Colorado Firecamp - South Canyon Fire, OSHA Briefing Paper

Note: This document was released as part of the Cramer Fire inspection file as a copy of a fax sent from the OSHA Denver Office on July 12, 2001 - presumably to assist the Thirtymile Fire investigation.

Also read the 1998 report, “Fire Behavior Associated with the 1994 South Canyon Fire on Storm King Mountain, Colorado”

EXECUTIVE SUMMARY

The Occupational Safety and Health Administration (OSHA) has completed its investigation of the July 6, 1994, South Canyon Fire catastrophe which resulted in the death of fourteen firefighters, one from the Bureau of Land Management (BLM), and thirteen from the U.S. Forest services (USFS).

Under the authority of Section 19 of the “Occupational Safety and Health Act of 1970” and Executive Order 12196 of February 1980, OSHA conducted an independent investigation of the fatalities.

It is OSHA’s position that management of both agencies failed to provide adequate oversight of the South Canyon Fire to ensure that the strategies, tactics, and objectives being used did not compromise the safety of the firefighters. Top level administrators throughout the BLM and USFS must take immediate action to correct the occupational safety and health program deficiencies in their organizations to avoid a recurrence of this tragic event.

OSHA has determined further that the agencies violated standard firefighting procedures, and failed to recognize and timely respond to numerous factors that, together, clearly identified the South Canyon Fire as highly hazardous to firefighting personnel. OSHA has issued a Notice of Unsafe or Unhealthful Working Conditions alleging one willful1 and one serious2 violation of 29 CFR 1960.8(a), the Federal Agency counterpart of the OSH Act’s general duty clause. The following is a summary of the unsafe conditions or practices that led to the catastrophe.

The identity of the Incident Commander was not effectively communicated to firefighters.
Adequate safety zones and escape routes were not established for and identified to employees.
Available weather forecasts and expected fire behavior information were not provided to employees.
Adequate fire lookouts were not used on the fire.
Hazardous downhill fireline construction3 was performed without following established safe practices.
Management failed to provide the firefighters with comprehensive fire behavior information.
Management failed to ensure the evolution of the Incident Command System was commensurate with the fire threat.
Management failed to heed the safety practices contained in the Fireline Handbook pertaining to blow-up conditions.
Management failed to conduct adequate inspections of firefighting operations, including on-site, frontline evaluations, to ensure that established safe firefighting practices were enforced on fires of all classes.

No penalties have been proposed in connection with these violations since OSHA has no authority to assess penalties against other federal agencies.

1. THE ACCIDENT

On July 2, 1994, lightning ignited a single tree on Bureau of Land Management land approximately seven miles west of Glenwood Springs, Colorado. The fire started at an elevation of approximately 7000 feet on a ridge in extremely steep, mountainous terrain. Fuel in the vicinity consisted of juniper-pinon mix with dense stands of Gambel oak. Fuel moisture was very low as a result of prolonged drought conditions in the area.

On July 4, a Forest Service/Bureau of Land Management team of seven firefighters arrived on Interstate 70 below the fire, but did not begin actual firefighting operations as it was late in the day and there was an arduous 2 ½ hour hike to the fire site. A Red Flag Warning4 was issued by the National Weather Service. Fire size at this time was three to four acres.

The seven firefighters, led by a Bureau of Land Management Incident Commander5, hiked to the fire the following day and began fire suppression activities which included cutting a helicopter landing site, or “Helispot,” and constructing a fireline. A Red Flag Warning was again issued. Also on July 5, eight Smokejumpers from Montana parachuted to the fire site and helped with the fireline construction. The original fireline was overrun by advancing fire so a second line was begun. The Forest Service/Bureau of Land Management team hiked down the mountain that evening to conduct equipment repairs. The eight Smokejumpers continued to fight the fire until falling rocks forced them to cease firefighting operations and find a safe place to sleep on the mountain until morning. By this time the fire had grown to fifty acres.

