It’s Going to Happen Again

By Mike Lewelling – Fire Management Officer – Rocky Mountain National Park

The Safety Officer stated that the purpose of our review was to learn from this accident and to ask ourselves: “How could this accident be prevented?” A good goal, and a good question. But, even so, it is a question that bothered me.

I recently had the unfortunate job of completing an accident review on one of my Hotshots who had received a very serious chainsaw cut wound to a finger.

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By policy—and good practice—we convened an accident review panel. This group included the Hotshot Superintendent; my Supervisor; the Park Safety Officer; the injured Hotshot; and me, the Park Fire Management Officer.

The Safety Officer stated that the purpose of our review was to learn from this accident and to ask ourselves: “How could this accident be prevented?” A good goal, and a good question that we should always ask. But, even so, it is a question that bothered me.

Important Sideboards

It seems to me that to even frame such a question, some sideboards and assumptions first need to be made. These include:

  • Unwanted wildland fires will continue to occur.
  • Line Officers/Agency Administrators will continue to request that firefighters suppress wildland fires.
  • Wildland fires will continue to occur in uneven, steep, rocky terrain with countless physical and environmental hazards.
  • Firefighters will continue to utilize direct and indirect strategies and tactics to achieve the mission.
  • Hotshot crews will continue to be asked to accept potentially higher-risk assignments.
  • Firefighters will continue to utilize chainsaws to effectively and safely accomplish their mission.
  • More? What other high-risk duties do we ask our firefighters to accomplish—that aren’t going to change as long as we continue to ask them to operate in the wildland fire environment?

Removing the Non-Realistic Mitigations

These sideboards/assumptions prevent the “Root Cause” seekers from recommending non-realistic mitigations such as:

  • Not being near wildfires,
  • Not walking on steep uneven ground,
  • Not going near physical and environmental hazards,
  • Not using dangerous tools like chainsaws.

The fact is, we made a personal choice to work in wildland fire, and that choice of employment carries with it inherent risk. The sideboards/assumptions (listed above) come with accepting this job. As public servants, the very nature of our employment comes with risk—meaning if you don’t want to be exposed to risk, you can choose another line of work.

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Here’s What Happened that Day

Having framed this accident with sideboards, here’s what actually happened that day on the Clark Creek Fire on Colorado’s White River National Forest.

The Sawyer and Swamper were asked to take care of a 3×3-foot spot across the fireline that was smoldering in the duff under a tree.

This spot was on a steep slope. The Sawyer, working the bottom side of the tree, had moved to the tree’s high side. The Swamper was clearing brush that had already been cut below the tree.

The Sawyer and Swamper were approximately 10 feet apart.

The Swamper slipped and fell toward the tree—putting his hands out in front of him to break the fall. At the same time, the Sawyer reached out with the chainsaw to limb the tree. Both of those movements closed the gap. The tip of the chainsaw made contact with the Swamper’s right ring finger, cutting through his glove lacerating the finger from his main knuckle to the tip of his finger.

A well-orchestrated medical treatment and evacuation occurred. The Swamper was transported by the Superintendent’s vehicle off the fire and transferred to a waiting ambulance who got the Swamper to the hospital emergency room in an hour.

Key Factors in this Accident

In reviewing the accident, we looked at several key factors:

 Risk Management

The crew has chainsaw JHA’s that they go over at the beginning of the season and periodically review, as well as tailgate safety sessions each day based on the day’s work.  These processes identified potential hazards as well as mitigations of Sawyers and Swampers working together.

Mission Drive

There was no sense of urgency. The spot fire was not posing an immediate threat. The crew was just beginning work for the day to complete handline and the fire was not moving.

Team Selection

The Sawyer and Swamper have been working together all year. Each person had two years on a Hotshot Crew. Prior to being on the Hotshot Crew, the Swamper had six years of fire experience. He is certainly well aware of risks and is proficient in moving over steep, uneven ground. The fact of the matter is, as a Hotshot Saw Team, these two are as experienced as it gets.

