Grassy Ridge Fire Shelter Deployment

Lessons Learned Review

July 28, 2018

“There’s a lot of lessons to be learned, but no one learned as much as DIVS-2 and me.” – DIVS-1

Division Echo – Grassy Ridge Fire Grassy Ridge Fire – Shelter Deployment Lesson Learned Review

Table of Contents Lessons Learned Review ...... 1 Executive Summary ...... 3 Background ...... 4 Narrative ...... 4 Timeline Summary ...... 11 Firefighter Lessons Learned ...... 12 Using the Shelter ...... 12 Local Knowledge ...... 13 Technology ...... 13 Accident Investigation ...... 14 Taking Care of Our Own ...... 14 Things That Went Well ...... 16 Review Team Observations ...... 17 The Stigma of a Fire Shelter Deployment ...... 17 The Stigma of Accident Investigations ...... 18 Team Recommendations ...... 20 State Director Observations/Recommendations ...... 22 Appendices ...... 24 Grassy Ridge Fire Fuels, Weather and Fire Behavior Summary ...... 24 Lessons Learned Review Team Members ...... 30

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Executive Summary From the moment it started on July 26, 2018, the Grassy Ridge Fire demonstrated extreme fire behavior and intense rates of spread. The fire made a 13-mile run early in the morning of July 28, the day of the shelter deployment.

At approximately 1145 MDT, on July 28, the incoming Division Supervisor (DIVS-2) on Division Echo of the Grassy Ridge Fire, deployed a fire shelter on the side of a two-track road to deflect radiant heat. The deployment was determined necessary after his escape route was compromised.

Earlier that morning, and prior to the fire shelter deployment, DIVS-2 met up with Division Supervisor of Echo (DIVS-1) and they drove to Division Echo together. Both individuals, as well as a Rural Fire Department (RFD) engine, arrived at the agreed upon anchor point for a planned burn operation. Burn operations were discussed and DIVS-1, DIVS-2, and the RFD began firing.

DIVS-2 was in the lead of the burn operations, walking along the pre-planned route, where he was supposed to turn ‘right’ onto Road 1. However, after passing through the gate, DIVS-2 missed Road 1, and continued burning along the east side of Road 2. Shortly thereafter, DIVS-1, along with the RFD, arrived at the gate and turned onto Road 1, dragging fire with them. Approximately 200 feet down Road 1, DIVS-1 realized DIVS-2 was not in front of him and ceased burn operations. At that point, DIVS-1 returned to the anchor point with the RFD.

Simultaneous to burn operations occurring on Road 1, DIVS-2 noticed the main fire front was advancing quickly and made the decision to turn back toward the gate he originally passed through. After traveling approximately 475 feet back toward the gate, he realized there was fire on the west side of the road that was producing high intensity radiant heat. At that point, he realized his escape route was compromised. When the radiant heat became too much, he crouched on the ground in a kneeling position and deployed his fire shelter to shield himself from the heat.

After using his shelter to deflect radiant heat for approximately seven minutes, DIVS-2 walked out to the anchor point and met back up with DIVS-1. An ambulance was called to his location, and after medical assessment, a small burn blister was discovered on his right ear. The next day, DIVS-2 also discovered a small burn blister on his left elbow.

The Grassy Ridge fire burns through continuous sagebrush fuels east of the Little Ranch Page 3 of 30

Grassy Ridge Fire – Shelter Deployment Lesson Learned Review

Background The following is a narrative of the events and actions that took place related to the Grassy Ridge Fire shelter deployment. This narrative is based on data collected by an Accident Investigation (AI) Team. The team was requested by the Idaho State Bureau of Land Management (BLM) and tasked with reviewing the accident, as well as producing a learning document. The intent of the investigation is to learn from the events through the perspectives and conversations of those involved. Although ordered as an Accident Investigation Team, the team will be referred to hereafter as the Review Team.

The Grassy Ridge Fire was reported on July 26, 2018, at 1511. The fire started by lightning on BLM land 12 miles northwest of St. Anthony, Idaho. That evening a local Type III Incident Management Team (IMT3) assumed management of the fire. By 1848 that evening, the fire had increased in size to 1,478 acres. On July 27, the fire remained active and was reported at 5,000 acres at 0800 hours, 10,000 acres at 1508 hours, and 15,360 acres at 1841 hours. Due to the complexity and rapid growth of the fire, on the morning of July 28, the decision was made to order a Type II IMT (IMT2), which was scheduled to take over the incident the morning of July 29.

The Grassy Ridge Fire was burning in mixed age class sagebrush with varying degrees of grazing impacts. In some places, grass fuels were abundant and in other places, heavy grazing had removed all fine fuels from beneath the sagebrush. Fuel moisture conditions varied from average to below average, resulting in the potential for extreme fire behavior conditions across the fire area. The terrain is flat to rolling with low rises and ridges with several areas of sand dunes. Much of the area is inaccessible to vehicles and mechanical equipment due to large expanses of sharp broken lava rock causing fire equipment to remain on existing roads and trails.

“Old growth sage doesn’t need wind to move around.” - IC

Narrative Prior to the shelter deployment, incoming Division Supervisor of Division Echo, referred to hereafter as DIVS-2, met up with Division Supervisor of Echo (DIVS-1) at 0930 to discuss current operations and updated fire information.