On July 6, Red Flag Warnings were again issued by the National Weather Service along with a forecast of the passing cold front accompanied by the shifting and gusting winds. The Forest Service/Bureau of Land Management team hiked back to the fire site early in the morning to rejoin the Smokejumpers and construct a second helispot (Helispot 2). By noon, the Smokejumpers and the joint Forest Service/Bureau of Land Management team were joined by the ten Hotshot firefighters from Oregon who arrived by helicopter to Helispot 2. Winds were gusting at up to thirty miles per hour by 1:00 p.m., and the fire, which had expanded to over 150 acres, was burning erratically, with frequent spotting across firelines, tree torching, and re-burning of some areas. At 3:00 p.m., ten more Oregon Hotshots arrived at Helispot 2. Many of the firefighters were engaged in downhill construction. The cold front moved through the area at 3:20 p.m., with strong winds gusting to forty-five miles per hour. The fire activity immediately intensified with flame heights reaching 100 feet. Between 3:30 p.m. and 4:30 p.m., the fire reached “blow-up” proportions. Driven by strong winds, fueled by tinder-dry vegetation, and magnified by the steep terrain, the fire spotted below the firefighters and raced up the hill at a speed of nearly twenty miles per hour with flame lengths reaching 300 feet. Of the forty-nine firefighters on the mountain at the time of the blow-up, fourteen (thirteen Forest Service and one Bureau of Land Management) were unable to reach safety and were overcome by the fire. The other thirty-five firefighters barely escaped with their lives.

2. THE INVESTIGATION

The Occupational Safety and Health Administration (OSHA) Denver Area Office was notified of the accident on July 7, and dispatched three investigators to the scene the same day.

A joint Forest Service/Bureau of Land Management team also investigated the incident. The joint Forest Service/Bureau of Land Management team issued a report of their findings in August 1994. An Interagency Management Review Team (IMRT) was formed to followup on the initial investigative team’s work. The IMRT issued a report which contained a corrective action plan and set time frames for implementation of many of the recommendations identified in the initial report.

Although the OSHA investigation was conducted independently of the that investigation, OSHA participated as an observer during the initial phases of the joint team investigation. The independent OSHA investigation began with an onsite inspection of the fatality site and a review of various documents dealing with wildfire management and safety. At the site, inspectors took videotape, measurements, and made sketches. The interview process was delayed because the surviving firefighters were involved in fighting fires throughout the western United States. This necessitated OSHA inspectors going to the areas where these people were stationed and to the fires they were currently fighting. Over two thousand pages of interview statements were obtained from employees and managers. Additionally, an independent wildfire expert was retained to provide insight into firefighting operations. In total, OSHA investigators spent approximately 7 full months on this investigation.

OSHA did not concentrate its efforts on the technical aspects of the South Canyon incident; rather, OSHA focused on the occupational safety and health aspects of the incident. Further, OSHA did not question the decision to fight the fire — that is a question best debated by the experts — instead OSHA focused on those decisions made relative to ensuring the safety of the firefighters once the decision was made to fight the fire.

OSHA’s investigative team approached this investigation with a respectful somberness and a single-minded commitment — to identify the cause of this tragedy and to recommend corrective actions to ensure that a catastrophe such as this does not recur.

3. THE INVESTIGATION FINDINGS

A number of factors acted in cumulative fashion to create and intensify hazards to firefighters on the South Canyon Fire. Among those were a lack of adequate resources; dangerous weather, fuel, and terrain; failure to ensure that safe firefighting practices, as outlined in the 10 Fire Orders, the 18 Watch Outs, and the Common Denominators6 were implemented; a lack of a clear chain-of-command; and a lack of effective management oversight.

