Nuts and Bolts – Again
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Winter 2020 ▲ Vol. 9 Issue 4 ▲ Produced and distributed quarterly by the Wildland Fire Lessons Learned Center 2019 Incident Review Summary Nuts and Bolts – Again By Travis Dotson For more nuts and bolts lessons from real- deal incidents, check out the 2019 Incident his issue of Two More Chains is about things you can do. Actions you can take. Review Summary. Wait, haven’t we done this issue already? Yes we have. (See our Winter 2018 issue of Looking for Refresher training exercises? T Two More Chains.) But guess what? We’re doing it again. Why? This review summary provides multiple exercises related to recent incidents. It’s a Partly because it’s been a whole year and we have a great source for both formal and informal bunch of new reports with new lessons. And also training. Please use it to stimulate dialogue because it’s a new year with new reports and some of among your peers: the very same lessons from previous years. https://www.wildfirelessons.net/viewdocu Hold on. If the Wildland Fire Lessons Learned Center ment/annual-incident-review-summaries (LLC) is getting reports of the very same types of incidents occurring after we put a bunch of effort into sharing the lessons about how to avoid that incident (for instance, the dangers of loose lug nuts) isn’t that proof that what we are doing isn’t working? Maybe. But we don’t often get reports from folks who actually use the lesson. Why? Because using the lesson likely prevents the event that triggers a report. Make sense? Unfortunately, our “win column” is therefore sparse and hard to populate. So here we are again with a handful of hard hits and close calls (see the main menu below). Take a look and cherry-pick the nuggets that pertain to you and the people next to you. Put the lessons to use. Then please send us a note so we can put a mark in our lonely win column. Ash Pit Burn Injuries – Hey, watch where you’re stepping wildland firefighter! Page 3 Losing Lug Nuts – Ever had one of your rear duals pass you on the highway? Page 4 Chainsaw Cuts – Stop the Bleed – Are you ready to manage a major bleed on the fireline? Page 5 When the Bad Thing Happens . – Are you really ready? Page 6 Also in this Issue Ground Truths – Want to move the needle? Read this! Page 2 LLC Staff Picks – Check out what incident reports we think you should know about. Page 7 One of Our Own – We can learn a lot from Brian Kliesen’s ‘Stop the Bleed’ training insights. Page 8 Your Feedback – Readers respond to Kevin Reese’s hit by tree—and the bureaucracy—story. Page 12 Ground By Travis Dotson Fire Management Specialist Wildland Fire Lessons Learned Center Truths [email protected] Moving the Needle hen I introduce myself at emails sent, signatures provided, miles meetings or training, I flown, presentations made, blah blah W often say: “I’m just like blah . Basic swivel chair scorecard everyone else here. My career path stuff. was Ops, Ops, Ops, Desk.” Eventually we get to the part where one A few folks chuckle, others frown. of us says: “At this level, we have to accept that our role is just to move the Some of us desk pilots don’t really needle.” want to admit that we somehow ended up on the bad side of the More nods. Then we move on to the hike/sit ratio. I try to be a realist. awesomeness of scheduling leave in August. (Let me tell you, it is amazing. There is no doubt that I spend more #LifeFirst.) time reading and thinking about incidents and accidents than I do So how do we move the needle? exposed to the danger under the Here are the steps: trees. So it is. 1. Identify Your Sphere of Influence. One lament I hear a lot from folks like me—those of us who a. Everyone has influence. If you are the have transitioned into management-sized pants or even Squad Leader or Engine Captain, you have national policy sized-pants—is that it’s tough to not see way more influence than you realize. To this discernable proof of progress or impact. The conversation goes day I am living by practices instilled in me something like this: by my first fireground mentors. Accept this Me: “How’s the new job?” gift graciously and use it wisely. Desky McPaperpush: “It’s good; it’s a challenge. It’s nice to get 2. Identify the Change. paid more. But I struggle with how long it takes to really make a. Find one lesson that applies to your sphere an impact.” of influence. (You might start with the ones in this issue of Two More Chains.) Me: “Yeah, I hear ya. Not