Mulch Fire Facilitated Learning Analysis

Home , Ash pit

USDA Forest ServiceUSDA Forest—Southwest Service Region—Southwest—Coconino Region National—Coconino Forest National Forest

USDA Forest Service—Southwest Region—Coconino National Forest

Contents

Background ...... 3 Introduction ...... 4 The Story ...... 5 Initial Response ...... 5 Day 2: A Heavy Equipment Show ...... 6 July 12 – July 17: Isolate and Monitor ...... 8 July 18 to July 20: “We Started Getting More Aggressive with Water” ...... 9 July 21: Just Wet it Down and Monitor ...... 11 Sensemaking and Learning Opportunities ...... 16 What Went Well ...... 16 Setting the Tone ...... 17 Common Operating Picture ...... 18 Complexity ...... 20 Transition ...... 21 Understanding Why They Were There ...... 22 Bias for Action...... 23 Special Use Permits ...... 25 Be “That” Person ...... 25 Smoke ...... 26 Appendix A – Timeline ...... 28 Appendix B – PPE Report ...... 29

USDA Forest Service—Southwest Region—Coconino National Forest

Background

The 2019 Arizona fire season by the middle of July had been more active than average, owing partly to the late onset of monsoon season. Fire resources from the Red Rock Ranger District (RRRD) of the Coconino National Forest (COF) and Verde Ranger District (VRD) of the Prescott National Forest (PNF) were committed to fires and prescribed burns, while out-of-area resources were ordered to help cover local initial attack response. In the week leading up to the start of the Mulch Fire, Prescott Interagency Dispatch logged over 60 wildfires or smoke checks, while Flagstaff Dispatch Center (FDC) logged over 70 on the Coconino National Forest. Most of the firefighters that work on the Red Rock and Verde Ranger Districts are either from the local area, or have lived in the area for several years. They hunt, fish, hike, camp, and recreate in the forest they work on. They have moved away for jobs or school, but come back because this is home and this is their community. The fire organization on the two districts have functioned as a zone for over 25 years, sharing resources and duty officers across the Forest boundary on a daily basis. Besides federal firefighting resources from other areas, the Zone also used local government resources statused in ROSS. Central Arizona Fire & Medical Authority (CAFMA), headquartered in Prescott Valley, staffs several wildland engines with All- Risk-trained firefighters and firefighter-paramedics. Yavapai County operates a transfer station under a special use permit 2.5 miles from the Verde Ranger District office. The landfill co-located with it closed in 2001, but the transfer station still takes in tires, vegetative waste, and other materials. The mulch pile is mainly the result of increased work in the WUI in nearby communities.

USDA Forest Service—Southwest Region—Coconino National Forest

Introduction

A mulch pile caught fire in mid-July at a local transfer station, ultimately coined “This was nothing like anything I had the “Mulch Fire.” Every engine in the been on before.” local zone and several pieces of heavy equipment took turns rotating assignments on the incident in some of the toughest environmental conditions imaginable. On the 11th day of the fire, the Incident Commander (IC) sunk into an ash pit on the Mulch Fire. A second crew member stepped into part of the hole while attempting to rescue the injured firefighter. The crewmember suffered 2nd degree burns while assisting with the rescue of the IC, who suffered 3rd degree burns across most of his legs. What follows next is their story.

USDA Forest Service—Southwest Region—Coconino National Forest

The Story

Initial Response

The first firefighters to see the Mulch Fire were with Copper Canyon Fire District (CCFD) just down the street in Camp Verde, AZ. They received the call at 1153 AM, July 10, and arrived on scene with one engine, one water tender and a battalion chief at 1202. CCFD had responded to the transfer station several times over recent years, usually to extinguish fires in the garbage dumpsters. Had the Mulch Fire been of this type, CCFD would have kept command of the fire and put it out. Indeed, The Mulch Fire on July 10, 2019 CCFD told Yavapai County employees at the transfer station that they would have the fire out that day. This fire was nothing like one of those quick “surround and drown” fires, though. By the time the first Forest Service engines arrived 45 minutes later, CCFD had already drenched the fire with 20,000 gallons of water and still the fire was intensifying. The Prescott National Forest engine (PNF E-28), and an out-of-region engine on a severity cover assignment (R6 E-1) came on scene of the Mulch Fire and started to engage. Working with Flagstaff Dispatch Center (FDC), they determined that the site was within the Coconino National Forest boundary. A Forest Service Prevention Officer was requested to come to the site and investigate the cause of the fire. His first thought when he arrived was “Oh my God, this is going to burn forever.” At 1309, an hour into the fire, command of the incident transferred from CCFD to an ICT5 (and trainee) from R6 E-1. With incident command in Forest Service hands, CCFD departed the scene, leaving their “The Forest Service wanted it—but water tender for another 45 minutes no one really wanted it.” to help the Forest Service engines. The scale of the mulch pile was revealed in the ICT5’s size up to FDC at 1309: a mulch pile covering an acre of ground, 20-30 feet tall. Local firefighters already knew about this pile though. It had been growing for years and was the last pile that hadn’t been separated out by transfer station employees. A firefighter on PNF E-28 even remembered having the thought, “I hope we don’t have to deal with that, it’s bad enough when it isn’t on fire.” Now here he was, initial attacking the pile. Fire activity was minimal – creeping and smoldering – but no one on scene, had ever dealt with something like this. There was desert scrub on the

USDA Forest Service—Southwest Region—Coconino National Forest

hills surrounding the site, but the pile itself sat on a 20-foot-deep layer of barren earth covering 40 years of trash. The size of the pile, the fact that it was now about ¾ involved, and its location in the bare dirt, pointed to just letting it burn out. Acting on this strategy, they grabbed drip torches and lit the rest of the pile. Over the next few hours, significant progress was made to isolate the pile and protect the surrounding piles of slash and mulch, as well as prepare for the next day’s operations. County heavy equipment completed a line around the pile and pushed other piles away. The ICT5 ordered more heavy equipment, water tenders and water handling equipment – portable tanks, pumps, sprinklers, etc. – through FDC. With the increasing complexity of the fire, another transfer of command took place at 1601. The ICT5 fire transitioned to ICT4, with two PNF firefighters as ICT4 and ICT4-T: Frank and Chris. The final update to FDC for the night at 2256 identified the PNF E-28 as a night shift on the Mulch Fire.