OSHA has determined that the agencies violated standard firefighting procedures, and failed to recognize and timely respond to numerous factors that, together, clearly identified the South Canyon Fire as highly hazardous to firefighting personnel. OSHA issued a Notice of Unsafe or Unhealthful working Conditions alleging one willful and one serious violation of 29 CFR 1960.8(a), the Federal Agency counterpart of the OSH Act’s general duty clause. The Notices to the BLM and the Forest Service read as follows:

CITATION 1 ITEM 1 TYPE OF VIOLATION: WILLFUL
1960.8(a): The agency head did not furnish employees with places and conditions of employment that were free of recognized hazards that were causing or likely to cause death or serious physical harm in that the safety provisions of the National Wildfire Coordination Group Fireline Handbook were not adequately enforced:

a) The identity of the Incident Commander was not effectively communicated to firefighters.

b) Adequate safety zones and escape routes were not established for and identified to employees.

c) Available weather forecasts and expected fire behavior information was not provided to employees. This included weather (e.g. red flag warning, local forecast); fuels (e.g., types density, fuel moisture); and, topography (e.g., grade, contours, elevation).

d) Adequate fire lookouts were not used on the fire. Employees engaged in fire suppression activities, including downhill fireline construction into dense fuels, were not in a position to view the entire fire front and, therefore, could not be aware of potential hazards such as fire spotting and fire blow-up.

e) Hazardous downhill fireline construction was performed without following established safe practices and taking proper precautions. Unsafe practices included constructing downhill fireline adjacent to topographical chimney; failing to anchor the fireline at the top; constructing downhill fireline into dense fuels during potential blow-up conditions; and failure to strengthen the fireline as construction progressed downhill.

RECOMMENDED ABATEMENT:
Among others, one feasible and acceptable method of abatement to correct this hazard is to:

a) Ensure that the Incident Commander identifies himself as such on all radio communications and adequately briefs key personnel as to the identity of the Incident Commander.

b) Provide and identify to employees adequate escape routes and safety zones prior to engaging in fire suppression activities.

c) Provide comprehensive and timely weather forecasts and expected fire behavior information to employees engaged in fire suppression activities.

d) Provide adequate lookouts whenever there is the potential for fire spotting and fire blow-up. Lookouts must identify and communicate fire spotting and fire blow-ups to firefighters so that appropriate action can be taken.

e) When downhill fireline construction is attempted, the following precautions, among others, must be taken:

1) Downhill firelines must not be constructed adjacent to a chimney.
2) Downhill firelines must be anchored at the top.
3) Downhill firelines must not be constructed into dense fuels during potential blow-up conditions.
4) Downhill firelines must be strengthened as construction progresses.

CITATION 2 ITEM 1 TYPE OF VIOLATION: SERIOUS
1960.8(a): The agency head did not furnish employees with places and conditions of employment that were free of recognized hazards that were causing or likely to cause death or serious physical harm in that management failed to provide adequate oversight of the South Canyon Fire to ensure that the strategies, tactics, and objectives being used did not compromise the safety of the firefighters.

a) Management failed to provide the firefighters with comprehensive fire behavior information including fuel type, fuel moisture, topography, and local weather forecasts.

b) Management failed to ensure the evolution of the Incident Command system was commensurate with the fire threat.

c) Management failed to heed the safety practices contained in the Fireline Handbook pertaining to blow-up conditions, even though fires in the surrounding area (Bunniger Fire, Paonia Fire) with similar fuels were exhibiting extreme fire behavior.

d) Management failed to conduct adequate inspections of firefighting operations, including on-site, frontline evaluations, to ensure that established safe firefighting practices were enforced on fires.