quite like the immediate gratification of putting a tree right where you wanted it, huh?” 3. IMPLEMENT. a. This is the action part. Adjust your practice. Desky McPaperpush: “Exactly!” Lug nuts, soft stretchers, tourniquet This is where the recent advancer tilts their head to the side, training, emergency notifications, driving takes a deep breath and pauses for a beat. All to signal the SOPs—ACT on one of them. profound insight they are about to share with me. Then they 4. Repeat. release their wisdom: This moves the needle. “You know, back when I was on the crew, at the end of every shift I could look back and count the chains of line we put in or The process does not vary for different levels of the mopped-up and note the progress toward the stated objectives. organization. I never realized how deeply gratifying that was.” The big needle is made up of all the little needles. Find one and I nod slowly in genuine empathy and social nicety, giving the move it. impression I have never heard anyone say these exact same Swing on, Tool Swingers (and Spreadsheet Ninjas). words before. Then we usually joke about different measures we could substitute for chains of line: minutes on conference calls, 2 Ash Pit Burn Injuries There were a total of 10 burn injuries in 2019 that occurred when firefighters stepped or fell into ash pits. These instances occurred during mop-up, saw operations, and scouting. The stories and lessons that are available on this page just might help keep you out of the burn center. When the swamper stepped and reached for a Mulch Fire Ash Pit Burn FLA chunk of birch tree on the black side of the dozer line, his foot sunk into a hot ash pit, approximately 18 inches deep. As the swamper attempted to extricate himself, the sawyer stepped toward and reached for the swamper to help pull him out. They both sustained burn injuries to their lower legs. Swan Lake Burn Injuries “When injuries occur, we assess, stabilize, package, LESSONS transport and hand-off patients to a higher level When setting work priorities, ask yourself if you of care. But, then what? really need to be there – is it worth the risk? What (or who) determines the level of Be aware that the risks with ash pits are often care and location of not visible and may extend well beyond the treatment(s)? Can we immediate area. influence the process, and perhaps the Scout areas and use probes to test for extent outcome?” and depth of ash beds. From the Swan Lake A firefighter assigned to the Burn Injuries RLS Alaska Ash Pit Burn Injuries Martinez 3 Fire received 2nd and 3rd degree burn injuries below both knees. The firefighter, assigned to a Type 3 Engine on the incident, was performing suppression duties in an area of deep vegetation (duff) Where’s material, when he stepped into an the pulaski ash pit, sunk to his waist, and received injuries. handle? Martinez 3 Fire Burn Injury Firefighter shows the depth of an ash pit that was found on the line of the McKinley Fire. Handout: Hazards on the Line – Ash Pits Pose a Significant Risk to Firefighter Safety 3 Loose Lug Nuts In 2019, loose lug nuts resulted in one near miss and one dual wheel set bouncing through traffic on two Ford 550 Type 6 Engines within two days in the Rocky Mountain Region. The crew members in the Chase Truck were surprised to see the rear wheels start to wobble. They tried both the radio and the cell phone, but were not able to contact the Engine before the dual wheels came off. Rotor resting on pavement. Notice bent studs on the left. The Two Rocky Mountain Region Engine Lug Nut Incidents RLS Lessons Learned by the Operators Carry a torque wrench on each Engine and tighten to the specified torque frequently after changing a tire. Tightening lug nuts with a lug wrench or breaker bar may give the false impression that they are tight enough. Look for wear and stretch in studs. Rotate the spare tire into the tire rotation schedule to create even wear on all the tires. More Lessons from This Lug Nuts RLS: Loose lug nut indicators will be installed on some engines to evaluate their usefulness. For more information, watch the video found here: https://youtu.be/sfgfps4ouGU. Torque specifications will be posted on vehicle dashboards. This Has Happened Before! More Lessons on Lug Nuts Three incidents from 2017 in which the wheel lug nuts came loose or fell off and the operators submitted an RLS or a SAFENET on the incident: o Mile 0 Rx Fire; o Long Valley Fire; o Type 6 Engine Wheel Stud Malfunction RLS.