A Career Fire
Fighter was Killed and a Career Captain was Severely Injured During a
Wildland/Urban Interface Operation - California
RECOMMENDATIONS/DISCUSSIONS
Recommendation #1: Fire departments and fire service agencies
should ensure that the authority to conduct firing out or burning out
operations is clearly defined in the standard operating procedure (SOP)
or incident action plan (IAP) and is closely coordinated with all supervisors,
command staff and adjacent ground forces.
Discussion: It may be advantageous or necessary to conduct firing or
burn-out operations in certain areas during a fire. Each and every fire
fighter must be assigned to a team of two or more and be given specific
assignments when conducting such an operation.1 Firing out operations
is a way of attacking a very intense fire. Burning out is used to widen
a control line by eliminating unburned fuels between the control line
and an advancing fire front.2 Any firing out or burning-out operation
requires considerable preparation, organization and coordination. Safety
must be given first priority. No operation, regardless of strategic importance
or other critical factors, is worth risking human life.3 Overall fire
strategy and authorities must be clear to all personnel employing firing
out or burning-out, since fire behavior or fire control operations on
adjacent divisions are likely to be affected.4
Regardless of the purpose and which tactic is chosen, certain basic safety
procedures should be followed when conducting firing out or burning-out
operations because any additional fire may increase the risk to life and
property.
The following are examples of safety guidelines pertinent to this incident:
- Firing operations should be supervised by qualified personnel
- Firing operations should be coordinated with incident command and
crews operating in the area
- Firing operations should be done by trained personnel that have authorization
from their supervisor and the command staff
- Constant radio communications must be maintained so firing operations
can be coordinated with other fireline operations
- Escape routes and safety zones should be identified and clearly marked
before starting firing or burn-out operations
- If firing out becomes too intense for the crews to control, it should
be stopped until control is regained and the firing operation is modified
to reduce the intensity
- Firing operations should be initiated from and terminated at an anchor
point.2
Recommendation #2: Fire departments and fire service agencies
should ensure that all resources, especially those operating at or near
the head of the fire, are provided with current and anticipated weather
information.
Discussion: A “Fire Weather Watch” indicates a possible
critical fire weather pattern (i.e., strong wind, dry lightning, dry cold
front, low relative humidity.) A “Spot Weather Forecast” should
be requested for fires that have potential for extreme fire behavior,
exceed the initial attack, or are located in areas for which a “Fire
Weather Watch” or “Red Flag Warning” has been issued.5
A “Fire Weather Watch” had been issued at 0900 hours for
this fire on the day of the incident. The victim’s crew was not
aware of the “Fire Weather Watch” issued earlier that day
and not provided with a “Spot Weather Forecast.”
Recommendation #3: Fire departments and fire service agencies
should stress the importance of utilizing LCES (Lookouts, Communications,
Escape Routes and Safety Zones) to help identify specific trigger points
(e.g., extreme fire behavior, changes in weather, location of fire on
the ground, etc) that indicate the need for a crew to use their escape
route(s), and/or seek refuge in a designated safety zone.
Discussion: In the wildland fire environment, Lookouts, Communications,
Escape Routes, Safety Zones (LCES) are key to safe procedures for fire
fighters. The elements of LCES form a safety system used by fire fighters
to protect themselves. LCES is a self-triggering mechanism that allows
the lookout to continuously assess and reassess the fire environment and
to communicate those threats to fellow crew members.5 Being on the alert
to the indicators of extreme fire behavior will help fire fighters identify
established trigger points (e.g., increased spotting, approaching weather
front or change in wind direction, etc). Trigger points allow crews the
necessary time to utilize escape routes to reach safety zones. Seeking
refuge in an apparatus or permanent structure should not be considered
a safety zone but rather a survival site. Key points regarding shelter
deployment, building refuge and vehicle refuge can be found in the Fireline
Handbook and the Incident Response Pocket Guide.5, 6
Radio communications allow lookouts, supervisors, crew members and air
resources to warn crews of any situational changes in weather and fire
behavior. Ample warning of changing conditions would provide fire fighters
with the necessary time to utilize escape routes to the designated safety
zone(s).