RECOMMENDED ABATEMENT:
Among others, one feasible and acceptable method of abatement to correct this hazard is to:

a) Provide comprehensive and timely weather forecasts and expected fire behavior information to employees engaged in fire suppression activities.

b) Ensure that the Incident Command system evolution is commensurate with the fire threat, and establish a chain-of-command to ensure accountability for firefighters’ safety.

c) Adhere to the safety practices contained in the Fireline Handbook pertaining to blow-up conditions, especially when fires in the surrounding area with similar fuels are exhibiting extreme fire behavior.

d) Develop and implement an effective inspection system of firefighting operations to include on-site, frontline evaluations to ensure that established safe firefighting practices are enforced on fires of all classifications. When situations arise involving multiple agencies’ responsibilities for conditions affecting employee safety and health, coordination of inspection functions is essential.7

4. CONCLUSIONS

The root cause of this catastrophe may have been best summed-up by wildfire expert, William Teie, who stated in his report to OSHA:

“If a knowledgeable fire manager had reviewed the strategy, tactics and operational objectives being used on the South Canyon Fire, timely revisions in the plan may have been made and the disaster avoided….Management must exercise its responsibility to see that the overall plans fit into overall management objectives and are safe.”

It is essential that the agencies develop, implement, and evaluate an occupational safety and health program for wildfire suppression activities in accordance with requirements of section 19 of the OSH Act, Executive Order 12196, and the basic program elements prescribed in 29 CFR 1960.8

To better protect firefighters and prevent catastrophes such as the South Canyon Fire from recurring, there must be an increased level of oversight on incident management. The agencies’ expectations for safe firefighting operations must be defined and shared with all agency personnel involved in firefighting. Agency administrators must ensure that the firefighters and Incident Commander recognize and are held directly accountable for safety, as paramount to fighting the fire. At every level of the organizations, compliance with the standard Fire Orders and careful observance of the “Watch Out” situations and Common Denominators must be promoted and enforced. The consequences of compromising these orders and guidelines must be made clear to all individual involved in firefighting.

As previously stated, OSHA has concluded that the primary cause leading to the deaths of the fourteen firefighters was that no one person or group was responsible for ensuring the safety of the firefighters. During fire suppression operations someone must be responsible — and accountable — for assuring that operations are conducted safely. OSHA believes that BLM and USFS must develop a policy of zero tolerance for safety and health infractions. The key to avoiding a recurrence of this catastrophe is to assign safety and health responsibility to specific individuals involved in wildfire suppression activities, and to hold these individuals accountable for ensuring the safety of the firefighters at all times and under all conditions; in short, develop and implement an effective safety and health program, especially for wildfire suppression activities.

Change must start with management, from the top to the bottom of each agency involved in wildland fire suppression. The unsafe conditions and practices identified in the Notices being issued by OSHA are symptomatic of the lack of management attention to ensuring that firefighting operations are conducted with safety of firefighters as the primary goal.

OSHA believes that the joint investigation conducted by the Bureau of Land Management and the Forest Service was thorough and provided very reasonable and sound recommendations for change. The subsequent Interagency Management Review Team developed an excellent report and blueprint for change. In particular, the three implications for management highlighted in the IMRT report must be given high priority with the five federal wildland agencies to avoid recurrence of the South Canyon tragedy.9 OSHA further supports the efforts of the agencies to address the more systemic issues of suppression preparedness, fuels management,, and the wildland/urban interface. If those fundamental policy issues are not squarely addressed, the safety and health of firefighters may be placed unnecessarily at risk.

OSHA’s goal is to ensure that firefighters are provide with a safe and healthy environment in which to conduct their critical functions. OSHA stands fully prepared to assist the federal wildland agencies in the furtherance of this goal.

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Cramer Fire Dedication

Lessons Learned

Management Evaluation Report

Factual Report

Gallery of Cramer Fire Report Images

Accident Prevention Plan

OIG Investigation

OSHA Investigation

HFACS—"Swiss cheese" model of Accident Causation

—OSHA Briefing Paper— South Canyon Fire

Citations for U.S. Forest Service and Bureau of Land Management

EXECUTIVE SUMMARY

1. THE ACCIDENT

2. THE INVESTIGATION

3. THE INVESTIGATION FINDINGS

4. CONCLUSIONS

Cramer Fire
Dedication

—OSHA Briefing Paper—
South Canyon Fire

Citations for U.S. Forest Service
and Bureau of Land Management