seams to separate, allowing super-heated gasses to enter.

Quartz thread becomes brittle and can break at 2,000°F, aluminum foil will melt at 1,220°F, and silica cloth, one of the layers in the shelter, becomes brittle at 2,000°F, according to data in the investigation report. The failure of the seams and the brittle silica cloth found in some areas indicates that the temperature of the fire was over 2,000°F, hotter than many fires.

With the spectacular failures of the shelters on the Yarnell Hill Fire, some are calling for firefighters to be outfitted with designs that are more survivable. I received a call several weeks ago from a father of one of the Granite Mountain 19 that is exploring options for better shelters.

A company in Valencia, California is asking for donations so that they can build a prototype of a shelter made with ceramic fiber that, depending on the grade, can withstand continuous use up to 1,472°F or 2,462°F. Jim Moseley is the CEO of the company, SunSeeker Enterprises, Inc. which in addition to designing a new-generation fire shelter sells “fire blankets to 3000°F” for structures. Mr. Moseley is featured in the video below in which he is seen wearing clothing advertising a golf course and a shark-watching tour company. He also is the principle in The Great Trombonist, LLC, based in Los Angeles.

Finding high-temperature-resistant material is one step toward producing a practical fire shelter. But the finished product and everything that goes into it has to be high temperature resistant, foldable into a small space, easy to quickly deploy, durable enough to be carried by firefighters for years, affordable, and not too heavy.

A better fire shelter is needed. We hope that Mr. Moseley or someone else can come up with a better design that meets the requirements.

Some will no doubt say that firefighters should avoid a situation where a fire shelter, a last resort, is needed. Of course that is true, and no firefighter should DEPEND on a shelter to save their lives. And, no firefighter should DEPEND on aircraft to serve as a lookout, drop life-saving water or retardant, or extricate them before an entrapment or at the end of a shift. But, firefighters, in spite of their best intentions and wildland firefighting experience, find themselves forced into fire shelters. That is the reality. If possible, we should take steps to improve their chances of survival.

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