Cnf Lesson Learned 01-2010

CNF LESSON LEARNED 01-2010

Date of Incident: January 6, 2010

Subject: TERRA TORCH BURN INCIDENT

Incident: On January 6, 2010, a fire fighter suffered burns to his left forearm area while operating a terra torch during a prescribed burn operation. Below is a brief summary of the incident:

0830: Three fire fighters were selected to conduct ignition burning with a Terra Torch. Crew was briefed by Fire Boss (T) on Terra Torch operations, emergency procedures, and mixing of fuel. After this they attended the regular burn briefing. 1000: Fire ignition began. Fire Fighter (F/F) 1 began applying fire. F/F 1stated he could feel the heat that was being put out by the terra torch and proceeded to do his best to keep away from the radiant heat. 1015: F/F 1 stated that after 10-15 minutes of applying fire down the road, he started to get hot and decided to take a break. At this point, F/F 1 switched out with another fire fighter assigned to the terra torch. F/F 1 supported the new terra torch operator. At the time of the switch, F/F 1 felt Nomex shirt was hot but experienced no pain or burning sensation. 1030: Around this time, a break was taken to evaluate fire behavior. It was at this time that F/F 1 noticed feeling pain in his left forearm. F/F 1 lifted his sleeve and noticed that the skin was red and looked like it had been sunburned. F/F 1 then reported the injury to the Fire Bose (T).

After the burn injury was reported, it was evaluated and discussed among several supervisors and the affected area appeared to display 1st and slight 2nd (some blistering) degree burns. The Burn Boss then made the determination to send the injured fire fighter to urgent care for further evaluation and determination of whether F/F 1 needed to go to the burn center. Urgent Care determined that the affected area had 1st and 2nd degree burns. F/F 1 was given medical care and told to return the next day for further evaluation.

The next day, F/F 1 noticed less redness in the affected area but an increase in blister size. F/F 1 reported to work, reported the change to a Battalion Chief and was advised to report to the burn center to have the area looked at. F/F 1 called the Albuquerque Service Center and got approval to go to the burn center. The Burn Center evaluated and treated F/F 1’s injured area and classified the burns as 2nd degree with one small spot that showed the beginnings of a 3rd degree burn. F/F 1 is currently on light duty and recovering well.

Fire Fighter 1 Lesson Learned: While the firefighter felt radiant heat while operating the Terra Torch, he didn’t find this unusual as he had previously operated the Terra Torch on two separate occasions. F/F 1 recommends that Personnel Protective Equipment (PPE) requirements be increased during Terra Torch operations to adjust for the increased exposure to radiant heat.

Lessons Learned: - Ensure fuel mix utilized for Terra Torch is consistent with the manufacturer’s mixing guidelines to minimize heat released during use. (see below MTDC link) - During Terra Torch tailgate session/brief, ensure it is clear to operators that there will be an increased exposure to radiant heat and what precautions to take to minimize exposure. - Ensure Terra Torch operators and those supervising keep an increased awareness of the operator’s firing pattern and take steps necessary to maintain firing pattern at a 45 degree angle to minimize operator exposure to radiant heat. - Ensure Terra Torch operators and those supervising maintain awareness of the manner in which fire application is being conducted. (i.e. ensure fire application is done in small bursts rather than in steady flows)

Recommendations: - Prior to next use of Terra Torch…review Batch Mixer/Terra Torch Operation Manual (see below MTDC link) and Terra Torch Job Hazard Analysis. - Conduct Terra Torch operational use training utilizing the Batch Mixer/Terra Torch Operation Manual. (see below MTDC link) - That PPE for Terra Torch operations be reviewed and, if deemed necessary, requirements be increased to minimize radiant heat exposure. - Review NWCG Standards for Burn Injuries dated July 10, 2008, and make recommendations CNF leadership can follow when dealing with a burn incident. - Utilize this incident to develop CNF Terra Torch Operational procedures and Operator training requirements.

MTDC link http://fsweb.mtdc.wo.fs.fed.us/aerial_ign/fuelgel/equip/firecon/manual/manual.htm#intro