Individual crews observed the fire from their individual vantage points.
There were no assigned or designated lookouts for the Task Force or adjacent
ground forces operating on or near the ridge to observe and communicate
their observations of the fire’s progress up the drainage.
There are numerous examples of where communication was effective among
individual crews but not between crews. One example of a successful outcome
involved the Hotshot crew operating at the north end of the ridge. Their
supervisor, standing in the safety zone, ordered his crew to his location
after he observed an increase in fire activity along the ridge. Unfortunately,
this radio transmission was made on the Hotshot crew’s tactical
channel and was not heard by the victim’s crew or other crews operating
on the ridge.
Recommendation #4: Fire departments and fire service agencies
should ensure that, at a minimum, high-risk geographic areas are identified
(e.g.; topography, fuels, property, etc.) as part of the pre-planning
process and that that information is provided to assigned crews.
Discussion: Pre-incident plans are guidelines intended to assist fire
officers in establishing priorities and making fireground decisions. The
pre-incident plans should be reviewed at least annually and updated as
needed.2 Copies of pre-incident plans should be made available to all
assigned crews. The pre-incident plans should contain, at a minimum; maps
(showing topography, possible staging areas, target hazards, access routes,
water sources, and possible facilities such as base camps, helibases,
and helispots), list of special concerns/needs (special hazards, fuels,
expected fire behavior, etc.) and history of previous fires, an invaluable
resource for out-of-area crews providing mutual-aid.
In this incident, none of the officers or fire fighters assigned to the
Task Force had ever fought a wildland fire in this region of California.
Fire history, fuels, weather, topography and crew training/experience
varies throughout the state. This creates a situation where crews may
be unfamiliar with local factors affecting fire behavior and is listed
as one of the eighteen “Watch-Out” situations taught to all
wildland fire fighters - “Unfamiliar with weather and local factors
influencing fire behavior”5 that have been identified as a contributing
factor in wildland fire fighter fatalities.
The CDF Green Sheet and the report produced by the victim’s fire
department both pointed out that an incident involving the deaths of 11
fire fighters, occurred less than 1.5 miles southwest of the entrapment
site under very similar weather conditions in November of 1957. This information
was not made available to the victim and his crew.
Recommendation #5: Fire departments and fire service agencies
should ensure that incident command system (ICS) span-of-control recommendations
are maintained.
Discussion: Span-of-control refers to the number of personnel reporting
to any given individual. Optimum span-of-control in the incident command
system (ICS) is five, with an acceptable spread of two to seven. On a
situation that is not yet under control, no one operating under ICS should
have more than five personnel reporting to him or her. Span-of-control
ratios can be driven by a number of factors such as the training and experience
of the fire fighters, complexity of the incident, or the type or timeframe
of the incident.7
This incident can best be described as a fast moving complex incident
that would have required a tight span-of-control. The span-of-control
at the Division level on this incident was 27 to 1 and exceeded the acceptable
ratios as outlined by the ICS.
Recommendation #6: Fire departments and fire service agencies
should consider the implementation of a carbon monoxide-based monitoring
program for wildland fire fighters.
Discussion: Crew members reported that the victim reacted in a confused
or disoriented manner during the critical minutes as the fire approached.
Hypoxia, the reduction of oxygen in blood or tissues, can cause an altered
mental status and the victim had two potential reasons for hypoxia: carbon
monoxide poisoning and/or a severe asthma attack.8 An asthma attack of
sufficient severity to cause hypoxia typically is preceded by symptoms
of respiratory distress such as shortness of breath, difficulty breathing,
wheezing, or chest tightness.9 According to his crew members, the victim
never displayed any of these symptoms. The NIOSH medical investigator
considers asthma an unlikely cause due to the lack of symptoms, coupled
with the victim’s relatively mild underlying asthma.
