2008 Fireline Fatality Report

[superfire]

some very good points

my point has beenthat there is three basic failures in this case.

1: Untrained sawyers
2: Failure on the part of the IC on scene
3: Failure of on site medics in three areas
A: Not doing a proper head to foot evaluation
B: Trying to use an air ambulance instead of the faster ground transport
C: Failure to use local resources

 

[techdave]

One thing I agree with Newsawtooth on

Hi NST, thank you for your reasoned response to first post, which had a tad too much of a damn the torpedoes to it.

Having just re-read Fire on the Mountain, about the West canyon Fire on Storm king mountain, I see better where you are coming from.

USING IT AS AN EXAMPLE

Blaming Mackey for cutting line downhill trying to hook the fire at the end of ridge is missing teh bigger picture because:

Since among other things, neither he nor Blanco should have been left in charge as the fire and crew grew, the bickering higher up denied them logistic and air attack support that would have changed the outcome. Also no one did anything to make sure the crews were briefed onlocal weather patterns, fuel conditions (Gambrel Oak when dry), and the Red flag Cuoco of NWS had issued.

Lots of ass-covering afterwards. where Agencies worked to cover theri Legal LIABILITY instead of self examination. So yes, i can see that investigation and blaming the dead CAN be counter productive.


BACK TO THIS THREAD
having said all that, I still see major character flaws in the the little triggermen who laweryered up and would not tell what really happened.

One thing for sure, the REMF who has never done a job is slowly taking over American Management!!

 

[char]

A.) A Law Enforcement investigation was initiated immediately after the accident. The individuals involved got lawyers, took the 5th and chose to say nothing about the incident. Once the criminal investigation was concluded without any charges, the fact finding investigation quoted in this thread was resumed. The individuals obviously decided not to make any comments about the incident due to their previous interactions with Law Enforcement.

B.) I look at the falling diagrams and the pictures from the technical assessment and come to the conclusion that they may have been attempting to "drive" the tree that was burned out and leaning that killed Palmer. In other words, they may have intentionally struck the 2nd tree with the 1st tree and terribly miscalculated the results. It is very difficult to tell.

C.) Worst stump I have ever seen. They were obviously out of their league.

D.) If you are going to go after the 19-22 year olds for getting in over their heads and violating procedures, you should go after the guy who canceled the Coast Guard ship as well. And the direct line supervisor (task force leader) for failing to provide/require adequate oversight (single resource qualified supervision). And then, why not the IC for running a shody operation? See where this goes? Pretty soon you have an organization that is so paralyzed by risk that NOTHING happens to stop fires. On the other hand, there need to be consequences...

E.) Calling in contract fallers on campaign fires is a great idea. They have the experience and knowledge for the most part to operate safely if they have a Felling Boss with them to run the fire side of things. You should know that agency "C Fallers" are certified by an outside individual from the timber community. One such individual in Oregon and Washington is Douglas Dent.
Can we compare an agency faller and a private timber faller? Probably not. But I'd wager that the agency C Fallers are more risk averse. I know I am. One key factor in being certified "C" is the ability to judge ones own skills and be comfortable turning down a tree even with peer pressure or mission pressure on your back.

 

[newsawtooth]

Techdave, you have addressed the complexity of the situation that is not present in most smaller scale operations. There was more at work in the accident than just one mistake. I can appreciate your contention that refusing to cooperate with investigators amounts to shirking responsibility.

char, good post. I wondered if they were using the Ponderosa as a driver tree as well. Your assertion that C cutters are trained to refuse unsafe assignments is compelling as well. I have heard this from friends that are C certifiers, who are for the most part relatively risk averse people.

superfire, you have illustrated the swiss cheese model of accident progression. Often, accidents cannot be pinned on a single event, or one hole. But a series of events or holes that contribute to a failure.

 

[superfire]

the basic things

I see this as how the basic incident management can be FUBARed. Most tree falling accident can be put into three categories :

A :
Sawyer has limited time running saw or is running two big of power saw for their physical ability.