At approximately 1015 on July 28, Operations (OSC3) was flying over Division Echo of the fire, and determined that the area surrounding a ranch, known as the Little Ranch, would provide a good opportunity to gain control over that portion of the fire. OSC3 provided the information to DIVS-1, and DIVS-1 and DIVS-2 traveled to the Little Ranch. Page 4 of 30

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Upon their arrival to the Little Ranch house, DIVS-1 and DIVS-2 noted the advancing fire front and agreed that transitioning command and control of Division Echo at that time would not afford DIVS-2 with the necessary situational awareness to carry out a plan of attack in a safe and informed manner. For the purposes of this narrative, DIVS-1 maintained command and control and provided operational direction.

By 1130 hours, the Grassy Ridge Fire had almost grown to 60,000 acres. Discussions at Little Ranch allowed Division Echo resources to identify a safe anchor point, which was approximately one third of a mile from the Little Ranch house and 50 feet from Camas Creek, and further identify a plan to burn out along the south side of Camas Creek near Little Ranch (see Map 1).

Based on observed fire behavior from the previous two days, OSC3 believed the creek provided a ‘best option’ for stopping the fire’s progress.

Map 1: Division Echo

In order to build a viable plan, DIVS-1 and DIVS-2 began driving down the multiple roads along the south side of Camas Creek and discussed burning options with OSC3, who was in the helicopter overhead. After talking over potential burn operations options, DIVS-1 and DIVS-2

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agreed on a plan to burn along one of the main roads paralleling Camas Creek. Concurrently, resources assigned to Little Ranch began structure protection operations around the ranch house.

DIVS-1, DIVS-2, and a Rural Fire Department (RFD) engine moved from the Little Ranch house to an identified anchor point where they would commence firing operations. At the anchor point, it was confirmed that firing operations would take place along one of the routes they had just scouted. While scouting, DIVS-1 and DIVS-2 encountered several local ranchers who were in the area attempting to herd their cattle to a safe location. Based on their local knowledge, they confirmed the burn out should begin at the east end of the anchor point and continue west toward the gate. Just a few feet beyond the gate, Road 1 and Road 2 converged at a fork. The burn out would continue along Road 1 until they were far enough along that the Little Ranch area would be protected from the advancing fire front. DIVS-2 would be in the lead, followed by DIVS-1 and the RFD. After the plan was finalized, firing operations began at approximately 1136.

“You can brief fire behavior all day, but it’s not real until you see it and breathe it.” - IC

As DIVS-1 provided direction and instruction to the RFD, DIVS-2 lit a drip torch and began burn operations along the planned route. DIVS-1 fired several Very pistol rounds into the burn area to help generate interior heat. After observing that DIVS-2’s burn was not carrying very well, DIVS-1 instructed one of the RFD crewmembers to fire up a drip torch and start lighting a little deeper in, to try to get a cleaner burn. DIVS-1 worked closely with the RFD, as the RFD firefighter on the drip torch had minimal experience with firing operations. As burn out operations progressed, smoke was visible on the low ridge to the south, but the main fire had not crested the ridge onto the flat. While DIVS-1 and the RFD were working on getting a cleaner burn, DIVS-2 continued burning toward the gate. The planned burn out route would continue through the gate and then follow along a road that ‘turned to the right,’ or Road 1.

When DIVS-2 reached the gate, he looked back over his shoulder and shouted to DIVS-1, “If we are going to catch this, I need to get fire on the ground!” At approximately 1138, with the fire directly in front of him, DIVS-2 continued firing along what he thought was Road 1, but it was actually Road 2.

The fuels consisted of six to seven foot tall sagebrush, with heavily grazed grass in between. DIVS-2 had to step off the road often to find fuel pockets he thought could carry his firing operations. The density and height of the sagebrush along the south side of the road made it difficult to see the fork in the road, leading to Road 1. As DIVS-2 burned along what was really

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Road 2, he noticed his firing operations continued to be spotty among the heavily grazed sagebrush. As DIVS-1 and the RFD approached the gate, DIVS-1 drove his command vehicle slowly in front of the RFD crewmember using the drip torch. The RFD engine followed closely behind. After passing through the gate, DIVS-1 and the RFD turned onto Road 1, continuing to light fire as they moved along the road. Approximately 200 feet down Road 1, DIVS-1 became concerned that he could not see DIVS-2, and ceased burning operations along Road 1. DIVS-1 called DIVS-2 on the radio, but received no response. DIVS-2 heard DIVS-1 calling him on the radio and responded, but did not get a reply from DIVS- 1. DIVS-2 did not realize it at the time, but his radio was set to the Air to Ground frequency, with the scan function on. This allowed him to be able to hear DIVS-1 on the tactical channel (Tac2), but when trying to respond to DIVS-1, he was actually transmitting on Air to Ground. At this point, DIVS-2 was approximately 630 feet down The sagebrush near the anchor point was 6-7 feet tall Road 2.

Map 2: Shelter deployment site on Road 2 Page 7 of 30

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DIVS-2 continued burning approximately 110 feet further down the road until arriving at a heavily grazed area. He noticed the main fire had crested the ridge less than a half mile south of him. Based on observed fire activity, DIVS-2 believed the main fire was going to cross the road he was on “50 to 100 yards” in front of him. Seeing no point in trying to burn any further, DIVS-2 turned around and began heading back toward the gate in the direction he originally came from. After traveling about 475 feet down the road toward the gate, DIVS-2 noticed fire on the west side of the road, which was causing high radiant heat, opposite of where his burn operations occurred on the east

side of the road. The deployment site is approximately 220 feet from the gate.

Fork immediately after the gate. Individuals are walking down Road 2. Road 1 is to their right. Page 8 of 30

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In an effort to escape the radiant heat, DIVS-2 turned the opposite direction, walking southwest toward the direction of the main fire. After determining he could “I thought about the shelter… no I can ride this out… I have felt hotter before.” - DIVS-2 not get away from the radiant heat walking opposite the direction of the gate, he turned back around and started walking northeast in the direction of the gate again.

