WaterfallWaterfall FireFire LessonsLessons LearnedLearned JulyJuly 20042004 CarsonCarson City,City, NevadaNevada PetePete Anderson,Anderson, StateState ForesterForester--FirewardenFirewarden InitialInitial FireFire InformationInformation July 14, 2004

¾ Detection and Initial Dispatch: 0257 ¾ Cause: abandoned campfire ¾ Location: hills west of Carson City ¾ Responding Resources: Carson City Fire Department (CCFD) and Nevada Division of Forestry (NDF), and USF Humboldt-Toiyabe Forest (HTF) ¾ Type-3 Organization formed at 0600 with IC’s from NDF, CCFD and HTF ¾ Type-2 ITM ordered at 0800 based on complexity analysis ConditionsConditions PriorPrior toto IgnitionIgnition

¾ Steep canyon slopes with urban developments immediately adjoining the wildland forest boundary

¾ Fuel loading moderate to heavy

¾ Road systems a combination of paved, gravel and unmarked single lane, and narrow roads on the sides of slopes common

¾ Prolonged drought resulting in very low fuel moistures

¾ Energy Release Component above 97% level

¾ Predicted Haines Index of 5 with potential of large fire growth high

¾ Multiple jurisdiction area – Sierra Front Cooperators

TheThe SierraSierra FrontFront WildfireWildfire CooperatorsCooperators

Director Agencies Associate and Cooperating Agencies ¾ Donner Department ¾ Bureau of Indian Affairs, Western Nevada ¾ Lake Protection District Agency ¾ Meeks Bay Fire Protection District ¾ Bureau of Land Management, Carson City ¾ Fallon Naval Air Department District and Bakersfield District ¾ California Department of Forestry ¾ Nevada State Fire Marshal’s Office ¾ Carson City Fire Department ¾ Northstar Fire Department ¾ Central Lyon Protection ¾ Sierra Pacific Power Company District ¾ South Lake Tahoe Fire Department ¾ East Fork Fire Protection District ¾ Smith Valley Fire Protection District ¾ Mammoth Lakes Fire Protection District ¾ Sparks Fire Department ¾ Nevada Division of Forestry ¾ Squaw Valley Fire Department ¾ North Lake Tahoe Fire Protection District ¾ Truckee Fire Protection District ¾ North Tahoe Fire Protection District ¾ Yerington/Mason Valley Fire Protections District ¾ Reno Fire Department ¾ Storey County Fire Department ¾ University Of Nevada Cooperative Extension ¾ Tahoe Douglas Fire Protection District ¾ Nevada Division of Emergency Management ¾ U.S. Forest Service, Humboldt-Toiyabe ¾ California Office of Emergency Services National Forest, Inyo National Forest, ¾ Camino Dispatch Center Tahoe National Forest, Lake Tahoe Basin ¾ Owens Valley Dispatch Center Management Unit ¾ Sierra Front Dispatch Center ¾ Grass Valley Dispatch Center ¾ National Weather Service GeographicGeographic AreaArea ofof JurisdictionJurisdiction FireFire FactsFacts

8,7008,700 AcresAcres BurnedBurned

z 2,7822,782 HumboldtHumboldt ToiyabeToiyabe

z 2,5072,507 CarsonCarson CityCity

z 2,4952,495 PrivatePrivate LandLand

z 710710 StateState ofof NevadaNevada

z 206206 TribalTribal LandLand

100%100% Containment:Containment: JulyJuly 20,20, 20042004 WaterfallWaterfall FireFire ProgressionProgression JulyJuly 1414th –– 1717th 20042004 StagingStaging AreaArea 22 PriorPrior toto BurnBurn OverOver

FactorsFactors ContributingContributing toto EntrapmentEntrapment andand BurnBurn Over:Over: InjuriesInjuries andand MedicalMedical EvacuationEvacuation

