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 Wildfire Safety Drill, 2007April 13-15, 2007 Anderson Ranch Fire — August, 1997 Investigation Report Communicating Intent and Imparting Presence
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United States Forest Service Boise NF Department of Agriculture File Code: 6700/5100 Route To: Date: August 18, 1997 Subject: Anderson Ranch Fire; Vehicle Burnover To: Forest Supervisor, Boise NF On Friday August 8, Forest Service vehicle 4965 was damaged by the Anderson Ranch fire. Guy Pence asked Greg Keller (Deputy North Zone FMO) and me to investigate this incident. We were to investigate not only the damage to the vehicle, but also the potential fire entrapment (see WO June 5, 1997, letter) We were given a letter of delegation on Saturday August 9. That afternoon, Greg flew over the area with maps and the ATGS Jack Brinkerhoff, to gain an understanding of the topography and insight to the fuels and fire behavior. I listened to what had been recorded on the BILC tapes for August 8. Summary of the InvestigationForest Service vehicle 4965, a 4x4 ¾-ton pick-up, sustained damage to the emergency brake, front tires, windshield wipers, paint/chrome, and the plastic grill components. In addition to the damaged vehicle, the investigation team discovered several areas of concern. Firefighter safety was compromised; documentation of mandatory training for several individuals was in question. We ascertained that crew members of E-211 were not carrying their fire shelters (required PPE for firefighting) during the suppression operations. The engine is understaffed for 7-day coverage. Some of the actions of the crew and overhead point to concerns of their knowledge, skills, and ability. The job hazard analysis appears to be inadequate. In reconstructing the case, the accident sequence is considered in reverse order. Enclosed is the Anderson Creek fire investigation and review. R. DANIEL DOLATA Enclosures ANDERSON CREEK FIRE INVESTIGATION AND REVIEW
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| Initial Organization | |||
Vehicle |
Name |
Position |
ATA |
E-211 |
Jones, Kurt |
Incident commander Hose handler Firefighter |
1510 1510 1510 |
| P-212 | Oppenheim, Clint | Engine operator | 1510 |
4965 |
O’Quinn, Richard |
Firefighter and driver Firefighter Firefighter |
Approx 1530 |
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|||
Firebird |
Brinkerhoff | 1555 | |
| H-81EA | Plus 3 | Firefighters | 1536 |
The crew retreated into their safety zone, the burn, with one person experiencing heat and smoke problems. Vehicle 4965 was damaged by the passing flame front as described above.
Arrived in vehicle 4965 after E-211 and P-212. The vehicle was not parked in a safe, accessible location pointing away form the fire, with windows closed (see map for vehicle locations). IC Jones directed them to get down to the bottom and help the helicopter by digging line uphill. Their briefing was very short. They started down the hose lay and determined they could not make their way to the bottom. They then joined the E-211 crew in the downhill wet line construction and hot spotting with hand tools. Radio communication was hampered by having ground, air, and command on the same TAC channel.
1. Unsafe behavior, unsafe mechanical, or environmental conditions.
2. Truck was parked on a slope in unburned fuels near the top of a draw. “Vehicles should be parked in a safe, accessible location pointing away from the fire, with windows closed and keys in the ignition”, Fireline Handbook, page 5.
3. Fire “hooked” into chimney and made a run up to where the truck was parked, and damaged.
4 . Crew fled to safety zone. Engine 211 and P-212 were moved to safety. There was not enough time or personnel to move vehicle 4965.
A downhill line construction operation was taking place on a 32 percent slope in light flashy fuels. The crew stated they were familiar with the downhill line construction guidelines and expressed some concern about the assignment. One crew member was unfamiliar with the downhill line construction guidelines but was aware that it was a watch out situation. They all felt that due to the current fire activity, 6 to 12-inch flame lengths and light fuels, and good access into their safety zone (the burn), that it was a reasonable assignment.
The causes leading to this situation are cross-referenced with the Fire Orders, Watch Out Situations, Downhill/Indirect Line Construction Guidelines and Carl Wilson’s Common Denominators of Fire Behavior on Tragedy Fires.
The following Fire Orders were ignored or compromised:
“Fight fire aggressively but provide for safety first.” They were being aggressive, but failed to provide a safety zone for the vehicles or a driver to move all the vehicles when the fire approached their position.