At approximately 265 feet from the gate, DIVS-2 contemplated running through the heat toward the gate, or running north toward Camas Creek, which he thought to be close. DIVS-2 was unsure of his exact location on the road, as the road curvature, height of sagebrush, and smoke obscured his ability to see the gate. DIVS-2 reported feeling high radiant heat on his ear and contemplating his potential next steps: He could run into the black on the east, but it was still hot. He could hunker down and hope the fire passed him. He could run to the north toward Camas Creek in front of the head of the fire, but realized he probably would not make it in time. DIVS-2 remembered he had not heard back from DIVS-1 when returning radio communication and checked his radio to make sure it was functional. He noticed it was on the wrong radio channel, and switched it to Tac2, however, he did not attempt to make radio contact with DIVS-1 at that time.

Within a few minutes, at approximately 1143, DIVS-2 could not tolerate the radiant heat any longer and made the decision to pull his fire shelter out to help shield the radiant heat from his body. DIVS-2 set his drip torch on the ground, left his gloves and pack on, crouched down in the kneeling position, folded out the fire shelter in front of him, pulled one edge up with his arm and put one foot in the other end to expand it. He then put his other arm inside it and unfolded it and brought it down over him, still in the crouching position.

DIVS-2’s deployed shelter Page 9 of 30

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He noticed that when pulling the shelter over himself, he inadvertently covered his extinguished drip torch in the shelter with him. DIVS-2 did not make an attempt to remove the drip torch because his decision to deploy the fire shelter was determined by his need to shield himself from radiant heat. He did not feel he was deploying his shelter to save his own life. Later, DIVS-2 relayed to the Review Team he was hesitant to pull his shelter because he did not want to be the reason why an Accident Investigation “The decrease in radiant heat Team was at the fire. was amazing.” – DIVS-2 At about the same time as DIVS-2’s shelter deployment, DIVS-1 and the RFD turned around, passed back through the gate, and gathered at the anchor point. Once regrouped at the anchor point at 1152, DIVS-1 made radio contact with DIVS-2 and asked if DIVS-2 was in a safe spot and was ok. At that point, DIVS-2 was no longer in his shelter and responded that he thought he was in a safe spot and he was alright. At approximately 1211, DIVS-2 walked past the gate and into the anchor point where he got in DIVS- 1’s truck.

After some discussion, DIVS-1 and DIVS-2 discovered that “I don’t want to be ‘that guy.’ What I mean when DIVS-2 began burn operations past the gate, he by that is the reason you all [Review Team] burned along Road 2, instead of Road 1. Once safely at are here.” – DIVS-2 the truck with DIVS-1, DIVS-2 contemplated keeping the shelter deployment to himself. He considered either hiding the shelter in his pack or throwing it in the fire to burn because of shelter deployment stigma.

After some internal deliberation, DIVS-2 reported the fire shelter deployment to DIVS-1, who then notified OSC3, who “I looked up, I looked down, but I didn’t in turn notified the Incident Commander (IC). The IC then look around.” – DIVS-2 immediately called for an ambulance to provide a medical assessment of DIVS-2. DIVS-1 and DIVS-2 drove back up to the Little Ranch house and met the ambulance, where the medical crew performed an on-site assessment of DIVS-2, noting redness on his right ear and a blister the approximate size of a No. 2 pencil eraser. No further medical treatment was administered on-site and DIVS-2 did not want any further medical attention. The next day, DIVS-2 noticed a small burn blister on his left elbow, which was of similar size to the blister on his ear. He did not seek further medical care.

“I still don’t know how he made it out.” - RFD

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Timeline Summary 7/26/2018 1511 – Grassy Ridge Fire reported to Dispatch. 1630 – Local Type III team begins management of the fire (approximate time). 1848 – 1,478 acres. 7/27/2018 0800 – 5,000 acres. 1508 – 10,000 acres. 1841 – 15,360 acres. 7/28/2018 0129 – IC(t) reports fire has moved approximately seven miles to the west and may engulf the Devils Hole fire from a few days prior. Looking at probably 14 miles of open fireline. 0630 – Briefing 0930 – DIVS-1 meets with DIVS-2. Discuss plan for the day. 1015 – OSC3 and IC take recon flight. 1035 – OSC3 directs DIVS-1 and DIVS-2 to the Little Ranch. 1100 – DIVS-1 briefs engines at the Little Ranch. 1110 – DIVS-1 and DIVS-2 scout roads for burnout. 1130 – DIVS-1, DIVS-2, and RFD engine arrive at anchor point. 1136 – Burnout operations start at anchor point. 1138 – DIVS-2 takes the wrong road to continue firing operations (approximate time). 1141 – DIVS-1 tries to call DIVS-2 on the radio (approximate time). 1145 – DIVS-2 deploys fire shelter. 1152 – DIVS-1 makes radio contact with DIVS-2 on tac 2. 1211 – DIVS-2 walks out to the anchor point and gets in DIVS-1’s truck. 1215 – DIVS-1 called OSC3 to notify him of the shelter deployment. 1230 – Fire crosses Camas Creek. Engines and helitack crew suppress fire near Little Ranch structures. 1240 – Fire estimated at 60,000 acres. 1241 – IC orders ambulance. 1330 – Patient assessment complete. No treatment required. Ambulance leaves scene. 2009 – 75,698 acres. 2334 – IC reports fire is laying down and stopped pushing toward Dubois.