Training

The Sawyer and Swamper have had basic saw training, years of crew experience snagging, cutting hotline, bucking, felling, etc. In addition, the entire crew spends a great deal of time on Sawyer and Swamper operations as a standard operating procedure. 

Team Fitness

This accident occurred first thing in the morning. Both employees had good rest. They had just eaten, were warmed up, and were very situationally aware. Both of their physical fitness levels are outstanding. The crew was toward the beginning of their third assignment of the year.

Environment

This was a typical fireline environment that you would find on any fire in mountainous terrain. Cannot be avoided.

Work Complexity

Limbing and brushing-out around a tree is a skill that both of these employees were very proficient at. They had done this countless times this fire season. 

Complacency

The Sawyer and Swamper were situationally aware and are on their game when the saw is running. Although brushing and limbing are a task frequently done, when the saw is running, these two pay extra attention.

History

Looking back at this IHC’s history, this is the first reported chainsaw cut accident in more than 20 years. This is an astonishing feat given the countless hours of exposure and technical difficulty of their chainsaw operations.

These two employees were doing the job they were asked to do. And they were doing it in a way that was professional, competent and how they were trained to do it. The Swamper simply slipped and tried to arrest his fall by putting his hand out in front of himself. I do not know of anyone who has not slipped, tripped or fell at some point.

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My True Answer: “I Don’t Know”

My empathetic mind—as a leader of employees who are real people with real families and loved ones—cannot process that there is an acceptable level of accidents/injuries or fatalities in our line of work. However, the practical part of my mind has to acknowledge that once we agree to an acceptable level of risk, do we not also—at the same time—accept a certain level of loss? It’s a simple mathematical equation; probability and consequences.  If we accept that we have a 99% chance of success, that also means we accept the 1% chance of loss.

As leaders, we ask our employees to accept risk by completing assignments for us. If we ask them to accept this risk, did we just make a subconscious decision to accept the potential for loss should something go wrong?

I do not say “accept loss” as some flippant resignation that by accepting this concept that people getting hurt or killed is ok.  I want the people I lead to know this is a possibility, and in some part of their brain they will take that extra look, take an extra second, make a different decision that makes a positive difference in the future.

Therefore, my true answer to “How could this accident be prevented?” is: 

I don’t know.

Do You?

 

 

 

 

 

 

This Hotshot Was Burned When His Saw Geysered – Listen to His Lessons.

By Travis Dotson

Nic bucked up the tree he had just put on the ground. Then he shut the saw off and sat with his saw partner for 15-20 minutes. Nic got up to cut another tree. The saw wouldn’t start.

He had heard all the stories.  He had talked about geysering in training. He had even experienced fuel geysers before.

Watch:

Nic is solid. Chances are you’re solid as well.

Solid does not mean accident proof.

Wisdom from Nic:

  • “It caught me off guard because it didn’t match up to any of the signs I’d recognized before. I’ve been surprised once, I can be surprised again.”
  • “I never thought I would get hurt by opening my fuel tank. It’s not one of those things you recognize as being a major hazard.”
  • “I definitely don’t feel like I can predict it anymore. I don’t think it’s worth betting on, just treat it like it’s always going to geyser and put yourself in a better place whenever you plan on opening the cap.”

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Now you know – do something different.

We Made it Out, But it Was Very, Very Close – Reflections From The Nuttall Fire.

Everyone was moving in slow motion. On our intercrew I could hear our Lookout giving us updates calmly but forcefully: It was time to be gone.

 

By Matt Holmstrom

Current – Superintendent Lewis & Clark IHC

Nuttall Fire – Squad Leader Lassen IHC

There are so many impressions and recollections that I have from that day, July 2, 2004. Some of them are lessons I tried to learn and pass on to my guys, some that, even now, I’m not sure that I have fully processed. I do know it was very, very close.

And I do know that this is in contrast to the official record.