Day 2: A Heavy Equipment Show

The Incident Commander Trainee, Chris, spoke with the Agency Administrator (AA) on the second day of the incident. Chris briefed the AA on the situation, and confirmed they were getting the resources they needed for the fire. The heat of the pile and its vertical dimension didn’t make anyone comfortable setting foot on the pile. This was heavy equipment work, and operations revolved around the use of a dozer and an excavator to tear the pile apart. Coconino National Forest Dozer 1 (DZ-1) arrived that morning and worked with an excavator, that had been there since the day before, to break An excavator moving burning mulch down the pile and spread it out to let it burn. The excavator operator, Jerry, was with the Forest Service road crew, and had extensive heavy equipment experience. He had turned down the initial assignment when he was ordered as a dozer operator, but negotiated bringing and operating an excavator, which he felt was the right tool for the job.

USDA Forest Service—Southwest Region—Coconino National Forest

The intense heat, copious ash, and smoke made it very difficult to effectively work the pile. Just being outside at all was difficult for firefighters. There was the Arizona summer heat, of course, but then there were the “fire beetles.” Known and despised across the West by firefighters, they were out in greater numbers than anyone had ever seen – they swarmed anyone who ventured outside from head to toe. “I had my hair in pigtails, and the Among the engines on the fire, plans beetles were crawling through the were discussed for how to rescue an braids.” equipment operator if they got stuck in the burning pile. Jesse, operator of DZ- 1, thought this was like nothing he had ever done before. While pushing forward through the burning material, the combination of light ash and smoke in the air became so thick that Jesse had to shut off his air “It was like a having a pickle jar over conditioning to seal himself off. During your head full of smoke.” these brief periods, the cab of the dozer became sweltering, and he was soaked in sweat. In the afternoon, an adjacent pile of slash and large cottonwood rounds ignited from a spot fire. At the request of ICT4-T Chris, DZ-1 began pushing this new burning pile into the mulch pile. After several runs, DZ-1’s air intake hose collapses and the motor died. It wouldn’t restart and had burning rounds stacked next to it. Jesse immediately asked the engines to come and spray down the area to cool it off. As Jesse attempted to restart his machine, Jerry used the excavator’s arm to reach into the pile and push the burning rounds and slash away from the dozer. Finally DZ-1 started up again, and Jesse limped it back out of the pile into safety. Once out of the pile, he noticed smoke pouring from the dozer. When he opened the air DZ-1 shrouded in smoke and ash intake housing, he saw the air filters were burning and called for water to put out the fire inside the dozer. The hardline on COF E-37 Charred air intake tube from DZ-1

USDA Forest Service—Southwest Region—Coconino National Forest

couldn’t reach, so a firefighter ran and grabbed a sprinkler, dragging it over and using it to extinguish the filter fire. Heavy equipment hadn’t been totally effective on the first full day of operations. DZ-1 sat stationery for the next few days while a mobile mechanic worked on it. He determined the turbocharger was destroyed from ingesting unfiltered ash, dust and hot gas. The damage to the dozer was serious enough to knock it out of action for several days. That night, Jesse’s eyes were nearly “Water was boiling in the swollen shut from the dense smoke and excavator bucket it was so hot.” ash inside the dozer’s cab. They were so bad, he needed someone to drive him home.

July 12 – July 17: Isolate and Monitor

Following the incident with DZ-1, operations on the Mulch Fire settled into a daily pattern of heavy equipment moving smoldering mulch onto flat ground to let it burn down. Firefighters used hoses to wash and cool the equipment to keep their motors running in the ashy, dusty, roasting atmosphere. Sprinklers fed by Mark III pumps kept the other neighboring piles wet and less receptive to spot fires. After the fourth day, no more spots were found. The consensus in the entire East Zone fire organization was that letting the mulch pile burn itself out within its footprint was the best course of action, rather than trying to extinguish it. Chris continued to have regular conversations with the Agency Administrator every evening through July 14th, providing updates on progress and again confirming that he was getting the resources he needed. Conditions on the ground for firefighters were worse than many of them had ever experienced. The hot summer days regularly exceeded 105°F, while two days reached a blazing 108°F. Temperatures on the site would have seemed much hotter, as the transfer station was barren, dusty, and swirling with ash. The fire beetles were a constant pest: “The more you sweat, the more they bit you.” The berms surrounding the transfer station eddied the winds, swirling ash and smoke disturbed by the heavy equipment. And this wasn’t regular wildfire smoke: because most of the combustion was smoldering, the smoke was “dirty”. The “It was almost like a giant pile of heavy equipment’s air filters had to be coals; that’s how much heat blown out several times during the day, and there was.” were replaced every shift. Sometimes yellow or green smoke emanated from the pile. When the wind blew the plumes of dust, ash, and smoke into the firefighters, it “felt like a sandstorm.” On top of it all was the noise – the loud irritating buzzing of the Mark III pumps, the racket of the heavy equipment moving and working, the beep-beep-beep of back-up alarms, all day long. Another pile began to spontaneously combust, but the

USDA Forest Service—Southwest Region—Coconino National Forest

firefighters patrolling for spots quickly identified it and were able to dismantle and cool that portion of the pile. During the hottest couple of hours of the day, firefighters retreated into air-conditioned cabs of equipment and engines, sometimes struggling between the need to urinate and their aversion to the awful conditions outside. At some point, dozer operator Jesse thought, “Was the juice worth the squeeze?” The longer they worked on the pile, the smaller it got, but the hotter it got also. Whenever he disturbed the surface of ash and mulch underneath his machine, a plume of hot ash and unburned particulates billowed around DZ-1 and immediately flashed with fire as it mixed with the air. Firefighters said as the equipment worked, they could feel the ground shaking from 60 feet away, even inside trucks. They had never felt the ground shake that far away from heavy equipment before. On July 15, a transition occurred from ICT4 Frank to COF firefighter Tom as the qualified ICT4, with Chris staying as trainee. Tom would remain with the fire for the duration of this story. The Agency Administrator role was transferred to Patricia, the unit District Ranger, on the 15th as well, with a site visit to give the AA a chance to build situational awareness and understanding of the operations on the Mulch Fire. This visit made several on the fire feel like their current operations and the risk was understood and shared by the Agency Administrator.