¾ At 1105 hand crew reported 2 potentially serious injuries from falling rocks. ¾ Technical rescue was required resulting in diversion of tactical suppression resources. ¾ EMS personnel and equipment were dispatched from CCFD. ¾ Response led to increased radio traffic and increased vehicle traffic into Staging Area 2.. FactorsFactors ContributingContributing toto EntrapmentEntrapment andand BurnBurn Over:Over: TrafficTraffic ¾ RescueRescue ofof injuredinjured ledled toto increasedincreased vehiclevehicle traffictraffic intointo StagingStaging AreaArea 2.2. ¾ DIVSDIVS BB personnelpersonnel forcedforced toto egressegress backback towardtoward StagingStaging AreaArea 2.2. ¾ UncontrolledUncontrolled accessaccess onon KingsKings CanyonCanyon RoadRoad allowedallowed unauthorizedunauthorized personnelpersonnel andand vehiclesvehicles toto enter,enter, including:including: • private parties • unassigned fire and non fire personnel • media • incoming Type-2 IMT members FactorsFactors ContributingContributing toto EntrapmentEntrapment andand BurnBurn Over:Over: FireFire WeatherWeather andand ConditionsConditions July 14, 2004, 1230 – 1300

¾¾ MainMain firefire spottedspotted overover KingsKings CanyonCanyon road.road. ¾¾ SpotSpot firesfires grewgrew immediatelyimmediately beyondbeyond control.control. ¾¾ AdditionalAdditional spottingspotting andand downdown canyoncanyon windswinds spreadspread firefire toto thethe east.east. ¾¾ NorthNorth endend ofof firefire blewblew upup withwith highhigh intensity,intensity, developingdeveloping aa significantsignificant columncolumn resultingresulting inin inin--drafting.drafting. ¾¾ DownDown canyoncanyon windswinds causedcaused thethe southsouth endend ofof thethe firefire toto spreadspread northnorth andand easteast burningburning throughthrough StagingStaging AreaArea 2.2. EntrapmentEntrapment andand BurnBurn OverOver SummarySummary July 14, 2004, 1315

¾ BurnBurn overover lastedlasted approximatelyapproximately 22--55 minutes.minutes. ¾ EntrapmentEntrapment andand burnburn overover ofof 2121 personnelpersonnel andand 1818 vehicles.vehicles. ¾ 22 personspersons receivedreceived firstfirst andand secondsecond degreedegree burnsburns (firefighter(firefighter andand newsnews reporter).reporter). ¾ 33 vehiclesvehicles destroyed.destroyed. ¾ SeveralSeveral additionaladditional vehiclesvehicles receivedreceived minorminor toto severesevere damage.damage. Staging Area 2 After Burn Over

BurnBurn OverOver InvestigationInvestigation

¾ Multi-agency investigation team formed. ¾ Investigation team comprised of diverse cadre with inter-agency representation and expertise. ¾ Team members were from BLM, NDF, USDA FS, Central Lyon County Fire District, Clark County Fire Department, and Reno Fire Department. ¾ Reviewed participating agency policies and guidelines. ¾ Interviewed over seventy people. ¾ Made several site visits. ¾ Reviewed written and photographic documentation. ¾ Grouped findings into 10 categories. BoardBoard ofof ReviewReview ¾ Five-members from multiple jurisdictions ¾ Chaired by Eldorado Forest Supervisor John Berry ¾ Nevada State Forester Pete Anderson ¾ Carson City Fire Chief Lou Buckley ¾ Humboldt-Toiyabe Deputy Forest Supervisor Ed Monnig ¾ Forest Service Wildland Fire Safety Manager Steve Holdsambeck BurnBurn OverOver InvestigationInvestigation FindingsFindings

1. EnvironmentalEnvironmental andand firefire behaviorbehavior 2. MultiMulti--jurisdictionaljurisdictional incidentincident managementmanagement 3. CommunicationsCommunications 4. FirefighterFirefighter andand PublicPublic SafetySafety 5. TransitionsTransitions 6. RolesRoles andand ResponsibilitiesResponsibilities 7. OperationsOperations andand tacticaltactical decisiondecision makingmaking 8. EntrapmentEntrapment 9. ManagementManagement 10. PolicyPolicy 1.1. EnvironmentalEnvironmental andand FireFire BehaviorBehavior

¾ Very low fuel moistures as a result of prolonged drought. ¾ Energy Release Components above 97%. ¾ Potential of large fire growth high with predicted Haines Index of 5. ¾ Fire activity (intensity, spotting, and rates of spread) increased dramatically starting about 1200. ¾ Blow-up on north end of fire and subsequent in- drafting contributed to south end of fire spreading northeast and the burn over at Staging Area 2. 2.2. MultiMulti--jurisdictionaljurisdictional IncidentIncident ManagementManagement