Hypoxia due to carbon monoxide poisoning is a more likely scenario. Although
wildland fires generally do not expose fire fighters to high levels of
carbon monoxide averaged over an entire work shift, they can expose fire
fighters to dangerous concentrations for short periods of time during
specific activities.10-12 In addition, carbon monoxide exposures were
found to be higher during prescribed burns, presumably because fire fighters
feel compelled to keep the fire within prescribed boundaries at all costs.13
“The increasing problem of residential influx to wildland areas
may cause more overexposure to smoke as firefighters feel compelled to
protect structures despite heavy smoke situations.”13
At approximately 1100 hours, the victim was exposed to carbon monoxide
during mop-up operations for about 50 minutes. At approximately 1215 hours,
the victim was protecting a residential structure by supervising a “burn
pile;” a small “prescribed burn” to reduce fuel load
around the home. To control the pile, water was applied to the ground
around, and onto, the pile. The latter activity probably increased the
pile’s generation of carbon monoxide due to incomplete combustion.
He did this for approximately 25 minutes before the fire conditions dramatically
deteriorated. In addition, the victim encountered conditions that may
have increased the severity of the exposure: exertion related increase
in minute ventilation (how fast and deep the individual was breathing),
long duration of exposure (approximately 30 minutes at the scene, about
50 minutes of mop-up in the late morning, and at least 12-hours during
the previous shift), altitude (3800 feet), simultaneous exposure to airborne
irritants (wildland fire smoke), and proximity to engine tailpipe exhaust.14,
15 During the autopsy, a carboxyhemoglobin level of 27% was found, demonstrating
his significant exposure to carbon monoxide. Although carboxyhemoglobin
levels do not correlate well with clinical findings, profound unconsciousness
has been reported with levels less than 20%.16, 17
While these findings can explain the victim’s confused behavior,
it is unclear why his Captain and other crew members, working under similar
conditions, did not experience symptoms or signs of carbon monoxide poisoning.
Upon hospital admission, the Captain had a carboxyhemoglobin level of
4.6%. Prior to hospital admission, the Captain’s resuscitation efforts
included intubation and administration of 100% oxygen; measures that speed
the elimination of carboxyhemoglobin. Assuming he was intubated and receiving
100% oxygen for about one hour prior to his carboxyhemoglobin level being
drawn, the Captain’s estimated peak carboxyhemoglobin level would
have been approximately 9.2%.18, 19 Possible explanations for the discrepancy
between the Captain’s and the victim’s carboxyhemoglobin levels
include: 1) the victim had higher exposures to carbon monoxide due to
any of the factors listed in the previous paragraph, or 2) individual
variation.
Fire management and safety officers responsible for health and safety
of fire fighting personnel should consider using CO monitors to manage
fire fighter’s acute overexposure to components of smoke. To monitor
acute exposures, field personnel need to calibrate and activate a CO monitor
during wildland fire fighting operations. The monitors are already set
to alarm at certain levels, and can be used as an “early warning
device” to trigger actions to reduce exposures. Managers should
also develop a written smoke exposure plan. This plan should focus on
responding to CO monitor warning alarms, and include health surveillance,
training, and tactics to minimize exposure.5, 20 Since smoking increases
CO levels, encourage smokers to quit and non-smokers to not start. The
victim and the Captain of E-6162 were non-smokers.
Additionally,
Recommendation #7: State agencies, local municipalities and community
organizations should consider developing statewide guidelines and local
community plans for managing fuels in the wildland/urban interface.
Discussion: A number of organizations at the state and national levels
provide community leaders and citizens with guidelines that can be utilized
in identifying specific threats to life and property (i.e., wildfires),
best practices and available resources.
The following are links that provide information regarding the wildland/urban
interface:
The incident site occurred in a community that was identified and designated
by the California Fire Alliance as having a Hazard Level Code of 3, indicating
the highest fire threat level. The surrounding communities also had a
Hazard Level Code of 3.