July 18 to July 20: “We Started Getting More Aggressive with Water”

The ninth day of operations on the Mulch Fire began just as the previous week. By this point in the fire, air filters on the dozer were being changed twice a day due to the amount of ash and dust. Sometime during the day on the 18th, however, firefighters from one of the engines noticed that when spraying water to cool the equipment, the overspray onto the pile reduced the smoke wherever it hit. After days of awful smoke and ash in the air, they finally found a way to make the Mulch Fire less miserable to work on. For the first time since July 10, the approach to the fire changed. At the end of the day, July 18, Chris received a resource order to a nearby fire on the PNF, leaving Tom as the sole IC of the Mulch Fire.

USDA Forest Service—Southwest Region—Coconino National Forest

Soon after engaging with hoses on the mulch pile, firefighters discovered they could straight stream with their 1.5” nozzles and cool the surface, sometimes boring holes into the layers of hot, semi- combusted fuel and ash below. Water use was more than 20,000 gallons per hour, but the heat of the smoldering mulch was so much that it caused deep pools of water to sustain a rolling boil even after a firefighter walked away from it. The hottest area of fire was now the area outside the original pile footprint that machinery had been using for days as an area to spread out smoldering mulch. This entire area was a uniform expanse of hot white ash just slightly above ground level, which firefighters left to burn out. The original pile itself was only a few feet tall now and cooling it with hoses seemed to be working. A firefighter working the Mulch Fire It finally seemed like the end of the Mulch Fire was in sight. They could mop up what remained of the original pile with huge amounts of water, and let the hottest area burn out. With Tom overseeing operations and firefighters spraying water directly on the pile, the next several days developed a new pattern: Spray water on the Mulch Fire in the morning, leave it to burn down through the heat of the day, and return in the evening to drench it again. As other fire activity picked up on both the COF and PNF, this lower level of engagement seemed

USDA Forest Service—Southwest Region—Coconino National Forest

more appropriate. The Mulch Fire was finally, after eleven long days, on the glide slope towards containment.

Drone photo of the Mulch Fire on July 18 For the better part of two weeks, Mulch fire resources had taken an unusual problem and worked through it over time. They consulted Google, they experimented and adjusted. They had a plan to put the fire into patrol status on July 23rd.

July 21: Just Wet it Down and Monitor

When Central Arizona Fire and Medical Authority (CAFMA) Engines 12 and 42 first arrived on scene of the Mulch Fire, they really didn’t think much of it. Like any fire, it had its hazards, but what had been a 20-foot tall pile of smoldering mulch was now “a two- foot high blob of black ash.” It seemed out, or at least, very little threat. The objective for July 21st was to wet it down and monitor. The CAFMA engines were assigned to remain IA ready for the Verde Valley Zone from the Mulch Fire, and these operations were planned to continue until the 22nd. They were covering behind other engines that were assigned to a new initial attack start. Forest coverage had fallen below drawdown, so the engines were called from Prescott Valley to respond to any new starts on the Forest. Until receiving an in-briefing at the Verde Ranger District office from Tom, it hadn’t crossed the minds of any of the CAFMA firefighters that they would be engaging on the Mulch Fire. Tom directed the engines to come up and stage for IA from the Mulch Fire.

USDA Forest Service—Southwest Region—Coconino National Forest

The Mulch Fire roughly as it appeared July 21 Once on scene, the CAFMA engines received a quick briefing from Tom. Captain 12, Greg, reiterated their assignment to serve as IA response for the East Zone. Everyone on the fire remained in their air-conditioned vehicles to finish lunch, and afterward this lull continued, with no activity around the fire at all. The slow tempo of the day made Greg antsy, and after lunch he told his guys they would take the opportunity, with all this wildland equipment around, to do some training. His newest crewmember, Robert, had only 5 months in the department, and was “hungry, ravenous” to learn the job. They sprayed their entire tank through their new engine’s bumper monitor, then went through a drafting exercise on one of the four portable tanks to refill it. Then they taught Robert how to start the notoriously tricky Mark III pump. With the pumps running and hose lays charged, Tom continued the same tactic from the previous days. The CAFMA firefighters followed suit, grabbing nozzles and mimicking the technique the Forest Service firefighters had developed. Their perception of a benign, smoldering pile immediately changed once the pumps were buzzing and

USDA Forest Service—Southwest Region—Coconino National Forest

water started flowing. When the stream from the 1.5” hoses penetrated the ashy-mud crust on top, it instantly boiled. Steam explosions propelled dust, ash, embers, and rocks at least 20 feet in the air, where they sheared off in the wind like smoke columns. Particulates rained back down, falling down Robert’s shirt and giving him small superficial burns. The heat was deep and intense. The morning briefing had identified footing as the number one hazard on the incident. The CAFMA engines adapted their structural firefighting training for walking on roofs to this very different surface they were standing on. Some noticed their boots occasionally sink into the ash, but only a few inches. Tom was out in front of all of them, but not far away. The ground he was standing on “looked like concrete.” In the last 11 days, firefighters had sprayed approximately 500,000 gallons of water onto the Mulch Fire. Over the next hour, all seven CAFMA firefighters from both engines rotated through spraying water and cooling down in their trucks’ air conditioning. The mulch pile sat in the sunbaked center of a county transfer yard, the temperature climbing to 104°F. Greg was standing just out of the pile area, watching operations in a lookout role. He had an unobstructed view of the activities of all the firefighters on the Mulch Fire. “There was a thick crust from all that Tom was moving carefully through the water—Tom just found the soft spot.” ash, spraying water. He paused for 15- 20 seconds scanning the area for heat when his right leg sunk to his knee through the crust. He stepped out only to have his left leg sink in deeper, pulling the right leg back in. Greg watched as Tom suddenly disappeared up to his belly button in an ash pit. As he sank, his arms shot out to the ground in front of him and he screamed in pain. He was in the hole less than four or five seconds before he pulled himself out and started “log-rolling” out of the blistering-hot pit, his helmet falling off as he extricated himself.