“Initiate all action based on current and expected fire behavior.” The fire was approximately 35 acres on initial attack. The fire had spread 30 chains in 30 minutes. The IC and crew ignored this “fire history” when attempting to build line downhill into Lester Creek, even though at the time, the fire had “laid down.” The potential still existed when the fire “lined up” (Doug Campbell’s prediction system) with slope, aspect and wind to make the critical fire run. The run in question, advanced 27 chains in 5 minutes (359 chains per hour), with calculated flame lengths of 13 to 20 feet.
“Determine safety zones and escape routes.” The crew in fact had a very good safety zone, the burn, while constructing direct fireline. When the fire run up the drainage occurred, the crew moved quickly into this safety zone. Three crew members moved directly uphill for some distance before contouring across the slope into the burn. One crew member suffered from heat and smoke during this process. The one escape route and safety zone not provided for was for the vehicles. E-211 and P-212, because operators were present, were moved a safe distance from the fire area. Vehicle 4965 was damaged as previously described.
The following Watch Out Situations were ignored or compromised:
“Safety zones and escape routes not identified.” See 7 above. Again, this is in reference to the vehicles.
“Unfamiliar with weather and local factors influencing fire behavior.” See 3 above.
“Building fireline downhill with fire below.” All crew members and the IC were aware of the downhill line situation. They failed to observe or predict the fires hooking motion in the bottom of Lester Creek and the spot fire across the drainage to the north. They had proceeded some 700 feet from the engine at the time of the fire run. It is also reported the two engines ran out of water at this time as well. This fact, with the increasing fire activity, made the hose lay operation questionable at best, with 700 to 800 feet of line construction remaining. Again, the point of concern is not having adequate safety zones for the vehicles.
“Attempting a frontal assault on fire.” Once the fire hooked and spotted to the north of the proposed line, they found themselves in a frontal assault configuration, necessitating the removal of the engine and patrol truck, and the events leading to the damage of vehicle 4965.
“Unburned fuel between you and the fire.” Again, once the fire hooked and spotted to the north of the proposed line, there was some 1,500 feet of unburned fuel between the trucks and fire edge.
“Wind increases and/or changes direction.” All crew members and the IC report a wind shift and increase in wind speed. The IC stated, “The helicopter operations caused the flare up,” a possible excuse. Regardless, the fire responded to aspect, slope, and wind to sustain its run.
“Getting frequent spot fires across line.” While in this case they reported only one spot fire, that was more than enough. The spot fire in conjunction with the hooking action of the main fire, converged to make the one rapid uphill run.
The crew apparently did not recognize the potential of parking the vehicle in unburned fuels. They were “doing direct line construction with one foot in the black.” What could be safer?
Downhill/Indirect Line Construction Guidelines compromised resulting in the crew having to make use of their safety zone (the burn) and the damage to FS vehicle 4965:
“The decision is made by a competent firefighter after thorough scouting.” It is unclear whether the IC scouted the line or could see the entire operation from his vantage point. He did have communication with H-81EA and air attack (Firebird).
“Downhill line construction should not be attempted when fire is present directly below the proposed starting point.” By all accounts, the fire was directly below the starting point and the crew as it proceeded downhill. The crew did have an adequate safety zone (the burn); the vehicles did not. This resulted in the moving of E-211 and P-212 and the damage to 4965.
“The fireline should not lie in or adjacent to a chimney or chute that could burn out while the crew is in the vicinity.” This is probably the most significant factor relating to the fire run, forcing the crew into the black, the moving of the vehicles and damage sustained to vehicle 4965. The resulting fire behavior and run should have been predicted or anticipated when making the tactical decision to attack the fire in this location.
As stated above, the water supply was exhausted with an additional 700 to 800 feet of line construction to be completed.
The following is a list of Carl Wilson’s Common Denominators of Fire Behavior on Tragedy Fires, all five of which apply on this incident:
“Most incidents happen on the smaller fires or on isolated portions of larger fires.”
“Most fires are innocent in appearance before the ‘flare-ups’ or ‘blow-ups.’ In some cases, tragedies occur in the mop-up stage.”
“Flare-ups generally occur in deceptively light fuels.”
“Fires run uphill surprisingly fast in chimneys, gullies, and on steep slopes.”
“Some suppression tools, such as helicopters or air tankers, can adversely affect fire behavior. The blasts of air from low flying helicopters and air tankers have been known to cause flare-ups.”
