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?

 

 

 

 

 

 

7 thoughts on “It’s Going to Happen Again

  1. Pingback: It’s Going to Happen Again – Site Title

  2. The reason they are called accidents is because they are unplanned. No one starts out to injure themselves and it will never be “0”.

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  3. The term “mitigation” is an overused buzzword and a total misnomer. We don’t mitigate shit, we adapt to it. Risk adaptation is a far better concept. Sometimes we learn from incidents/accidents and the conclusion is that some things are unavoidable. Too many people in fire assume that just by “learning” about an incident we can theow a quick acronymic fix in there.

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  4. I agree it will happen again, and I sypathize with the acronym frustration, but I am happy that we are given the chance to try and glean some knowledge from others misfortune, accidents, or mistakes. At the very least, as the author says, it gets us thinking and talking about anything we can do better.

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  5. Reblogged this on Out of the Desert and commented:
    Additional sideboards that are accepted by wildland firefighters are that (1) the general public will continue to build homes in the wildland urban interface, and (2) the public and supervisory managers will continue to expect wildland firefighters to risk physical harm and death to protect homes. Mr. Lewelling’s article is timely and provides excellent insight in to frustrations within the firefighting community.

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  6. Pingback: Sorting the Lumps | Wildland Fire Lessons Learned Center

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