I was a young Squad Leader that day. One Foreman was detailed away and the other was in a large-scale lookout. So it was the Superintendent, another Squad Leader, and myself running the crew.

I remember that during the previous shifts we had been burning across these ridges and for at least one night shift. The slop-over on the Division that day wasn’t too large and certainly wasn’t very active. I thought it would be a good transition day from nights to days.

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We were cutting direct line and making good progress with the other crews. On our initial scout that morning we had identified the same “safety zone” that everyone else did. This would become the safety zone that the Flagstaff IHC ended up deploying in.

The fact that 80+ people all thought that a SZ that 20 people later deployed in looked good should give a good indication of our mindset. The Augusta IHC ended up in a nearby aspen grove with our Superintendent. Lassen and Plumas IHCs ran uphill back to the road system.

One of the Most Terrifying Moments in My Life

On that run, at the start, I was impatient to get going. I was trail, making sure that everyone had been accounted for and was together moving up the line.

Plumas was ahead of us and it seemed to take forever for the hike to start. Everyone was moving in slow motion. On our intercrew I could hear our Lookout giving us updates calmly but forcefully: It was time to be gone.

As we started up slope, the gaps started almost immediately. The Squad Leader leading our crew out was very tall and was striding it out, gapping the slower guys at the back. I was annoyed and was trying to close up those gaps. That’s when I had one of the most terrifying moments in my life.

I looked back below us to gauge the distance between us and the fire—fire that we could now hear. What I saw made me almost physically ill: one lone blue hardhat at the bottom of our line, looking around, obviously confused.

At first, I thought that I had miscounted. That I had missed one of my guys. I immediately started another head count. I was turning around to go back and shouting down at them to hurry when the two overhead from Plumas thundered past me downhill on the run.

Because both crews wore the same color hats, I couldn’t tell that this person was a Plumas firefighter, and not one of mine.

Of course, we all made it out that day, but that was a powerful reflection in leadership that I have always carried with me.  Those two guys ran down at fire coming uphill at them to help a slower teammate who somehow just got separated in the retreat. I got to see leadership and bravery exemplified, and tempered with humility.

Mike Sherman and Pete Duncan, my hat is off to you both for your courage and leadership. Again, none of this is in any official records, mostly because those guys are humble. They’ll probably be mad at me for mentioning them here.

I was in Disbelief—I Felt Tricked or Somehow Betrayed

Our Lookout, my Captain, later asked me why we didn’t leave when he first told us about the activity below us. He had eyes on the entire Division, gave us plenty of advance warning, and we could’ve left far earlier.

I couldn’t answer then and I would struggle to answer now.

I reflect back to the confidence that I felt that morning. The idea that this would be a good shift to transition over from the night burns we’d been doing and into the day shift. I remember being extremely convinced that The Plan was solid. After all, it was developed by guys who had been fighting fire longer than I’d been alive. If they weren’t concerned, why should I be?

I remember even once we were pulling out, I was in disbelief. I felt tricked or somehow betrayed. The fire had not done what it was supposed to, what we had planned for it.

I had completely forgotten that there is a home team, and we were not it. Looking back, I would say that we got head-faked by our earlier work. We were victims of our own making – through several successful shifts and the corresponding over confidence.

So, what did I take away from the Nuttall Fire?

  • Every day is a new day. Don’t be overconfident.
  • All transitions are tough and may be dangerous.
  • Listen to your Lookouts, you put them there for a reason.

Always remember that the fire gets a vote on your plan—Mother Nature always bats last.

 

 

When You’re the Division Supervisor and Fire Shelters Come Out

“I try to cultivate relationships and build trust so I can create an environment where people feel safe telling me that my idea is a bad one.”

By Jayson Coil

Division Supervisor on the Nuttall Fire

When I reflect on the events surrounding the entrapment and subsequent shelter deployment on the Nuttall Fire there is one main lesson that continues to resonate with me. Along with this lesson comes the acknowledgement of the cost of this lesson.