¾ NDF was assumed to be the jurisdictional agency. ¾ Unified Command was established at initial attack with IC from both NDF and CCFD. ¾ Agency Administrators concurred with the objectives and plan for managing the fire. ¾ Command and Operations personnel recognized a high potential for significant downhill fire spread. ¾ Trigger points for initiating disengagement and egress from area were not identified or communicated, and responsibilities were not assigned. ¾ Staging Area 1 established at Carson Middle School to receive incoming resources, with staging area manager assigned. 3.3. CommunicationsCommunications

¾ Communications plan was developed with assignment of five radio frequencies including command, two tactical frequencies, air to ground, and air to air.

¾ Poor radio discipline and/or not using assigned radio frequencies resulted in tremendous radio traffic on both command and tactical frequencies.

¾ Radio traffic congestion resulted in many overhead personnel reverting to home unit (unassigned) frequencies and cell phones for much of their communications, resulting in critical conversations not being available for all personnel who had a “need to know” creating more confusion regarding fire status and firefighting actions. 4.4. FirefighterFirefighter andand PublicPublic SafetySafety

¾ Check-in procedures did not provide complete accounting of all personnel the fire area. ¾ Quality of briefings varied widely. ¾ Assigned and unassigned personnel in fire area without wearing PPE. ¾ Uncontrolled access into Kings Canyon resulted in private parties, unassigned fire and non-fire management personnel, the media and incoming Type 2 IMT members in Staging Area 2 . ¾ Command and operations personnel observed heavy congestion at Staging Area 2 but took no effective action. ¾ 2 firefighters on hand crew received potentially serious injuries from falling rocks. ¾ Helicopter bucket operations were diverted to cooling fire perimeter near the rescue operations. ¾ Trigger points for disengagement and egress were not identified or commonly understood, no contingency plan in place when expected events happened. 5.5. TransitionsTransitions

¾ At 0600 command and general staff structure changed with arrival of a replacement IC from NDF and an additional IC from the HTF. ¾ Change resulted in three ICs working in Unified Command representing NDF, HTF, and CCFD. ¾ Lead IC role not clearly assigned or understood. ¾ Type 2 IMT on scene At 1200:

z One unified IC provided an initial briefing to the incoming.

z One Unified IC was not aware of this briefing.

z Other Unified IC departed for the fire line as OSC (T) on the Type 2 IMT, assuming the Type 2 IMT was taking over management of the fire at 1200.

z Transition to the Type 2 IMT occurred at 1600.

z Decision to transition to the Type 2 IMT at 1600 was not positively communicated to the Type 3 ICs. ¾ Failure to communicate led to erroneous assumptions and at least one IC disengaging as a commander. 6.6. RolesRoles andand ResponsibilitiesResponsibilities

¾ Numerous changes in personnel filling positions, Many of these changes were not announced to superiors or subordinates. ¾ Changes were not relayed effectively to management at Staging Area 1 for use in briefing incoming firefighting. ¾ Confusion about names of the ICs and who was in charge at OSC and DIVS levels. ¾ Responsibility for management of Staging Area 2 and traffic on Kings Canyon Road was not fully understood or accepted by the DIVS. ¾ Some unassigned “free-lancing” fire management supervisors entered fire area and started giving tactical direction and assignments to resources without knowledge or approval of operations overhead. ¾ These actions created confusion among firefighters about who was in charge and may have contributed to untimely delays for disengagement. 7.7. OperationalOperational && TacticalTactical DecisionDecision MakingMaking

¾ Air Tactical Group Supervisor arrived at 0619 and immediately ordered airtanker and helicopter resources. ¾ First Single Engine Airtanker (SEAT) was enroute to fire at 0656. ¾ Crews constructing direct handline with aerial support could not get anchor points established on north end of fire at Division A/B break. ¾ The ICs and OSC recognized the potential for heavy congestion of people and vehicles at Staging Area 2 and agreed to limit access to only resources that had a tactical assignment. ¾ Their actions to implement this decision were ineffective. ¾ Direct attack with hand crews was ineffective without aerial support, primarily from helicopters with water buckets. 8.8. EntrapmentEntrapment