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7/29/2018 0518 – IC reports advancement of fire stopped with wet line and dozer line. 0600 – Transition to Type II Team at 103,935 acres.

Firefighter Lessons Learned The following lessons learned and short discussions were developed from interviews with firefighters involved in the shelter deployment incident on July 28, 2018. The sections on Local Knowledge and Technology are important components that can greatly impact Situational Awareness on the fireline.

Using the Shelter

“They don’t unfold like the practice shelters. Interesting how cumbersome it was.” - DIVS-2

While this didn’t have an impact on the outcome of this deployment, DIVS-2 was surprised at how much different deploying a real fire shelter was compared to the practice shelters used during Fireline Safety Refresher training. In the heat and potentially high winds that real fire shelters are often deployed, this is something of which to be mindful.

• Have you practiced with a real fire shelter?

“I thought about the shelter…no, I can ride this out…I have felt hotter before.” - DIVS-2

“Even if it is not lifesaving, pulling it sooner is better than later.” - DIVS-2

“I remember the distinct observation - instant radiant heat relief. The decrease in radiant heat was amazing.” - DIVS-2

DIVS-2 was starting to feel the effects of radiant heat as he was headed back toward the anchor point. The burning sensation on his ear was his first indicator that it was getting too hot. This can be a difficult position to be in. Determining whether it is just “passing heat”, or if it is going to be sustained heat, can make the difference between being temporarily uncomfortable, and finding yourself in a dangerous life threatening situation. In fast moving desert fires, the high intensity, short duration heat pulses that are experienced can potentially lead to a delay in deploying the fire shelter due to the uncertainty of whether or not the heat is injury inducing versus life-threatening. As DIVS-2 shared with the Review Team his experience in using a fire shelter, he described the effectiveness of the shelter, and how the radiant heat relief was immediate.

• When is it appropriate to use your fire shelter? • Is the shelter just another piece of Personal Protective Equipment (PPE)? • Do you practice under realistic conditions? Page 12 of 30

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Local Knowledge

“RFPAs (Rural Fire Protection Association) and ranchers are a huge source of local information.” - DIVS-1

Several times during our interviews, the lack of specific knowledge about the local fire area was mentioned. The fire area was riddled with dirt roads that locals knew intimately, however, incoming resources unfamiliar with the area were hindered by this lack of knowledge. Local knowledge can be invaluable, especially in time-compressed situations. Locals know what roads cross which railroad tracks, where the water sources are located, and what roads continue through the desert and which ones lead to dead ends. Local knowledge is more than just useful. It can be critical when decisions need to be made quickly and reliable information isn’t readily available. While DIVS-1 and DIVS-2 were scouting for the best place to begin burn operations, locals within the area that were out herding cattle away from the advancing fire front provided important information related to roads, water sources, and bridge locations.

• How do you quickly gain situational awareness in a new area? • How do you train with your local cooperators to work cohesively with agency mission and firefighting operations?

“You can brief fire behavior all day, but it’s not real until you see it and breathe it.” – ICT3

Fire behavior varies dramatically from one ecosystem to the next. Similarly, fire behavior in the same ecosystem can vary dramatically from one year to the next. Weather and fuels conditions contribute heavily to the variability of fire behavior. On July 28, the weather was hot and dry, and the Grassy Ridge Fire was burning in old-growth sage that had not experienced fire in decades. Many desert areas of Idaho have sagebrush that is two to three feet tall, however within the Grassy Ridge fire area, the sagebrush was often six to seven feet tall. This difference in sagebrush height can change fire behavior immensely. As a fire moves across the landscape, the additional fuel loading contributes to both increased rates of spread and fire intensity. What might look like a normal desert fire, can quickly turn into a fire that is moving more quickly and with more intensity than expected.

• How do you describe extreme fire behavior to incoming firefighters?

Technology “I asked him about his ability to receive AirDrop maps, he didn’t have that capability.” - DIVS-1

“We need to develop a training course on how to use technology.” - DIVS-1

“Local knowledge is critical. You have to be able to download information. However, sometimes it is impossible during IA, especially if fire maps are no longer valid.” - DIVS-1 Page 13 of 30

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The intense 13-mile overnight movement of the fire made all maps of the fire that next morning irrelevant. Within Division Echo, this presented a major challenge for DIVS-1 and OSC3. As the fire continued to move toward the Little Ranch area, there were no paper maps available, showing accurate fire information.

Earlier that morning, DIVS-1 was able to download an Avenza map onto his tablet. When DIVS- 2 arrived later that morning, his mobile device was not set up to use the Avenza maps. All of these factors combined lead DIVS-1 to conclude that it would not be prudent to transfer command immediately to DIVS-2.

As firefighting operations become more reliant on technology, on-the-ground firefighters are struggling with the best use of its application. There remains a difference in the ability for overhead and IMT’s to utilize this technology and the ability for firefighters on the lines to take advantage of it. Often times firefighters are fighting fire in locations with minimal to no cellphone service, or they are providing their own mobile devices that are not compatible with current maps or other software applications, preventing them from downloading the best available information. In order to help combat future occurrences of inabilities to utilize technology, the firefighting community may consider developing a training course that teaches these necessary skills.

• How do you use your smart devices? • Are the apps you use compatible with other types of technology? • What type of training is available for new technology? Is training available for all firefighters including non-federal resources? • If you rely solely on your technology, what is your backup plan if that technology fails?

Accident Investigation

“The term ‘investigation’ determines how people will read the document. They will read it to find out who the bad guy was. If you read a Lessons Learned document, you’re going to read it to learn.” - SOFR

Apprehension surrounding the word “investigation” was apparent. Many of those interviewed expressed concerns when faced with the possibility of having to talk to an Accident Investigation Team. This will be discussed later in the Team Observations section.