USDA Forest Service—Southwest Region—Coconino National Forest

Circle is general area where Tom fell through – yellow flags indicate his Greg held out his hands, palms helmet (left) and radio (right). facing Robert. Everyone was screaming, “Stop!” but with the persistent loud drone of the Mark III’s or the adrenaline in his system, Robert just didn’t hear their shouts or see Greg’s “stop” signal. He “high- stepped” through the same area of intense hot ash Tom fell into, powering through the deep ash, water, and embers to reach solid ground next to Tom. Everyone on scene responded to assist the two burned men. One moved around the outside of the mulch pile, running on solid ground to where the two men stood. Robert and Tom were assessing their injuries. Tom had removed his shirt, pants, socks and boots to examine the extent of his injuries and to keep his clothes from sticking to his body. After Tom assessed his injuries, he walked back to his truck where he then received medical attention. The engine overhead had quickly determined a command structure for the incident- within-an-incident (IWI). Another CAFMA captain was IWI IC, and Greg’s engine boss trainee handled communications, while Greg remained with the firefighters receiving medical care. After a quick discussion of going through the Medical Incident Report (MIR) over the radio with Flagstaff Dispatch, it was decided that the simplest and fastest way to obtain medical evacuation was by simply calling 911. They requested two ground ambulances through 911 emergency dispatchers. While the medevac was being requested, treatment of the two firefighters had begun as soon as they had self-extricated to the back of Tom’s pickup truck. They began cooling the burnt skin with water bottles with holes punched through the caps. Limiting the flow of cold water onto the firefighters kept them from cooling too quickly. Both men also received IV fluids within 10-15 minutes of initial injury, with Tom receiving the bag of lactated Ringers, the preferred fluid for burn injury fluid replenishment. With patient treatment started and medevac set in motion, the IWI IC drove out to meet and direct in the ambulances as they arrived. Once on scene, CCFD medics conferred with Greg and decided to elevate mode of transport to two air ambulances: one for each injured firefighter. Tom was loaded into the first helicopter about 20 minutes “I told Copper Canyon I thought they later, with Robert on the next helicopter. both needed air evac, but that I was Both firefighters were in-bound to emotionally invested, and it was their Maricopa Burn Center in Phoenix. call.”

USDA Forest Service—Southwest Region—Coconino National Forest

The string of notifications had begun – from the firefighters on scene to the duty officer to dispatch and FMOs. There was some confusion about the extent of injuries at the highest levels of COF management, but the most important elements for the firefighters worked like clockwork. While they flew to Phoenix, the COF “Care Team” began spooling up to support Tom. Run like a modified ICT3 organization, the team includes a hospital liaison, and experts in administrative and logistical support for an injured Federal employee. Meanwhile CAFMA and the International Association of Firefighters (IAFF) rallied in support of Robert. Robert’s less widespread, less severe burns responded quickly to treatment at Maricopa Burn Center and his recovery is already underway. Tom has a longer road ahead. Doctors estimate at least a month in the hospital, followed by up to a year for full recovery.

USDA Forest Service—Southwest Region—Coconino National Forest

Sensemaking and Learning Opportunities

How in-the-moment decisions and events made sense to those involved, and what we can learn from them. Decision makers very rarely have the luxury of knowing all available information when faced with complexity and uncertain outcomes. They must make decisions based on predictions and the anticipated trajectories of events that have yet to unfold. Outcomes are never guaranteed and they have varying degrees of uncertainty based on many factors that interact within dynamic environments. Decision quality and luck (good and bad) combine to form outcomes. In order to study and learn from unintended outcomes, it is important to separate decision quality from luck. By focusing on the decisions that were made, with the information that was available at the time, we may gain a better understanding of the situation and enable learning (rather than judgment). We must also remain mindful of the effect of hindsight bias. It is often easy to look back and connect “dots” that were not apparent in real-time, and to make a judgment (e.g. that was a bad decision). In order to learn from past decisions we must suspend judgment and, instead, try to understand how things made sense at the time – and leading up to – unintended outcomes.

What Went Well

 Firefighters that worked on the Mulch Fire realized that the environmental conditions (smoke, heat, bugs, etc.) were a very real concern. Because of that they rotated personnel in and out of those conditions regularly, to minimize any one person’s exposure to the outside conditions. They also rotated which engines were assigned to the fire, to minimize the exposure of any one engine module.

 All overhead personnel early on realized the need for heavy equipment, which was ordered and received in a very timely manner. Use of the equipment was necessary with the overall plan of the fire and to reduce exposure to firefighters.

USDA Forest Service—Southwest Region—Coconino National Forest

 Firefighters on the Mulch fire recognized that they were in a hazardous situation. Due to the hazards they discussed various scenarios that they could encounter during the incident (i.e., rescuing an operator from his machine in an emergency, placing sprinklers around the perimeter of the piles to reduce the likelihood of spot fires, etc.)

 Many of the firefighters and equipment operators felt that there were good daily briefings and that they had clarity on tactics and objectives.

 The day the injuries were sustained, the medevac procedure was very fluid and quick. Having paramedics on- scene was a huge advantage The use of equipment and sprinklers on the Mulch Fire for the injured firefighters.

 The Hospital Care Team assembled served an instrumental role in assuring the families of the injured firefighters had all logistical necessities taken care of. Additionally, this support has been of great value to the families and the other firefighters to see that no firefighter will stand alone.

 The Hospital Care Team instituted a no identity, no profile protocol (NINP). This essentially eliminated access to the victim without a password, and helped protect the victim and his family.