¾ Personnel at Staging Area 2 were not advised about buildup of fire activity south of their location nor the fire front spreading toward them. ¾ Improperly parked vehicles at Staging Area 2, vehicles without operators present, and congested two way vehicle traffic on Kings Canyon Rd. led to entrapment and burn over. ¾ Operator of a Central Lyon Co. engine stopped his egress at exit of Staging Area 2 to allow a news media vehicle heading up the road to turn around and exit area. ¾ A pine tree adjacent to road crowned out and ignited front of engine. Operator received burns and abandoned his vehicle. This event blocked any additional vehicles egress from Staging Area 2. ¾ One entrapped engine with a remote controlled water nozzle was able to apply water to other vehicles during burn over. ¾ Neither Unified ICs nor Agency Administrators were advised of the burn over and entrapment in a timely manner. 9.9. ManagementManagement

¾ ICs, Agency Administrators, and fire managers lacked a common understanding of transitions from Type 3 to Type 2 IMTs. ¾ No common understanding of how Unified Command functions or roles and responsibilities of each IC on Type 3 incidents. ¾ Local agencies lacked a single common interagency operating plan for managing Type 3 fires burning on multiple jurisdictions. ¾ Assigned Type 3 Incident Information Officer did not understand Nevada State Law regarding media access to the fire line. ¾ Fire management did not close areas around fire to public prior to the entrapment. 10.10. PolicyPolicy

¾ During the time period of initial and extended attack through the burn over at Staging Area 2, most fire suppression policies and procedures of the responsible agencies were followed. However, in some cases either action or inaction by firefighters resulted in policy and/or procedural non-compliance. ¾ Fire Orders that were violated or not mitigated.

z Maintain prompt communications with your forces, your supervisor, and adjoining forces.

z Give clear instructions and insure they are understood.

z Maintain control of your forces at all times.

z 10 Fight fire aggressively, having provided for safety first. ¾ Watch Outs that were violated or not mitigated.

z No communication link with crewmembers or supervisor.

z Constructing line without safe anchor point. LessonsLessons Learned:Learned: IncidentIncident ManagementManagement

1. ICIC isis ICIC untiluntil relievedrelieved ofof command.command.

2. TheThe ICIC needsneeds toto bebe clearlyclearly identifiedidentified toto allall personnelpersonnel andand transitionstransitions inin commandcommand announcedannounced onon commandcommand net.net.

3. TheThe ICIC doesdoes notnot necessarilynecessarily needneed toto changechange becausebecause ofof changechange ofof jurisdiction.jurisdiction.

4. FillFill necessarynecessary ICSICS functionsfunctions asas incidentincident expands.expands.

5. UnifiedUnified CommandCommand onlyonly hashas 11 ICIC inin charge.charge.

6. AvoidAvoid complacencycomplacency afterafter orderingordering IMT.IMT. LessonsLessons Learned:Learned: CommunicationsCommunications

1. KeepKeep toto assignedassigned frequencies.frequencies. 2. UseUse RadioRadio disciplinediscipline toto minimizeminimize radioradio traffic.traffic. 3. UseUse assignedassigned frequencies:frequencies: a) Operation talk to Divisions on command net b) Divisions talk to fire resources on tactical c) Prioritize appropriate channel 4. UseUse cellcell phonesphones forfor logisticslogistics only,only, notnot operations.operations. 5. EnsureEnsure criticalcritical communicationscommunications areare heardheard byby allall personnel.personnel. 6. MaintainMaintain communicationcommunication linklink withwith crewcrew membersmembers andand supervisor.supervisor. LessonsLessons Learned:Learned: FirefighterFirefighter SafetySafety

1. HaveHave sufficientsufficient numbernumber ofof SafetySafety Officers.Officers.

2. EveryoneEveryone isis responsibleresponsible forfor safety.safety.

3. ExpectExpect incidentsincidents withinwithin incidentsincidents duringduring wildlandwildland urbanurban interfaceinterface fires.fires.

4. DevelopDevelop “May“May Day”Day” proceduresprocedures likelike thosethose usedused atat structuralstructural fires.fires.