Taking Care of Our Own

“Don’t leave someone by themselves immediately after an event.” – SOFR

As soon as DIVS-2 received medical attention from a local ambulance, a decision had to be made. What do you do with someone who has just experienced a non-injury shelter deployment? Many Page 14 of 30

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times, these individuals will be pulled off of the fireline and provided a hotel or other quiet area to get away from the fire. After his event, the last thing DIVS-2 wanted to do was “hotel up”. After DIVS-2 had been evaluated by ambulance personnel, he and DIVS-1 talked about the best course of action. Based on the professional judgment of DIVS-1, DIVS-2 was allowed to stay with DIVS-1 for the remainder of the day, as they worked to secure the rest of Division Echo. This would provide DIVS-2 an opportunity to still focus on the fire, but not be put back in a potentially dangerous situation, while also being in the company of another person. Keeping DIVS-2 with him allowed DIVS-1 to monitor DIVS-2 and really make sure he was doing okay. DIVS-2 relayed to the Review Team that continuing to help with firefighting efforts, even in a reduced capacity, was much better for his wellbeing than having to spend the next few days idle.

• How would you provide support to someone after they experience a traumatic event, when there are no injuries? How far into the future do you do check-ins with the affected individuals?

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Things That Went Well The Review Team encountered several areas of commendation that are worthy of note during the course of the investigation. The below list identifies areas to which the team would like bring special attention.

• DIVS-1 recognized the danger of transitioning Division Echo to DIVS-2 immediately upon his arrival. Such a quick transition would only create confusion for command and control of initial attack efforts. This decision was also made considering the fact that all available maps were outdated due to the rapid rates of spread of the fire. • After the shelter deployment, the SOFR ensured the ambulance was still en route, even though DIVS-2 felt medical attention was not necessary. • Despite early apprehension to talk to an ‘investigation’ team, all involved resources were willing to share the events of July 28. Many felt that an investigation was ‘scary,’ however, if the firefighting community would benefit from any lessons learned, they exhibited a willingness to talk. • The local RFPA program proved to be a great source of local knowledge during initial attack. • Despite the rate at which the incident was escalating, ground and air resources coordinated efficiently and effectively to create a good plan of action. • All individuals involved recognized the importance of reporting the shelter deployment, despite some initial reluctance and apprehension.

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Review Team Observations The Stigma of a Fire Shelter Deployment For firefighters, the stigma of deploying a fire shelter can be enormous. The implications of this stigma can make the difference between deploying a fire shelter in a timely manner, or waiting until the last second, thereby unnecessarily increasing risk in an already hazardous environment. This stigma can also create internal conflict when reporting deployments due to the belief that the ensuing accident investigation may produce a fate worse than the deployment itself. Unfortunately, these are not unusual sentiments within the wildland fire community. The fire shelter is provided to every wildland firefighter, with the intent that it should only be used as a last resort. Each individual is intimately familiar with its purpose, yet it carries with it an unwritten rule that it should not be used.

Two days after the incident, DIVS-2 walked the Review Team through the sequence of events leading up to the shelter deployment. He described the tension he felt when considering whether or not to use his shelter. His thoughts ranged from the desire for relief from the radiant heat, to the possibility of standing before an Accident Investigation Team. DIVS-2 shared that this internal conflict directly contributed to his decision to not utilize his shelter sooner. DIVS-2 elaborated on the options he contemplated immediately following the shelter deployment: “Should I take the shelter to a still active part of the flaming front and try to burn it? Should I stuff it in my pack and dispose of it later in the day? I used the shelter to escape the radiant heat, and I don’t consider that use as a lifesaving measure. Maybe the deployment was not a big deal, and getting rid of the shelter would turn out to be a lot less headache and hassle in the long run.”

Regardless of your opinion on the actions taken by DIVS-2, his concern over the subsequent investigation holds merit. The intimidating process of an accident investigation met him face-to- face two days later. The impact of this was evident when DIVS-2 relayed his pre-deployment thought process to the Review Team as he recounted the shelter deployment sequence of events.

The perception among the wildland fire community is that if a shelter is deployed, something, or someone must have failed. This sense of failure continues to contribute to the stigma of deploying a fire shelter. The desire to avoid failure can directly impact time sensitive decision-making and cause otherwise rational firefighters to take unnecessary risks. These perceptions and concerns can cloud judgment during an incident, as well as contribute to feelings of shame and confusion after the incident. The dilemma is obvious: if deploying a shelter is considered a failure, then deploying a shelter should be avoided at all costs. The wildland fire culture has reacted to and been changed by events in the past regarding fire shelter deployments and accident investigations. The outcomes from fires such as the Thirtymile Fire and Cramer Fire, along with other watershed

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moments in the past, have created apprehension and mistrust among many firefighters related to making decisions in high stress situations.

If this stigma of using a fire shelter were an isolated sentiment in the wildland fire community, it wouldn’t be worth discussing in this report. However, it is far from isolated. In fact, this is likely the overwhelming sentiment among firefighters across the country (2 More Chains, Fall 2011). This is not the philosophy intended for our firefighters, yet it is the very real conundrum that they face.

DIVS-2 was faced with the dilemma of: using his fire shelter; not reporting the ensuing deployment; and subsequently destroying the evidence of the fire shelter deployment. DIVS-1 was faced with the opportunity to not report the use of the shelter after DIVS-2 revealed to him that he had deployed. This opportunity for learning would never have occurred had either of them chosen any of these paths. The Review Team is grateful for the choices that DIVS-1 and DIVS-2 made, thus allowing the Review Team an opportunity to generate learning moments from this event. It is the hope of this Review Team, (and all of the individuals we interviewed during this review), that our wildland firefighting culture, and the policy that guides it, will recognize the challenges faced by wildland firefighters and take appropriate steps to change the way we view and react to events like fire shelter deployments.