Setting the Tone

The FLA Team noticed that the tone for the Mulch Fire was set early as a “nuisance” or “headache” and affected how personnel viewed this fire. Without intention you can label events or incidents in a way that has a negative or less than positive connotation. The Mulch Fire made people groan from the beginning and everyone seem to know that it was going to be a long miserable event. Agency Administrators viewed this fire through what they were hearing from the IC until the mid-point in the incident when the local district ranger was able to get out on the

USDA Forest Service—Southwest Region—Coconino National Forest

fire. They were told environmental conditions were tough, it was going to take a long time, and that they had a plan to let it burn itself out. Firefighters viewed this fire from the ground and understood it was going to be a challenge. It was at a transfer station on a very hot and dry sight and in an unfamiliar setting. The terrain, environment, and fuels were not familiar and it was not going to be an “enjoyable” fire. Fire Leadership had their own view of this incident and knew it would be long and tough. It seemed like they started down the right path and had a reasonable approach to the incident. There was a lot going on around the Forest at the time and this did not seem to be the most pressing incident nor did it seem at first glance to be overly complex.  Firefighters on the Mulch Fire knew this was not a high-profile fire for the Forest and that it was not seen as a major threat compared to other fires on the Forest.  How do firefighters communicate that something viewed as a nuisance is really complex and that they may not understand all of it? If they had concerns, how would they be received?  With the tone set would agency administrators consistently see a sense of urgency to make field visits and to really inquire about the tactics, strategy, and exposure to firefighters?  If the tone is this is a nuisance fire and not a threat does it encourage fire leadership and agency administrators to engage in robust discussions on values at risk, incident objectives, turn back standards, etc? What can you do to make sure that all incidents or events involving a firefighter response are treated as meaningful work by both the firefighters and unit leadership?

Common Operating Picture

After conducting interviews with all personnel involved on the Mulch Fire it became clear that there was not a common operating picture throughout the organization. What does “intent” mean to different people? If you ask firefighters if they have received leader’s intent, they will likely reflect on the morning briefing and tell you that they received task, purpose and end state for the day’s shift from their supervisor. But, where did the supervisor receive his or her intent? In theory, intent should be developed by the Agency Administrator in consultation with Fire Management, then flow to the Incident Commander, module leaders and to the firefighters. However, this communication chain requires some interpretation and translation (AAs are not likely to provide the same scope of task, purpose and end state for the ‘boots on the ground’).

USDA Forest Service—Southwest Region—Coconino National Forest

Agency administrators did not have a clear understanding of what this fire was or what the approach should be in the beginning. There were conversations between the IC and the agency administrator daily about what the fire was doing and our approach to it but they did not have a “slide reel” to fall back on creating a clear picture. On July 15th the agency administrator made a site visit and got a clear picture of what they were doing to spread the pile out and let it burn itself out. Once they started to get aggressive with water the agency administrators again did not have a clear picture of what was happening on the ground. Operators on the ground had a variety of experiences with this fire and their picture was a snapshot of the entire event. Operators at the beginning experienced putting line around the fire and pulling other fuels away from the main fire to prevent spotting. The next group of operators experienced a heavy equipment show where they were pulling the pile apart and spreading it out to enhance burning. Another group was involved in trying to smother the fire with water and experienced the fire as a large ash pile that was greatly diminished in size from its original state. Operators on the ground had a clear view of the operations they were part of and felt they had clarity on objectives and leader’s intent for the period they were on the fire. Fire management on the Forest had a different view into this fire from where they were sitting. The Forest Duty Officer visited the site and felt the response was appropriate and the strategy of pulling it apart and let it burn out was the right way to go. Use heavy equipment and reduce exposure to firefighters. Once the pile burned down Fire Management at the Forest level understood they would put the fire into patrol and monitor status.  This incident had periods where everyone had a clear picture of what the operating picture was. However, it was a prolonged incident which had periods where there was not a common operating picture among all personnel involved.  When there is not a common operating picture it is not possible to maintain shared risk and to have clear Leader’s intent throughout the organization.  It is not uncommon for the operating picture to shift on a fire due to the dynamic nature of the work firefighters do and the environment they work in. Communication is critical for everyone to gain and maintain that common operating picture.  For a unique event such as the Mulch Fire there really is no baseline or common understanding of what they are going to do operationally, no common understanding of what the turn back standard is, and a lack of overall understanding of options or approach.  For a more routine type of fire there is a common level of understanding what to expect due to the letter of delegation from the Forest Supervisor to the IC’s for all type 4 & 5 fires.

USDA Forest Service—Southwest Region—Coconino National Forest

 Fire management feels that upon reflection a letter of delegation on this incident would have been appropriate and helped everyone gain a more common operating picture and leader’s intent.  A delegation letter would have provided intent that would help the ICT4 and trainee develop objectives with the Agency Administrators and Fire Staff to ensure the common operating picture was shared at all levels of the organization.  Transitions at many levels of the organization were part of the story on the Mulch Fire and contributed to the lack of common operating picture. What can you do on unique events like the Mulch Fire to gain and maintain a clear operating picture throughout an incident?

Complexity

What makes an incident complex? Is it fire behavior – driven by fuels, weather and topography? Is it socio-political concerns or proximity to WUI? What about a lack of familiarity with localized or situational factors? For example, if a module from Central Idaho’s Salmon River Breaks was inserted into Southern California’s WUI environment (or vice versa), would an incident’s complexity level or the responders’ comfort levels change? Complexity and expertise may be intertwined. A highly experienced Type 3 IC from one location may be very uncomfortable in another. Yet, qualifications and complexity analyses may not reflect this reality. Fire managers stated that a delegation letter specific to the Mulch Fire would have been helpful to set objectives from Line Officers and Fire Staff to the Incident Commander and Trainee. Is supplying a delegation letter to a Type 4 IC an indicator of complexity that is not captured in the Risk and Complexity Analysis? Does the complexity analysis firefighters use for wildland fires apply to a mulch fire? The firefighters all mentioned different challenges that were overcome. There wasn’t a sense among firefighters that things kept going wrong, but how do they track issues to determine when little things add up to something big?  Initial attack IC’s are trained to take on and adapt to obstacles and issues. Our resources get prioritized for a new start, the wind shifts, spot fires, snag patches, logistics issues, the list goes on and on. Wildland firefighters possess ingenuity and are problem solvers. They troubleshoot equipment, field repair needed items, and adapt and overcome.  Troubleshooting and repairing pumps and equipment that broke down, cooling off heavy equipment to keep it running, outflow winds, spot fires, smoke impacts to firefighters, the public, and roadways, and an unfamiliar fire situation are some of the challenges that were dealt with.

