Esperanza Fire

Accident Review Board Action Plan

CDF Green Sheet

Accident Investigation
Factual Report

Cover & Table of Contents
Executive Summary
Narrative
Maps
Photographs
Timeline
Investigation Process Summary
Human Findings
Causal Factors and Contributing Factors
Appendix 1 — Fire Behavior Analysis Summary
Appendix 2 — Fire Operations Analysis Summary
Appendix 3 — LCES Analysis Summary
Appendix 4 — Standards for Fire Operations Analysis Summary
Appendix 5 — Compliance Analysis Summary
Appendix 6 — Fire Weather Analysis Summary
Appendix 7 — Human Factors Analysis Checklist Summary
Appendix 8 — Personal Protective Equipment Analysis Summary
Appendix 9 — Equipment Engine 57 Analysis Summary
Appendix 10 — Video Documentation Listing
Appendix 11 — Glossary and Acronyms

Esperanza Fire Accident Investigation Factual Report Riverside County, California October 26, 2006

Appendix 5 – Compliance Analysis Summary

Thirtymile Hazard Abatement – Monitoring Checklist

Not a standard for other wildland fire agencies, Forest Service specific.

Summary: Unclear direction in the Cooperative Fire Protection Agreement regarding how/if/when this standard should apply.

Cramer Fire Accident Prevention Plan

Not a standard for other wildland fire agencies, Forest Service specific.

Summary: Unclear direction in the Cooperative Fire Protection Agreement regarding how/if/when this standard should apply.

Complexity Analysis

Not a standard for other wildland fire agencies, Forest Service specific.

Summary: Unclear direction in the Cooperative Fire Protection Agreement how/if/when this standard should apply (roles/responsibilities).

Personnel Medical Surveillance Folders

Employee medical surveillance records were reviewed.

Summary: Written Respiratory Protection Program for Self-Contained Breathing Apparatus (SCBA) was in place and to agency standards.

Employee IQCS Qualifications

IQCS qualifications for employees were reviewed.

Summary: All met IQCS standards.

Leadership Training

Engine 57 Captain’s training history, including all position prerequisites, included: L180 – Human Factors; L-280 – Followership to Leadership; L-380-Fireline Leadership; N9019 - ICT3 Simulation – Time Pressured Simulation Assessment; and S-215 – Fire Operations in the Wildland Urban Interface.

Leadership training standards for CAL FIRE firefighters differ from USDA Forest Service.

Summary: The outcome of this fire demonstrates the challenge in assessing the effectiveness of recent advancements and individual accomplishments in training. It does support the notion that training alone should not be the default proposed solution to achieve desired safety performance, especially given our understanding of the critical role human factors play in a dynamic fire environment.

The S-215 – Fire Operations in the Wildland Urban Interface was recently revised and improved. However, some questions remain about some of the practices/tactics taught that could conceivably make it more difficult for an engine to make a quick retreat.

Weather Forecast

A spot weather forecast was requested and received by the Incident Commander early on in the incident, prior to the accident. The spot forecast confirmed the Red Flag Warning. A Fire Weather Watch was issued for the area 2 days prior to the accident. A Red Flag Warning was issued the day before the accident. Witnesses’ statements and weather reports confirm “Red Flag Warnings” were in effect for the early morning of the incident. Refer to the Esperanza Fire Weather Summary for additional details on compliance.

Summary: The reported awareness by most firefighters about the Red Flag Warning for Santa Ana wind conditions did not seem to influence the strategy of engagement or temper the tactical decisions made in any discernable way.

Engine 57

Based on a site analysis and review of maintenances records, Vehicle 6652 Engine 57 was in good condition and fully operable for a Region 5 standard Model 62 (Type III) Engine.

Fire Shelter

Missoula Technology Development Center (MTDC) Equipment Specialist determined the fire shelters in the possession of firefighters were to standard.

Written Plans/Policies

A review of Agency Fire Management Plans show progress in the integration of interagency objectives and policies, but many important differences still exist.

Summary: Written direction for the management of fires is numerous, confusing, and in some cases, contradictory. There are separate or additional requirements that relate specifically to the agency responsible for managing the fire. Some agency protocols such as fire transitions (Type III to Type II/ I) documentation are generally the same, but lack consistency regarding safety. For example, CAL FIRE Incident Command Team Transition Briefing and Debriefing Form (7700) do not include a risk management or safety component.

The Cooperative Fire Protection Agreement, in place for the past several years and up for renewal, has resulted in a better understanding of the differences and strengths of each agency. An opportunity for improvement based on lessons learned is evident, particularly in the vital area of firefighter safety.

< < < continue reading—Esperanza Fire Factual Report, appendix 6—fire weather analysis > > >