IC Jones and crew did not recognize the danger of having fire below them in deceptively light fuels.
Whole crew did not fully understand the danger of downhill direct line construction.
Inadequate work standards.
Abnormal use of equipment.
Oppenheim and Jones have had the mandatory refresher training and Oppenheim has been step tested. The documentation for the refresher is what is lacking, NOT the training.
Inadequate Job Hazard Analysis.
The IC Kurt Jones was not at the point of attack with the hose laying operation. He was near E-211 assisting with the hose lay. That work assignment should have been assigned to Clint Oppenheim, the engine operator. During this operation, it appears he had little or no contact with the BLM helitack crew working the east flank. He was placed between the proverbial rock and a hard place in regards to being the IC, engine foreman, engine crew person, and lookout.
While the crew had use of all the tools and equipment provided for in wildland fire suppression operations, they were not used effectively or efficiently.
Scouting did not identify potential for change in fire behavior, weather or up slope fire run. Information from the air attack was either ignored or discounted in regards to the impending fire buildup in Lester Creek and position of the crew and vehicles on the slope above.
Radio or frequency management could have been managed in a better fashion by designating a “ground” tactical frequency, air to ground frequency, and a command frequency. All individuals with radio’s complained of “nonstop radio chatter from air attack to the ground”. As a minimum, an air to ground frequency should have been established.
Did the crew and IC adhere to all policy, guidelines, and orders for fire suppression activities? NO! As stated above, Fire Orders were not adhered to. Watch Out Situations were not heeded. Downhill Line Construction Guidelines were ignored. Two individuals did not have their fireline gear (fire shelters). The hose lay was unorthodox at best.
The positive actions were: first and foremost, the crew had a good safety zone that they were able to enter with no injuries to themselves. The air support operations were prompt and effective, including the delay of Air Tanker 60. The suppression actions after the fire run out of Lester.Creek were safe and effective.
Were the crew and IC aware of the Downhill Guidelines? Yes!
Did they recognize the potential? Apparently not. The fire had provided a “fire history” in the 15 minutes prior to their arrival. This history was ignored when making plans for the attack into Lester Creek. Even after warnings from the air attack, the line construction continued downhill. The potential of a rapid uphill run, on a southwest slope at 1630, should have been planned for.
If guidelines and policy were violated, how has this gained acceptance? As stated above, rules, policy, and guidelines were violated or ignored. We do not feel this is accepted practice here or elsewhere. It is more a symptom of lack of knowledge, skills, and abilities. Basically, the inability to recognize potentially hazardous situations. Simply put, the 10 years of experience of the IC needs to be put into perspective. As Norman MacLean states in Young Men and Fire, “You can’t learn much from fighting small fires in regards to fighting large ones.”
How do we break this cycle?
By continuing to do investigations on incidents such as Anderson Ranch, and reviewing the findings with the involved parties and other suppression personnel. This review should be in a training or learning atmosphere. There must be some measurable guide to determine if the individual(s) have, in fact, gained a new knowledge and understanding of the situation.
By having Forest and Regional standards strictly enforced in regards to red card qualifications. This is somewhat hard to address. Individuals have attended training sessions, completed task books and should be certified at a particular position. Yet we find that in certain circumstances, individuals do not exhibit the necessary skills to safely perform in a given position of set of circumstances.
By providing long-term appointments and upgrades to our attack module leaders and assistants. This in itself will not change the knowledge, skills, and abilities of any current individuals, but for the future, theoretically, you will be able to recruit and hire more qualified and knowledgeable individuals.
Having proficiency drills and exercises, to determine knowledge, skills, and abilities. This should be an opportunity to determine individual and crew knowledge, skills, and abilities. Point out deficiencies and promote correct or different ways to accomplish our assigned task of wildfire suppression.
GREG KELLER Deputy North Zone FMO
DANIEL DOLATA Safety and Occupational Health Specialist
APPENDIX
Photographs
Morning Fire Weather Report
Fire Behavior Report by Robert Patton
Map
WO letter re: investigating entrapments
Letter of Delegation
Job Hazard Analysis Dated April 5, 1984
Dispatch Log
SO letter re: readiness inspection
Other documents available:
Written statements from some of the crew
Written statement from ATGS
Investigator’s notes
Time reports PP15
Red card qualifications
Refresher training attendance list
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