USDA Forest Service—Southwest Region—Coconino National Forest

 Sometimes a series of problems on a fire are just minor annoyances that need dealt with, but sometimes they are trends that are indicative of a problem within our strategy or tactics that need addressed.  How do you monitor all of the issues collectively during the incident to determine if they are isolated events or if they have evolved into trends?  When do obstacles become indicators of changing complexity? On incidents you don’t have a mental image of, how do you know the right questions to ask to ensure risk and complexity are understood? If we’ve determined that it is time to reevaluate the incident complexity, is the Risk and Complexity Analysis the right tool for an all risk incident?

Transition

In wildland fire operations, transitions with incident management organizations are typically approached with caution. Situational awareness and experience that has been developed by outgoing resources is difficult to comprehensively communicate with incoming ones. Information gaps are inevitable. During the Mulch Fire they transitioned from a Type 5 to a Type 4 IC on the first day and then brought on a type 4 IC Trainee to take the reins for the first nine days of the fire. Another qualified ICT4 took over the fire on July 15th, and he retained command of the fire until the accident occurred. The ranger from the adjacent ranger district was the agency administrator for the first five days of the fire until the district ranger returned. There was a different Duty Officer for the zone the first day and then a new one for the duration of the incident. The Forest Duty Officer changed twice during the course of the Mulch Fire.  Do our actions always continue through transitions? Transitions are normally a time for heightened awareness on an incident and there were several transition on the Mulch Fire among agency administrator’s, duty officers, and incident commanders.  While you shouldn’t reevaluate every incident action during every transition, you should ensure that the actions are supported by the incoming agency administrator, duty officer, and incident commander.  An ICS-214 is the standard documentation to record the daily events and decisions on a fire. There can be value in handing the 214 over to incoming resources during transitions to help paint the picture of what has been occurring on the incident and what decisions have been made. On incidents without a

USDA Forest Service—Southwest Region—Coconino National Forest

WFDSS decision, how do we track events and decisions at the Agency Administrator and Duty Officer level? How do you maintain leader’s intent and a common operating picture through the entire incident when there are transitions at multiple levels of the organization?

Understanding Why They Were There

While firefighters on the ground had a thorough understanding of why they were there and what was being asked of them each day many others and some firefighters asked the bigger question of “why were they there”. This may mean many things to different people but for this section the intended context is “what are the values at risk and is this our jurisdiction”. According to the agreement with the State of Arizona and the Coconino National Forest the Forest Service is responsible for fighting fires that are on National Forest System Lands. This fire was on National Forest System lands. The firefighters articulated this to fire leadership and the agency administrator and that was the course they chartered A complication on this fire was that the fire was within the boundaries of the transfer station run by Yavapai County and under a special use permit. The permit holder has a fire plan as part of their permit but it does not cover mulch piles so it defaulted to the Forest Service. However, it is stated in the permit that the permittee is responsible for all operations at that site including incidents as a result of their operations.

“Oh my God, I had no idea the  This incident was new to all those pile was that big.” involved including the agency administrators and/or line officers. Once the firefighters determined this was on National Forest System Land and our agreement with the State of Arizona indicated this was our responsibility they followed that course of action.  There was not clarity from the agency administrators on leader’s intent for this fire beyond reducing smoke where possible, pulling the pile apart, and letting the pile burn down. Once the pile burned down it was harder to understand the values at risk and what the objectives were.  The normal routine is that the agency administrator works with the IC and their fire management staff to determine a course of action after they get past the initial burn period or initial attack phase of the fire. On the Mulch Fire the agency administrator was more or less approving the plan.

USDA Forest Service—Southwest Region—Coconino National Forest

 The FLA Team did not hear of any discussions between the permittee and the line officers about what their role was. It was never determined what role the permittee had to resolve this incident.  It is appropriate for us to have responded to this incident and to take some initial action. It is easy to understand why they were there.  The firefighters did their job and fell back to our letter of delegation and our agreement with the State of Arizona. Without a change in direction from the agency administrator the course will likely stay the same. Do you have to take on every incident that occurs on agency land? What is the permittee’s role to resolve the incident and how is that determined?

Bias for Action

Bias for action is a trait that is embraced and celebrated in the wildland fire culture, and it is a positive attribute in most situations. Most people in the profession either have it or quickly acquire it. It becomes second-nature, like a wildland “They are firefighters, they are going to firefighter heuristic that guides us want to attack it.” towards action (there is always something that we can be doing). But, there may be instances when inaction or disengaging may be a better option. The problem with this is twofold: (1) it is culturally counterintuitive; and (2) there are rarely clear signals for when it is appropriate.  While firefighters frequently reduce risk and exposure over a longer period of time by taking prompt action to stop an immediate threat, once that threat has been stopped, a tactical pause can determine what the right course of action for a new type of operation may be.  Operating under a pre-season delegation letter for Type 4 and 5 Incidents is normal for firefighters, and generally directs full suppression for most fires. If a new delegation letter is not provided, firefighters will likely continue to operate with actions directed towards a full suppression/100% out end state. If they are engaged with a different type of incident, is 100% out still the right action?  Agency administrators play a part and should be directing or helping to develop a plan for all actions beyond the initial attack phase of an incident. There is a significant role for the agency administrator to play evaluating different options at key decision points or transition points during an incident. How can one continually explore options that require minimal action to achieve the desired results and reduce exposure to firefighters throughout an incident as it evolves?

USDA Forest Service—Southwest Region—Coconino National Forest

Did They Have the Training to Take This On? Line officers to firefighters on the ground asked this question to themselves throughout the incident and after; wondering if they were the right ones to respond. The environment our firefighters work in is dynamic and often changing. It is hard to understand if our training is applicable to something like a mulch fire; especially when they regularly burn piles of slash and debris. Without formal training it is not possible to understand all of the intricacies of tactics needed, what the tradeoffs and benefits of specific actions are, what the hazards are, and what the appropriate personal “If you have to Google how to fight protective equipment is for something the fire, you’re not prepared.” like a mulch fire.