The Stigma of Accident Investigations Inextricably woven throughout the shelter deployment stigma is the stigma surrounding accident investigations. In a sense, one wouldn’t exist without the other. The Review Team listened as DIVS-2 recounted his inner turmoil when making the decision to deploy his fire shelter on the Grassy Ridge Fire. Very candidly, he said, “I didn’t want to deploy my shelter, because I didn’t want to be the reason you all are here.” His internal debate at the deployment site could have cost him precious lifesaving moments, while his mind was preoccupied with thoughts such as: “If I deploy my fire shelter, an Accident Investigation Team will be called. Based on what I know about past accident investigations, I want no part of an investigation.”

Accident investigations have deep roots within the history of the wildland fire culture. We have experienced tragic accidents with many fatalities over the years. Well-intended policy borne out of these tragedies has become mired down in the “whodunit” approach during the implementation of that policy. The belief is that if someone is injured, someone must have done something wrong, or if a fatality occurs, someone is at fault.

As a community, we endeavor to learn from these accidents, but sometimes our methods do more harm than good. Unfortunately, the word ‘investigation’ has become synonymous with the type of work performed by law enforcement. The possibility of an accident investigation can be terrorizing

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for firefighters. Although many accident investigations have produced a lot of good opportunities to learn, some of them have also put firefighters on high alert to the possibility that they could be perceived as being ‘at fault.’ The outcomes of several fatality fires have left the firefighting community uncertain of how to handle the possibility of an investigation.

Impacts from past actions taken by agencies as a result of negative outcomes on wildland fires are evident in the debate about professional liability insurance among the firefighting community. Professional liability insurance never used to be a part of any pre-season discussion among frontline firefighters. Now, it is a topic of discussion most firefighters have had. Questioning whether one should retain an attorney prior to talking to an Accident Investigation Team is something no firefighter should ever need to say.

Sidney Dekker, a Swedish researcher who studies human factors and organizational learning, offers the following observation in his paper, “When Human Error Becomes a Crime: Human Factors and Aerospace Safety,” 2003, 3(1) p 83-92.

“Taking a systems perspective: Accidents are not caused by failures of individuals, but result from the conflux or alignment of multiple contributory system factors, each necessary and only jointly sufficient. The source of accidents is the system, not its component parts.” “Moving beyond blame: Blame focuses on the supposed defects of individual (front- line) operators and denies the import of systemic contributions. Blame leads to defensive posturing, obfuscation of information, protectionism, polarization, and mute reporting systems.”

Additionally, Dekker (2002) also adds:

“The same sources also take progress on safety as synonymous to learning from failure. This makes punishment and learning two mutually exclusive activities: You can either learn from an accident or punish the individuals involved in it, but it is probably very difficult to do both at the same time.”

If the wildland fire community is ever going to move beyond the stigmas associated with fire shelter deployments and the ensuing investigations, we must change our approach to how we handle them. Line overhead, Fire Management Officers, Agency Administrators, and State Directors have continued to express a strong desire to learn from shelter deployments. If accident investigations imply blame or punitive action, they may very well be doomed from the start.

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Team Recommendations Collaborative effort between the Accident Investigation (AI) Team, the BLM Fire Safety Program Manager, and the BLM Idaho State Office, have identified three recommendations for consideration. Each of these recommendations were formulated in the spirit of encouraging and facilitating organizational learning.

• The initial Delegation of Authority (DOA) to the team should be written in a way that allows the team flexibility to determine if an Accident Investigation or a Lessons Learned Review is most appropriate. This recommendation is based on the observation that most initial reports contain uncertain details surrounding the actual event. • When a fire shelter deployment occurs, and no injuries or property damage that meet the Serious Accident criteria as stated in the Red Book (Chapter 18, page 360) are present, a Lessons Learned Review (LLR) should be performed instead of an accident investigation. • The Interagency Standards for Fire and Fire Aviation Operations (Red Book), and Departmental Manual 485, contain incongruent language regarding direction and standards for agency accident investigations. This language should be reviewed and rectified to better allow for more appropriate reviews and/or investigation of accidents.

One additional stand-alone recommendation from the team includes:

• Damaged and unusable fire shelters that are returned to fire caches, should be set aside and saved for training opportunities for firefighters.

All of these recommendations were rooted in hours of discussion on what constitutes an actual ‘accident’ and what type of review is most appropriate for the accident, specifically at the Grassy Ridge Fire. For the purposes of this recommendation piece, the Review Team used the Oxford English Dictionary’s definition of an accident: An unfortunate incident that happens unexpectedly and unintentionally, typically resulting in damage or injury.

Additionally, the team also referenced the Interagency Standards for Fire and Fire Operations (Red Book, Chapter 18, page 360) which defines a ‘wildland fire accident’ as: An unplanned event or series of events that resulted in injury, occupational illness, or damage to or loss of equipment or property.

These definitions help, but leave room for some questions:

• If the firefighter who deployed the fire shelter did not receive any burns, would it still be considered an accident?

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• If, instead of deploying the shelter, the firefighter had chosen to run through the heat and smoke, and still received the same small burns to his ear and elbow, would that be called an accident, even though he didn’t deploy his shelter? • What would have happened if he ran through the heat and smoke, and did not receive any burns at all?