When I refer to “cost,” I am not referring to the cost for me personally, but the impact the event had on others that day. Like any other fire, there are firefighters who depend on us (leaders) for their safety. This is not to say that individuals are not accountable for their own safety. But the actions that those of us in leadership positions advocate for can most certainly influence the risks that a firefighter faces. This is the “cost” I am referring to here.

A Potential Slow and Painful Death

For some of the people on H-4 that day, it was their first big fire. For them, it was not just smoky, it was the scariest thing they had ever experienced. For others, it was another one of too many close calls.

After this incident, some people left their careers for other professions. And, there may be other impacts to folks that I am unaware of.

The conditions that afternoon were bad. When the fire whirl crossed the helispot, it would have been a slow and painful death if anyone had inhaled those superheated gases.

I Would Be ‘That Guy’

I am certain somewhere in my own thoughts, along with the concern I felt for the other people, I was also troubled about the personal impact if we deployed our shelters. This was my Division. I would be “That Guy”.

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Of course, I know it should not be that way. Such a concern should not influence one’s decision. However, I know that it can.

I try to remember the potential of a given consequence when I consider a course of action—to help myself remember that the actions you take early in an incident can impact your options days down the road. I find this sort of assessment beneficial because it prevents me from anchoring into false assumptions.

But if I minimize this incident’s impact on others, what message would I be sending?

I Wanted the Plan to Work

So, what did I learn on July 2, 2004?

 

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I learned—and I have attempted to remind myself of this on every subsequent incident—that the effort you put into a plan and its implementation should not taint your assessment of risk on a given day.

Many people had worked hard on that line. They were invested. I was invested. I had just arrived at the lookout when everything started to pick up. I am thankful for the leadership many provided that day.

I do not look at this incident with the notion of how I could have changed things that day. Rather, I look at it from the perspective that I was invested more in that line because it was mine and because of the hard work crews had put into constructing it. I wanted the plan to work. I wanted the line to hold.

I felt accountable for the slopover. It was my Division. So, I wanted it fixed and the line to hold.

However, I would suggest that this is the wrong way to look at it. We deal with uncertainty and variables outside our control all the time. Often, these variables lead to unintended consequences. Today, I try really hard to recognize that and continue to reassess the quality of information I have received.

I try to declare my biases and invite others to challenge my assumptions. I want them to help me calibrate because I know self-assessment is not the solution. I try to cultivate relationships and build trust so I can create an environment where people feel safe telling me that my idea is a bad one. From my perspective, that is essential to effective leadership.

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In Honor of the Granite Mountain Hotshots

By Brit Rosso – Director of the Wildland Fire Lessons Learned Center.

June 30th 2017 – The fourth anniversary of the Yarnell Hill fire, where we lost 19 Granite Mountain Hotshots. A few weeks back I was asked if I could write something about Yarnell Hill to post on the fourth anniversary. I’ve been struggling ever since to come up with the right words to honor our fallen.

After some deep thought about this opportunity, I’ve decided to share a letter with you that was sent to me a few weeks after Yarnell Hill. I used to work with this letter’s author before coming to the Wildland Fire Lessons Learned Center. He was not a firefighter. He is now retired, out enjoying life. At that time, he asked me to share his letter with the families of our fallen Hotshots. I, in turn, shared his letter with a member of the Prescott Fire Department to pass on to the families.

Here’s a condensed version of this man’s letter. In honor of our fallen, I now share his words with you:

This is an open letter to the families of the elite Granite Mountain Hotshot Crew—all twenty members.

I am a biker. On June 3, 2013 I was camping on some U.S. Forest Service land near Happy Jack, Arizona.

After sleeping on the ground beneath the stars, I’m looking forward to a hardy breakfast at a nearby small café. I think it is called the Long Valley Café. But I’ve always called it “Happy Jack.”

Long Valley Cafe

The fire trucks parked out front do not register in my mind. I am only thinking of coffee and hot food. As I walk into this little restaurant, I see a whole bunch of firefighters. I see one waitress moving quickly and I can only imagine how long it will take for my breakfast to arrive. I whisper to myself: “This is a big mistake.”