These communities were in the process of establishing a committee to
deal with the threat of a wildfire when the incident occurred. The homeowners
of Residence #2 had cleared a large portion of the wildland brush in all
directions surrounding the house.
Approximately 70 feet of brush had been cleared to the east, 180 feet
to the west, 100 feet to the south, and 115 feet to the north of the house.
There was extensive management of the landscape vegetation and grounds
surrounding the incident site that consisted of a mix of herbaceous plantings,
a juniper hedge (near patio where victim was found), small woody shrubs,
a few small fruit trees and larger diameter oak trees.
Recommendation #8: Fire departments and fire service agencies
should provide members with annual medical evaluations consistent with
NFPA 1582, Standard on Comprehensive Occupational Medical Program for
Fire Departments.
Discussion: The affected fire department had already implemented a comprehensive
annual medical evaluation program. In addition, the victim’s personal
physician appropriately shared medical information (i.e. his asthma diagnosis)
with the fire department physician, but not other fire department or city
officials. The fire department physician (employed by a Health Maintenance
Organization under contract with the fire department) assessed whether
this condition could affect the victim’s ability to safely perform
the job. Specifically, they noted the victim never required any of the
following for this asthma: hospitalizations, emergency medical care (e.g.
a hospital emergency department), oral corticosteroids, or work restrictions.
In addition, the victim had normal PFTs as described in the above medical
findings section.
According to NFPA 1582, asthma compromises a member’s ability to
perform several essential job tasks of structural fire fighter.21 However,
the NIOSH occupational medicine physician and investigators believe the
fire department physician appropriately evaluated the fire fighter’s
underlying lung condition off his asthma medications. Since 1) these PFTs
and chest X-rays were normal, 2) his condition was easily controlled with
intermittent use of inhalers, and 3) in four years his condition never
affected his ability to perform the duties of a structural fire fighter,
NIOSH investigators agree with the fire department physician’s decision
to clear this fire fighter for unrestricted duty.
Recommendation #9: Standard setting bodies (e.g., NFPA, NWCG,
etc.) should consider developing a national standard that fire fighters
can utilize during wildfire incidents for identifying and marking wildland/urban
interface properties based on the ability to defend the structure(s) located
on that property.
Discussion: A structure triage checklist or assessment sheet is an invaluable
tool when evaluating and identifying structures that can be successfully
protected during a wildland fire incident. The evaluation (triage) of
a structure by an officer (preferably a wildland/urban interface protection
specialistb) is but one part of the size-up process when determining if
a structure can be protected from an approaching wildland fire. The safety
of fire fighters must be the primary consideration when evaluating whether
a structure can be successfully protected. There are three categories
of structures: those that are not threatened, those that are hopeless
or too dangerous to protect, and those that will be threatened and have
the potential of being saved.4 Determining which category a structure
will fall into should be based upon a logical process of determining anticipated
fire behavior, estimating the capabilities and availability of resources,
and analyzing the defensible space around the structures.
The ability to identify structures that are or are not saveable must
be communicated to other fire fighters in the area. A national standard,
utilizing alpha-numeric characters or symbols, is needed to provide the
wildland/urban interface protection specialist with a means to communicate
his findings to other emergency service personnel. Examples include: a
large A or 1 spray painted in fluorescent orange on the driveway near
the road would indicate that the structure on that particular property
is saveable, whereas a large X or 3 would indicate that the structure
is not saveable. Symbols such as an X (not saveable), a large circle (not
threatened), or a square (threatened but saveable) could also be utilized
as a means to communicate the triage findings of the officer (urban interface
specialist). A national standard would provide a system that would allow
all fire fighters, who may have responded from various regions of the
state or country, to understand which structures have been identified
as not saveable, not threatened or threatened but saveable.
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b A wildland/urban interface protection specialist is an individual that
meets or exceeds the minimum requirements outlined in Chapter 9 of NFPA
1051, Standard for Wildland Fire Fighter Professional Qualifications,
2002 edition.
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