Considering all of these questions, what is the accident? Is an accident defined by the entrapment? Is it the burn injury? Is it the entire series of events that led up to the entrapment and burn injury? If we are considering the series of events as the accident, how far back do we go?

If the act of deploying the fire shelter itself is considered the accident, there is little room left for us to expect that firefighters, if given a choice, will ever choose to do anything but wait until the last possible moment to deploy. Not wanting to be a part of an accident, firefighters may search for nearly any other option to avoid the “accident”. If that avoidance contributes to delaying a fire shelter deployment, or worse yet, a serious or fatal injury as a result of that delay, we have done great harm in defining a fire shelter deployment as an accident.

While an Accident Investigation document meets the ‘letter of the law’ of policy, it can miss the bigger intent of providing valuable lessons to the field. Organizationally, we strive to learn how and why accidents happen, and how we can prevent similar occurrences in the future

Past Accident Investigation documents have often not produced the intended outcomes of making the field a safer environment for wildland firefighters. Our history is replete with accident investigations that have recommendations - sometimes several pages thick – but still fail to change our actions and behaviors for the better.

The intent of our team, through this report and recommendations, is to provide the wildland fire community with tools to create a safer work environment that encourages the trust and courage to report when unfortunate events do occur.

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State Director Observations/Recommendations

During an initial attack or escalating incident, operational tempo can be intense. This is a critical time for firefighters at all levels to stick to the basics of their training and rely on Lookouts, Communication, Escape Routes and Safety Zones (LCES) to guide decision making and actions. While operational tempo and situation awareness were not necessarily contributing factors in the events leading to the shelter deployment at the Grassy Ridge Fire, the following are some observations and a recommendation from an agency administrator’s perspective that could help prevent future accidents. Observations

• Take time to do a radio check. This 30-second task could make the difference to ensure you have communication with your forces, your supervisor and adjoining forces. This is a fundamental principle of LCES. • Utilize flagging, or specific geographic indicators, when visibility is obscured due to fuels or smoke. This helps ensure all resources have a common operating picture. • No employee should ever hesitate to deploy their fire shelter if they deem it is necessary to protect themselves from radiant heat or to create a pocket of more breathable air. Fire personnel train annually on shelter use with the intent that if needed they should use it. There should be no circumstances under which an employee would face adverse actions for making the decision to deploy their fire shelter. A fire shelter is a piece of agency provided Personal Protective Equipment (PPE) and should be used when necessary as designed and intended. Properly deployed fire shelters have proven to save lives. • When a decision to deploy a fire shelter has been made, deploy as trained.

The Review Team for the Grassy Ridge incident found a reluctance by a seasoned division supervisor to deploy his shelter and a reluctance of the same division supervisor to report the deployment because of concern over what would result. Only through reporting and the willingness of those involved to discuss the events leading up to the deployment can the wildland fire community learn from the Grassy Ridge incident. Fire leadership needs to address these cultural concerns and emphasize that effective use of a shelter should be categorized as a success. When a shelter is deployed, something did not go according to plan, but a firefighter relied on their training and used their PPE, which ultimately worked to protect them.

Recommendation

• The Bureau of Land Management Assistant Fire Director should lead an interagency initiative to affect cultural change by emphasizing employees will not be subject to negative consequences as a result of deploying a fire shelter when necessary. The shelter is an Page 22 of 30

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important part of PPE that has and will continue to save lives and reduce injuries when used properly.

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Appendices Grassy Ridge Fire Fuels, Weather and Fire Behavior Summary General Seasonal Fire Conditions - Idaho Falls BLM District

The Idaho Falls BLM District experienced an average winter snowpack that lead into a generally wet spring, which allowed for abundant growth of fine fuels. Carryover fine fuels from 2017 also contributed to the above average fuel load leading into the 2018 fire season (see Fire Behavior Advisory below). Local fire resources on the Idaho Falls BLM District characterize the Grassy Ridge Fire area as drier than normal in some areas with higher than average fine fuel loading in un-grazed areas.

Several large fires occurred in June of 2018, which is unusually early for this part of the state. There were also two large fires directly adjacent to the Grassy Ridge Fire - the 4,353 acre Red Road Fire, which started on July 16 and the 2,338 acre Devils Hole Fire, which started on July 25. Both of these fires exhibited high resistance to control.

From Northern Great Basin Fuels and Fire Behavior Advisory (July 31 – August 13, 2018)

Significant carryover fine fuels from the 2017 fire season exist over western and northern Nevada, southern Idaho and northwest Utah with multiple new crops of cheatgrass from a wet 2018 spring. Continuous fine fuel beds are being observed, along with fuel loading 200- 300% of average in many areas. These dry fine fuels, along with near record low 100-hr and 1000-hr fuel moisture and dry brush will drive advanced to extreme fire behavior over western and northern Nevada, northwest Utah and below 7,000 feet across southern Idaho.

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Fuel Type and Topography

The Grassy Ridge Fire was burning in mixed age class Big Wyoming Sagebrush (2-7ft) with varying degrees of grazing impacts. In some places grass fuels were abundant and in other places heavy grazing had removed all fine fuels from beneath the sagebrush leaving very sandy soil. The terrain is flat to rolling with low rises and ridges with several areas of sand dunes. Much of the area is inaccessible to vehicles and mechanical equipment due to large expanses of sharp broken lava rock causing fire equipment to remain on existing roads and trails.

Areas characterized by heavily grazed sagebrush surrounding the Little Ranch and shelter deployment site

Flame lengths and fire behavior approached the anchor point in Division Echo during fire shelter deployment Page 25 of 30

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Fuel Conditions Information on fuel conditions was gathered from the Fire Behavior Analyst (FBAN) on the Type 2 team assigned to the fire.