The waitress is very fast. The next thing I know, coffee and water is on my table. Time is on my side, so I relax. I begin to look at the young men next to me. They appear to be very well fit, happy, and enjoying their breakfast with enthusiasm. Secretly, I hope there are a few eggs left over for me. They all look like they could be movie actors. They remind me of my son.

When the waitress hears my order—eggs over easy, hash browns, with corn beef hash—she writes it down and pours more coffee. The young firefighter next to me says: “That’s what I ordered. It was very good.”

I see this as an opportunity to make small talk. “What fires are you coming from?” Many of these firefighters quickly begin to talk at once—informing what, where, and how they left the last fire.

I am impressed. “Where are you going now?”

“We’re going to fires in New Mexico,” they say. I tell them that I just came from New Mexico and that two days ago there was severe lightning and rain. I tell them that I like their shirts with the words “Granite Mountain Prescott Fire.” This image sticks in my mind. I wish them well and say: “Be safe.”

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The firefighters get up, move toward their trucks, and are gone. But a young man comes back into the cafe and simply says: “Thank you, sir.” At the time, I thought he must be a bit homesick. I appreciated his comment immensely.

On July 1, 2013, the headlines immediately caught my attention. Nineteen firefighters die in Yarnell, Arizona. They are the elite Hotshot Crew from Prescott, Arizona. I read slowly knowing that the guys I met earlier were part of the Granite Mountain crew. Maybe this tragedy involved another crew?

The words became harder to read, but I continued. Toward the article’s end, my eyes see the words: “The elite firefighters are known as the Granite Mountain Hotshot Crew.” They are the same guys I had breakfast with at the café. Tears fill my eyes. My wife comforts me, but does not really know why I’m so upset. I tell her about my connection to these young men.

Even now, days later, I cannot stop seeing those young firefighters in my mind having breakfast at that small cafe. To their family, my tears do not stop and I send to you my most heartfelt condolences.

To the survivor of the twenty-person Granite Mountain Hotshot Crew, “Thank you. I am so proud of you and your service.”

Make sure you find a way to Honor the Fallen every day.

Close Call Stories – Trusting Intuition

This post uses a video from:

THE SMOKEY GENERATION: A WILDLAND FIRE ORAL HISTORY AND DIGITAL STORYTELLING PROJECT

The Smokey Generation is a website dedicated to collecting, preserving, and sharing the stories and oral history of wildland fire.


By Travis Dotson

“I still kick myself for this…”

Ever felt that way? We all have. That is called hindsight. When we look back it’s easy to see what we should have done.

How do we take a “bad feeling” into pro-active mode?

“It’s so hard to put your finger on that bad feeling.” Yes.

“Talk about it, get it out in the open…maybe you’re not the only one.” Action.

Be able to say this: “Here’s my worst case scenario for the day and it’s sure going that way right now, maybe it’s time to talk about it.”  Bam.

Thank you for the wisdom Dan.

 

This Has Happened Before…UTV Floorboard Fire.

By Travis Dotson

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OK – super simple deal here. Go look under your UTV, specifically look between the skid plate and the floorboard.  Chances are there is a bunch of grass and sticks and stuff packed in that little space. It’s probably all dried out and primed to ignite – all it needs is a heat source – and we drive these things around in one big heat source.

Don’t think it’s possible? Tell that to the folks who have had it happen to them. Thankfully, some of those folks took pictures and wrote up the event and shared it with us here at the Lessons Learned Center – now we can tell you to go clean your UTV up so it doesn’t catch on fire while you’re driving it!

Here are some quotes from the reports:

“…vegetation lodged between skid plate and underbody ignited, burning a hole through floorboard…”

“Firefighter noticed flames protruding through the floorboard. A shovel with sand and the UTV fire extinguisher were used to suppress the flames.”

“Described as looking ‘like a hay bale,’ the material—packed in tightly—completely filled the compartment.”

