Monday, December 9, 2013

Follow Up - The Yarnell Hill Fire

Late last week, the Arizona Division of Occupational Safety and Health (ADOSH) released its findings concerning the deaths of 19 Hotshot wildland firefighters during the Yarnell Hill Fire on June 30, 2013.  Its conclusions were markedly different than the investigation released earlier this year by the Arizona State Forestry Division (ASFD) which found no blame for the deaths.  ADOSH saw it differently to the tune of $559,000 in fines and penalties leveled against ASFD. Excerpts from pages 35-36 of the investigative report it commissioned tell a story of a dysfunctional chain of command that lacked an understanding of "where" (Emphasis and definitions added):
The Planning Section Chief (PSC) was ordered as part of the team, but did not arrive at the ICP until late afternoon. The Fire Behavior Analyst (FBAN) was also part of the initial team order and arrived in time for the 1000 briefing. A GIS Specialist was ordered as part of the team; however this position is not listed in the final organization chart of those assigned to the fire... 
The ICT2 (Incident Commander Type 2) had little choice but to accept the fire on the morning of June 30, however the job was made more difficult based upon the way the team was ordered. They did not arrive as a cohesive and functioning unit and spent the day trying to bring order to a very chaotic situation...
Communications on the Yarnell Hill Fire were inadequate from the time IMT2 arrived because the COML (Communication Unit Leader) arrived late. COML was not available to clone radios at the morning briefing. Tone guards were also a problem. Lack of communication is a significant safety problem...
An additional problem with the way the team arrived is that without a PSC, maps are not readily available to resources going to the fireline. GMIHC (Granite Mountain Interagency Hotshot Crew) was not provided with a map or aerial photo by ICT4 when they arrived on the fire. A map would have helped the crew estimate how far the Boulder Springs ranch site was away from the lunch spot and evaluate alternative escape routes including the two-track road to Boulder Springs Ranch. Visually, the ranch looks close from the top of the ridge where GMIHC initiated their descent into the canyon. The heavy brush in the canyon, combined with the rocky nature of the area, made travel difficult and slow. They may have underestimated the speed with which the fire was moving...
Additional details about this tragic incident can be found using the links below:

(Wildland Fire Associates, November 2013)

(Other supporting documents, including extensive number of maps)

Comment: Aviation accident investigators are taught to look for "the chain of events" that leads to the loss of an airframe and/or life.  Remove any link in that sequence and the accident doesn't happened. With this event, there were many of those types of links. Little doubt sending men to fight a wildland fire without any maps or aerial photos was one of them.

Photo credit: Christian Science Monitor

1 comment:

  1. What if?? a) At minimum, a hasty map of the area was created, printed 8.5x11 or 11 x 17 and issued to all on the fire ground? b) field units had GPS or personnel cell phones with MGRS/USNG displays as primary? c) air & ground assets used the same coordinate system as DoD does? d) If the decision to deploy shelters was made, that location was radioed out for all to hear with a coordinate of just 6 or 8 digits, along with the "mayday"? e) aerial assets,previously familiar with ground support per that coordinate system dropped water or retardant danger close to that position? Of course, this assumes the event transpired the same regardless. We all hope it would have been different.