 All red-carded employees are trained in wildfire suppression tactics and basic fire behavior during S-130 and S- 190. That training serves us well; however, not every fire may fit within the bounds of our experience or training. What do they do when they recognize something different? Many firefighters, managers, and line officers expressed their lack of knowledge when it came to dealing with such an incident.  Firefighters on the scene fell back to basics. They removed the unburned fuel from the burning pile and worked to contain the pile from spreading with heavy equipment. Many firefighters used Google to search for appropriate tactics and information when it came to the Mulch Fire.  A lot of people who saw the site asked why they were there. Stopping and saying you may not have the skills, training, or experience to tackle a situation like this may help others also see the limitations in their training.  With some exceptions, wildland fire firefighters don’t engage on car fires or structure fires on agency land because they don’t have the training or equipment to safely engage. When they encounter a new type of incident that they aren’t familiar with, what steps should they take?

Do experts cease being experts when they are unfamiliar with tactics or specialized skills with which they lack experience?

USDA Forest Service—Southwest Region—Coconino National Forest

Special Use Permits

Several personnel on the forest questioned whether they had the responsibility to take the fire on, but there was no clear understanding of the role of the Forest Service or the Special Use Permit permittee. As a multi-use land management agency, special use permits are present on almost every forest for a variety of activities. In the case of the Mulch Fire nobody had a clear picture of what the agency’s responsibility was at this transfer station. The Forest Special Uses Administrator had retired almost a year earlier, so that expertise was not available to firefighters. It is the line officer’s role to determine who is responsible for what at a site where a special use permit is authorized. This should be spelled out in the permit but “Regardless, it was on FS land so we sometimes conditions are different on the had to deal with it.” ground which may need further interpretation from the line officer.  Authorized Uses – Does everyone understand what activities are allowed under the permit? Do you have an understanding with the permittee who is responsible for what at the site under permit?  Fire Plan – Does the permit require a fire plan and is it appropriate for the activities authorized? Does it cover all aspects of their operation and clearly articulate what the permittee’s responsibility is?  Special Use Permit – Is the permit on your unit up to date? Has the permit been administered to standard?  Communication – Have there been conversations with the permit administrator, district ranger, and other disciplines (i.e. fire) about what activities are permitted on the unit and what plans are in place to deal with them? Do you have sites operating under a special use permit in your area that you may have to respond to?

Be “That” Person

Many of the firefighters, equipment operators and other personnel involved with this incident commented that there were things that did not seem right, were “I should have asked more pointed risky, and/or were unhealthy but did questions.”

USDA Forest Service—Southwest Region—Coconino National Forest not voice those concerns or at least not in a way that was clearly understood.  This is not a new issue or concept for the Forest Service. Significant time and resources have been placed on improving this with the culture of the organization. However, this is not easy and is a challenge even for the best organizations. Understanding that it may be hard to be “that” person is critical for leadership and individuals at all levels of the organization.  Many times individuals voice concerns in ways that don’t effectively communicate the issue or concern. It is important for individuals to use “clear text” when bringing up concerns so that it is clearly understood. In addition, it is important for leadership to seek understanding when individuals are giving cues that they have concerns.  There is no one way to address this issue and what works at one level of the organization may not work at the next level. Today’s concern may not be the same concern tomorrow as the incident changes over time, space and complexity. Regular reviews of the leader’s intent, what the risks are, the tactics, and options to achieve the desired outcomes may be a way to create space for concerns to be voiced. However, the culture may have the greatest impact on how and if these concerns are raised. How can you be deliberate about creating space for firefighters to share concerns from start to finish on any incident you take on?

Smoke

All individuals working and visiting the Mulch Fire expressed concern with the smoke density, color, and possible toxins within it. The mulch pile consisted of agriculture waste (manure, stable shavings), yard debris, and unseparated slash at the time of the fire. According to a local engine engaged in suppression duties, they encountered yellow smoke at times, so firefighters stayed in their vehicles. How do you share risk from the bottom up when you encounter smoke that is yellow in color?  Operators driving the heavy equipment noticed that the pile was “Was it unsafe; a little. Was it not just wood chips and slash, but unhealthy; absolutely.” also contained plastic and other materials. What started as a mulch fire may have been an ‘all risk’ incident. Does changing the name of the incident from wildfire to all-risk trigger a different response?

USDA Forest Service—Southwest Region—Coconino National Forest

 Being exposed to smoke is normal during wildfire operations, but should there be more training specific to firefighter health? Why do firefighters need to wait until they are qualified enough to take Rx-410 to receive training specific to smoke?  Communicating the site conditions including health exposure of personnel can help leaders understand and share risk with those on the ground. Does smoke cause you to change tactics and strategy, and if so what are the trigger points?

USDA Forest Service—Southwest Region—Coconino National Forest

Appendix A – Timeline

USDA Forest Service—Southwest Region—Coconino National Forest

Appendix B – PPE Report

U.S. Department of Agriculture, Forest Service, National Technology and Development Program (NTDP), Personal Protective Equipment (PPE) Report: Mulch Fire—Firefighter Burn Injuries On July 21, 2019, two wildland firefighters received burn injuries while performing wildland firefighting operations on the Mulch Fire, Coconino National Forest, AZ. This personal protective equipment (PPE) report is based on a site visit, interviews, and a visual examination of the equipment. Site Description The Mulch Fire occurred on a site previously used as a dump. The fire burned in a mixture of organic woody materials and trash (metals, plastics, etc.). Firefighters used heavy equipment to pull the mulch pile apart and allow the materials to burn out. The area where the accident occurred contained deep ash, described as “moon dust” (figure 1).

USDA Forest Service—Southwest Region—Coconino National Forest

Figure 1—The Mulch Fire accident site. The circle indicates the area where the firefighters fell into the ash. Accident Sequence Firefighter 1 was spraying water onto burning ash when his right leg sank up to the calf into the surface on which he was standing. He felt instant burning and shifted his weight to his left leg to pull his right leg up and out of the ash. Both legs sank deeper into the ash. He continued to sink into the ash until it was above his waist, almost belly deep. He shuffled his feet and turned around 180 degrees, toward solid ground. He lost his balance and fell forward onto his forearms, but was able to kick his legs and extract himself from the ash. He estimated he was immersed in the ash for about 4 to 5 seconds. Firefighter 2 saw what was happening and ran toward firefighter 1 to provide help. Firefighter 2 ran through a section of the ash, burning the lower portion of his legs. Injuries Firefighter 1 Abdomen: second-degree burns

USDA Forest Service—Southwest Region—Coconino National Forest

Left and right forearms: second-degree burns Back of left and right hands: second-degree burns Left and right legs: third-degree, circumferential burns Firefighter 2 Right lower leg: Partial-thickness (second-degree) burn (figure 2)

Figure 2—The right leg of firefighter 2, showing the partial-thickness (second-degree) burn injury received on the Mulch Fire.