5. EstablishEstablish safesafe anchoranchor pointpoint beforebefore constructingconstructing lines.lines.

6. RememberRemember thethe BASICS.BASICS. LessonsLessons Learned:Learned: StagingStaging AreasAreas

1. IdentifyIdentify StagingStaging AreaArea withwith signssigns andand vests.vests.

2. AssignAssign STAM.STAM.

3. SafeSafe areas,areas, dodo notnot locatelocate StagingStaging AreasAreas wherewhere therethere areare ongoingongoing operationsoperations andand possibilitypossibility ofof beingbeing overrun.overrun.

4. LeavesLeaves keyskeys inin ignitions.ignitions.

5. FollowFollow direction.direction.

6. BuildBuild aa traffictraffic plan,plan, includingincluding properproper parking.parking.

7. Don’tDon’t confuseconfuse “Drop“Drop Points”Points” withwith “Staging“Staging Areas.”Areas.” LessonsLessons Learned:Learned: MediaMedia ExpectationsExpectations

1. MeetMeet withwith mediamedia atat thethe beginningbeginning ofof seasonseason toto definedefine expectations.expectations. 2. ControlControl mediamedia throughthrough prepre--seasonseason trainingtraining andand education.education. 3. ProvideProvide escortsescorts forfor allall mediamedia personnel.personnel. 4. HaveHave aa wayway toto identifyidentify mediamedia peoplepeople fromfrom otherother personnel.personnel. 5. IncidentIncident PublicPublic InformationInformation OfficersOfficers needneed toto understandunderstand thethe lawlaw regardingregarding mediamedia accessaccess toto thethe fireline.fireline. 6. HaveHave adequateadequate numbernumber ofof PIO’s.PIO’s. LessonsLessons Learned:Learned: EntrapmentEntrapment AvoidanceAvoidance

1. FirefightersFirefighters shouldshould testtest theirtheir entrapmententrapment reactionreaction skillsskills throughthrough drillsdrills andand training.training. 2. WatchWatch forfor earlyearly indicatorsindicators ofof problemproblem firefire behaviorbehavior andand adjustadjust tacticstactics accordingly.accordingly. 3. IdentifyIdentify triggertrigger points/timepoints/time tagstags toto evacuateevacuate toto safetysafety zones.zones. 4. IfIf therethere isis enoughenough timetime afterafter entrapment,entrapment, useuse thethe timetime toto planplan forfor aa deployment.deployment. 5. ParkPark vehiclesvehicles correctlycorrectly atat allall times.times. 6. ProvideProvide traffictraffic controlcontrol toto avoidavoid unassignedunassigned andand unauthorizedunauthorized vehiclesvehicles inin restrictedrestricted areas.areas. LessonsLessons Learned:Learned: AgencyAgency AdministrationAdministration

1. AgencyAgency administratorsadministrators shouldshould decidedecide onon aa commandcommand structurestructure withinwithin anan area.area.

2. ExpectationsExpectations ofof ICIC shouldshould bebe defineddefined byby agencyagency administration.administration.

3. AgencyAgency administrationadministration inin contactcontact withwith inin-- comingcoming IMTIMT ICs’ICs’ isis essential.essential.

4. LocalLocal agenciesagencies needneed toto havehave aa singlesingle commoncommon interagencyinteragency operatingoperating planplan forfor managingmanaging TypeType 33 firesfires burningburning onon multiplemultiple jurisdictions.jurisdictions. LessonsLessons Learned:Learned: AccountabilityAccountability

1. AllAll personnelpersonnel arrivingarriving oror departingdeparting fromfrom thethe incidentincident needneed toto bebe accountedaccounted for.for.

2. CheckCheck--inin proceduresprocedures mustmust bebe established.established.

3. BriefingsBriefings mustmust bebe providedprovided inin accordanceaccordance withwith thethe IncidentIncident ResponseResponse PocketPocket GuideGuide (IRPG).(IRPG).

4. MaintainMaintain controlcontrol ofof youryour forcesforces atat allall times.times. FireFire--BurnedBurned AreaArea FireFire--BurnedBurned AreaArea FireFire--BurnedBurned AreaArea