B :

Sawyer is doing work that is beyond the technical knowledge they need to do the job

C:

Sawyer rushes the job because of time pressure to get the the job completed


These are what I have seen as a Pro Hand Faller and have been on several fires. This just seems to be happening to the wild land fire system more often. The IC system is standardized for the whole country . The one thing I said about the need for pro fallers is the person running the saw needs more education and a lot more to become a higher level
of Sawyer to handle the removal of KILLER TREES.

 

[char]

I see this as how the basic incident management can be FUBARed. Most tree falling accident can be put into three categories :

A :
Sawyer has limited time running saw or is running two big of power saw for their physical ability.

B :

Sawyer is doing work that is beyond the technical knowledge they need to do the job

C:

Sawyer rushes the job because of time pressure to get the the job completed


These are what I have seen as a Pro Hand Faller and have been on several fires. This just seems to be happening to the wild land fire system more often. The IC system is standardized for the whole country . The one thing I said about the need for pro fallers is the person running the saw needs more education and a lot more to become a higher level
of Sawyer to handle the removal of KILLER TREES.

Never going to happen. There are too many small fires to call in contract fallers everytime. On project fires why not call them in? When you are going to be there for the long haul you might as well get some pros in.

Practically every lightning struck tree probably meets the definition of "killer tree."

I don't know that the wildland fire agencies have more falling accidents per hour of falling than "pro fallers" but if you have some data to back that up I would be interested in seeing it.

The easiest way for this accident to have never happened is for the experienced folks on the line to ask some questions, required appropriate oversight and for the guys with the saw to have stayed within their limits.

 

[superfire]

Check out fire investigation photos 3048 ,this is what I learned in saw school to be a KILLER TREE. I think sawyers should be better trained in the use of specialized tree faces. Fire fighters need to be better controlled in the field, especially when a crew is sent to a assignment without there crew supervisor. In this case the crew was not in touch with their crew supervisor because he was not on the fire grounds, he was getting a vehicle serviced.

 

[char]

Check out fire investigation photos 3048 ,this is what I learned in saw school to be a KILLER TREE. I think sawyers should be better trained in the use of specialized tree faces. Fire fighters need to be better controlled in the field, especially when a crew is sent to a assignment without there crew supervisor. In this case the crew was not in touch with their crew supervisor because he was not on the fire grounds, he was getting a vehicle serviced.

Crews should not be sent to the line without proper, experienced supervision. Period.

Fire fighters need to be better controlled in the field, especially when a crew is sent to a assignment without there crew supervisor.

What are you getting at here? Are you trying to say that there are FF wandering around on fires without supervision on a regular basis? I don't know that you understand the ICS system if this is what you are asserting.

 

[superfire]

Crews should not be sent to the line without proper, experienced supervision. Period.



What are you getting at here? Are you trying to say that there are FF wandering around on fires without supervision on a regular basis? I don't know that you understand the ICS system if this is what you are asserting.

What i said is this crew in this incident came from out of state and had their truck break down and needed service,so they were basically going out to do a job with out the crew supervisor(he was also the vehicle operator) the supervisor was the one sent to get the truck repaired.

I still hold the IC system to blame, the IC failed to provided proper transfer to a medical facility. The local resources should haven been used over a air resources. A basic hospital was less then 45 minutes away not 4 hours.
As to incident command I worked several years as a EMT 2 so I know the system well.

 

[char]

what i said is this crew in this incident came from out out of state and had their truck break down and need service,so they were basically going out to do a job with out the crew supervisor(he was also the vehicle operator) the supervisor was the one sent to get the truck repaired.

I still hold the IC system to blame, the IC failed to provided proper transfer to a medical facility. The local resources should haven been used over a air resources. A basic hospital was less then 45 minutes away not 4 hours.
As to incident command I worked several years as a EMT 2 so I know the system well.

Ok. I agree with you there.

There is an interesting discussion going on at www.wildlandfire.con/theysaid.htm which touches on some of the medical issues.