Fuel Moisture

Fuel Moistures across the approximately 103,935 acre Grassy Ridge Fire area varied from above average to below average. The chart below shows that live fuel moisture measurements near Dubois, Idaho, where the fire shelter deployment took place, are well below average at 90% with the potential for extreme fire behavior. (See Figure 1 & 2)

Figure 1

Figure 2

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Grassy Ridge Fire Spot Weather Forecast Issued at 1244 AM 07/28/18 from the National Weather Service – Pocatello, Idaho Remainder of Night Shift and Day Shift on 07/28/18 DISCUSSION: A weak upper trough will continue to shear southeast through Montana tonight and Saturday supporting the possibility of thunderstorm activity over and north of the fire along the continental divide. The lower atmosphere is very dry and will support wind gusts up to 50 mph from thunderstorms in the area. REST OF TONIGHT Sky/weather……Mostly clear. CWR...... 0 percent. LAL...... 1. Min temperature..49 to 53. Max humidity...... 60 to 70 percent. Wind (20 ft)...... North winds 6 to 11 mph with gusts to 21 mph. Mixing height...... top of the inversion near 7600 MSL Transport winds.Northeast around 17 mph under the inversion and Northwest to 12 mph above the inversion. Haines Index...... 5 moderate. Rainfall amount...0.00 inches. TODAY Sky/weather...... Mostly sunny then becoming partly cloudy in the afternoon with a slight chance of thunderstorms. CWR...... 7 percent. LAL...... 1, then 2 in the afternoon. Max temperature.83 to 88. Min humidity...... 15 to 20 percent. Wind (20 ft)...... Northeast winds 4 to 10 mph shifting to the southwest 5 to 10 mph in the afternoon. Erratic winds expected near thunderstorms in the afternoon with potential gusts up to 50 mph. Outflow winds from thunderstorms may propagate up to 40 miles from storm. Mixing height...... Increasing to 11100 ft AGL in the afternoon. Transport winds..West to Northwest around 15 mph. Haines Index...... 5 moderate. Rainfall amount...up to 0.09 inches possible. SATURDAY NIGHT Sky/weather...... Partly cloudy.

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CWR...... 0 percent. LAL...... 1. Min temperature..Around 50. Max humidity...... 70 TO 80 percent. Wind (20 ft)...... North winds 5 to 10 mph with gusts to around 14 mph. Mixing height...... Top of inversion setting up around 6500 MSL. Transport winds..North to 16 mph under the inversion and Northwest to 15 mph above the inversion. Haines Index...... 5 moderate. Rainfall amount...0.00 inches. Discussion of weather and fire behavior leading up to Fire Shelter Deployment

From discussions with local fire resources assigned to the Grassy Ridge fire it was clear that fire behavior from July 26 to July 28 was heavily influenced by unpredictable afternoon thunderstorm and associated outflow winds. Sagebrush fuels were drier than average and there was an abundance of fine fuels that were fully cured. This combination caused the fire to exhibit extreme fire behavior over a three-day period. The fire made a 13-mile run overnight on July 28 and by the end of the day totaled approximately 70,000 acres (see Figure 3).

Fire behavior at 1100 in the morning before the shelter deployment consisted of a fire front estimated at 14 miles long, as reported from the Air Attack assigned to the fire. Flame lengths were six to 20 feet high and were being influence by subtle variations in topography and fuels. The Operations Section Chief that was flying in the helicopter estimated that when the resources arrived at the Little Ranch house they had approximately one hour before the fire would impact the north side of the creek.

Although onsite weather was not recorded at the shelter deployment site or on any other parts of the fire around the time of the deployment, the Gas Caves Remote Automatic Weather Station (RAWS) is 15 miles to the east of the deployment site and is representative of the overall fire area.

As recorded at the Gas Caves (GASCV) RAWS station 7/28/18 11:23 MDT: Winds:……………4mph gusting to 7 out of the ENE Temperature:……77degrees, RH:………………..31% At 12:23 MDT Winds: 7mph gusting to 13 out of the SE Temperature: 77 degrees, RH:………………..33% Page 28 of 30

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The weather recorded at the RAWS does not indicate that there were any unusual weather events occurring at the time of the deployment. The fire was fuels driven and being pushed by both general winds and terrain winds. Thirty percent humidity at the RAWS seems high for the observed fire behavior, but conditions were exacerbated by lower than average live fuel moistures and poor humidity recovery the preceding night. Local fire resources indicated that the Grassy Ridge Fire did exhibit extreme unpredictable fire behavior when outflow thunderstorm winds were present, but fire behavior at the time of the shelter deployment was not out of the ordinary given the size of the fire front that had been established in previous days.

Grassy Ridge Fire Progression Map – Total acreage on 7/29 at 2230 = 103,935 acres

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Lessons Learned Review Team Members

Team Lead: Dave Whitmer, Fire Operations Chief. Alaska Fire Service, BLM.

Lead Facilitator: Bodie Ronk, Safety, Health and Environmental Manager. NIFC, BLM.

Writer/Editor: Kari Cobb, Public Affairs Specialist. NIFC, BLM.

SME, Fire Behavior and Fuels: Kim Ernstrom, Fire Applications Specialist. Wildland Fire Management RD&A, NIFC, NPS.

SME, Fire Operations: Bryan Yeager, Fire Operations Specialist. Southwest Colorado Fire and Aviation Management Unit, BLM.

SME, Fire Operations: Mike Ellsworth, Assistant National Training Officer. NIFC, BLM.

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