Materials, Temperatures, and Characteristics

Material—Conditions and Corresponding Temperatures: Aramid cloth dye–sublimation 450 °F Chinstrap dye–sublimation 425 °F

USDA Forest Service—Southwest Region—Coconino National Forest

Human survivability—airway 300 °F Human skin—second-degree 131 °F blister

Equipment Analysis, Firefighter 1 Helmet  Bullard FH911H with flame-resistant (FR) chinstrap o Missing retroreflective strips  Manufactured 01/2016

The helmet was recovered from the site 2 days after the accident, lying in the ash where it landed after falling from the firefighter’s head. The helmet shell and suspension showed no visible indications of exposure to high temperatures. However, the chinstrap had dye-sublimation (change in color) on the exposed surfaces. The firefighter had stowed the chinstrap on the front of the helmet, above the brim. The dye-sublimation most likely resulted from the helmet lying in the ash for a couple of days after the accident (figure 3).

Figure 3—The helmet worn by firefighter 1, showing dye-sublimation (rust-colored area) on the chinstrap. FR shirt  Forest Service Specification 5100-91F

USDA Forest Service—Southwest Region—Coconino National Forest

 Manufactured 08/2005  93 percent meta-aramid, 5 percent para-aramid, and 2 percent carbon core

The shirt worn by firefighter 1 had visual indications of exposure to high temperatures on the front, right outside, and inside surfaces of the cloth. The outside of the shirt had a 2- by 4-inch area of dye-sublimation (figure 4). The inside surface had a 6- by 8-inch area of dye-sublimation (figure 5).

Figure 4—The front outside surface of the shirt worn by firefighter 1. The circle indicates the area of dye-sublimation (white discoloration) below the right pocket.

USDA Forest Service—Southwest Region—Coconino National Forest

Figure 5—The front inside surface of the shirt worn by firefighter 1. The circle indicates the area of dye-sublimation. FR pants  Forest Service Specification 5100-92G  Manufactured 08/2006  93 percent meta-aramid, 5 percent para-aramid, and 2 percent carbon core The pants worn by firefighter 1 had visual indications of exposure to high temperatures to the outside and inside surfaces of the FR cloth. The areas on the seat, near the crotch, both knees, and the cuffs had dye-sublimation to the fuzzing (early stage of fabric pilling). Fuzzing areas on the inside of the pants below the knees and near the cuffs also showed dye-sublimation. Some of the dye-sublimation on the cuff cloth may have resulted from previous exposure to high temperatures. The majority of the dye-sublimation, especially to the fuzzing, most likely occurred during this accident (figures 6 and 7).

USDA Forest Service—Southwest Region—Coconino National Forest

Figure 6—The outside surface of the front of the pants worn by firefighter 1. Arrows point to areas of dye-sublimation (orange discoloration) to the fuzzing and FR cloth.

Figure 7—The outside surface of the back of the pants worn by firefighter 1. Arrows point to areas of dye-sublimation to the fuzzing and FR cloth. Gloves  MTR wildland firefighting gloves, leather  Not worn, no visual signs of high temperatures

USDA Forest Service—Southwest Region—Coconino National Forest

Boots  White’s Smokejumper  12-inches high (figure 8)

Figure 8—The boots worn by firefighter 1.

Equipment Analysis, Firefighter 2 Pants  Forest Service Specification 5100-92L  Manufacture date not present  93 percent meta-aramid, 5 percent para-aramid, 2 percent carbon core

The pants worn by firefighter 2 had visual indications of exposure to high temperatures. The front of both legs, starting below the knees and extending to the cuffs, showed signs of dye-sublimation. The area of dye-sublimation on the right leg was 6 by 10 inches. The back of the pants had a ½- by 2-inch area of dye-sublimation, with one small spot near the cuff. The left leg had a 3- by 4-inch area of dye-sublimation. The

USDA Forest Service—Southwest Region—Coconino National Forest

inside of the pants had small amounts of dye-sublimation to the fuzzing and stitching at the cuffs (figure 9).

Figure 9—The outside surface of the front of the pants worn by firefighter 2. Arrows point to areas of dye-sublimation (orange discoloration) below the knees on both legs.

Boots  Zamberlan Extinguisher II WLF

The right boot had visual indications of exposure to high temperatures on a small section of the laces, most likely caused by the accident (figure 10).

USDA Forest Service—Southwest Region—Coconino National Forest

Figure 10—The boots worn by firefighter 2. An arrow on the right boot points to a spot of dye-sublimation on the bootlace. Summary The firefighters’ PPE had visual indications of high temperatures. Temperatures of 450 °F or more cause the dye in the cloth to change color. The shirt worn by firefighter 1 and the pants worn by both firefighters had dye-sublimation on the outside and inside surfaces of the cloth, indicating that temperatures of 450 °F were present on both the inside and outside surfaces of the cloth. However, the dye sublimation was not full- thickness (dye-sublimation transferring through the fabric from a heat source on one side of the material). The outside of the PPE sustained the majority of dye sublimation, with the exception of the shirt worn by firefighter 1. Follow your agency’s requirements regarding wildland firefighting PPE. It is important to understand that different agencies have different requirements for the following PPE items:  Eye protection

USDA Forest Service—Southwest Region—Coconino National Forest

 Fire shelter  Gloves  Head protection  Hearing protection  Pants  Shirt  Wildland fire boots Interagency Standards for Fire and Fire Aviation Operations (Redbook), Chapter 7: Safety and Risk Management, provides a good source for determining wildland firefighter PPE requirements.