“While using a 2016 Polaris 6×6 UTV on a prescribed fire, an accumulation of fine fuels located in an enclosed compartment under the UTV’s floorboard and above the skid plate ignited.”

“This fire melted a four-foot hole in the skid plate and floorboard and caused extensive damage to wiring and the gear selector cable.”

You get the picture – now go check your UTV.

Links:

UTV Floorboard Fire RLS 2017

UTV Flammable Debris RLS 2014

UTV Fire SAFENET 2014

Burn Injuries – Wrong Hurts

By Alex Viktora

Wildland Firefighters receive burn injuries every season. Often times some sort of flammable liquid ignites resulting in a burn, like the rather common drip torch leg burn scenario mentioned in this NWCG memo. Other times we fall in stump holes and ash pits—sometimes up to our waist!

And then there is the plain old flame front scorching our elbows through Nomex or the super bad deal entrapment situations. Bottom line, it happens. So we need to know how best to follow through on medical treatment for these instances—because you can do it wrong, and wrong hurts!

Read these reports using the links below:

Rim Fire Burn Injury    Farm Fire Burn Injury    Mystery Fire Burn Injury

Information Collected from Multiple Burn Injury Incidents—Here are Some of the Most Important Reminders, Lessons and Tips

 First of all, if you or someone with you, gets burned, report the injury! Even if you think it’s a minor burn, even if you think you screwed-up somehow—let someone know about the burn. Chances are it’s worse than it seems and time untreated can be a bad deal all around—from paperwork to infections. It’s just better to let someone know and get the ball rolling toward proper treatment.

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Go to the place that can help – It’s called Definitive Medical Care (Emergency Room, Clinic, etc.)

  • Burn injuries are often difficult to evaluate and may take 72 hours to fully manifest.
  • Burns are different. Not all doctors have experience with the types of burns that firefighters suffer. Burns require specialized experience to treat appropriately. This often means that the injured party will need to seek care at a Burn Center.
  • Burns must be kept clean. Therefore, the fireline isn’t a good place to try to manage a burn injury. If you’re treated and released, don’t go back to the line. Don’t go up on a lookout. Focus on taking care of your burn injury.

Nobody wants to hang out at the hospital, but make sure to run through this list before you are discharged:

  • Make sure your Agency Administrator is notified, especially if you’ll require follow-up treatment and referral to a Burn Center.
  • Agency Administrators should be involved if there is hesitation to refer to a Burn Center.
  • Referrals to Burn Centers are critical and must be in the patient’s hands before leaving the Emergency Room, clinic, or doctor’s office.
  • When there is any doubt as to the severity of the burn injury, the recommended action should be to facilitate the immediate referral and transport of the firefighter to the nearest Burn Center.
  • Physicians Assistants (PA) CANNOT write referrals for Burn Centers (or any other increased level of care). If a PA prescribes any follow-up, including Burn Center visits, it must be countersigned by a Doctor (MD).

Copy? Here’s the deal: Get your higher-ups involved. Have a discussion with your higher-ups about a Burn Center referral.

Burn Center Tips

  • Burn Centers have both in and outpatient services. If you think you might need to go to a Burn Center, ask to be referred—even if you won’t need inpatient treatment (hospital stay).
  • Burn Centers may prefer to consult via telemedicine (such as e-mailing photos or videos of the injury, video-calls, etc.), rather than transporting a patient to their facility.
  • Ask about the option to have a Nurse Case Manager assigned to the case.

OWCP Claimant tips

  • Your OWCP claim number is critical. Once you get this claim number, put it in a place you’ll be able to access when you’re on the phone with doctors, visiting the hospital, filling prescriptions, etc.
  • YOU—the patient and claimant—are ultimately responsible for your OWCP case. Get involved. Pay attention. Ask questions. If you’re not getting the answers you need, keep asking.

Call the Wildland Firefighter Foundation (208) 336-2996. They have experience dealing with folks who have received burn injuries in the line of duty.

Watch this video: