Monument Springs Fatality Facilitated Learning Analysis

Lincoln National Forest Sacramento Ranger District

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Contents

1. Leader’s Intent………………………………...………………… 3

2. Executive Summary………………………………...…………… 4

3. Background……………………………...……………………… 5

4. The Accident Narrative…………………………………………. 8

5. Monument Springs FLA Timeline……………………………… 15

6. Lessons Learned and Observations – Shared by the Participants……………………………………… 16

7. Organizational/Process Improvements – Lessons Learned………………………………………… 19

8. Facilitated Learning Analysis Team Members…………………. 20

9. Process Coach……………………………...…………………….20

10. Appendices Appendix A – Six Minutes for Safety: Fatigue/Stress…. 21

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2. Leader’s Intent

On May 14, 2013 Gilbert Zepeda, Acting Regional Forester of the Southwestern Region, requested a Complex Facilitated Learning Analysis (CFLA) be conducted to investigate the death of Daniel Davidson while on duty on the Lincoln National Forest, Southwestern Region according to the FLA process including:

 Follow the procedures displayed in the 2013 Facilitated Learning Analysis Implementation Guide.

 A review and description of the conditions leading up to the accident.

 Lessons Learned from the accident.

 Recommendations on how to prevent such an event or improve outcomes and processes.

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2. Executive Summary

The involved participants took swift action to save the life of their Crewmember, and in the aftermath, took measured steps to ensure that the family and

coworkers of the fallen Crewmember were cared for.

On May 5, 2013, while on a patrol hike in the Sacramento Mountains, a Crewmember from a Type 6 Engine collapsed and became unresponsive while ascending a hill in the Monument Canyon drainage. The Engine Captain and Engine Operator accompanying him went immediately to his aid, performing Cardiopulmonary Resuscitation (CPR) and rescue breathing.

A medevac flight, dispatched to their location by the Alamogordo Interagency Dispatch Center, arrived within 30 minutes. Once on scene, the medics assumed care for the Crewmember, administering Automated External Defibrillator (AED) shocks and epinephrine—and continuing CPR.

After a little more than one hour from the time of the Crewmember’s collapse, resuscitation efforts were halted under the order of the physician with medical control.

In the ensuing hours, the remainder of the Engine Crew awaited the arrival of the Sheriff and medical investigator. Because of privacy concerns, the Engine Crew decided not to state the name or the Forest Service affiliation of the Crewmember over the radio.

A critical incident stress debriefing was conducted by an interagency team from within the Geographic Area.

Representatives from the Engine and the District accompanied the body of the Crewmember to his hometown for burial.

Final Cause of Death The final cause of death was ruled as cardiac arrest related to dilated cardiomyopathy, an enlargement of the heart in the left ventricle that reduces the circulatory capacity and can affect persons of all ages without symptoms. In consultation with the medical professionals responsible for this determination, in the absence of symptoms, there would be no way for the employee or the agency to have prevented this tragedy.

While this was a tragic accident, beginning with the actions of the first responders through the follow-up by District management, this event offers evidence that past lessons learned (personal and organizational) influenced the decisions made during this incident.

From the recollection of past accident reports, FLAs, and other analyses—as well as through reaching out to mentors—the involved participants took swift action to save the life of their Crewmember and, in the aftermath, took measured steps to ensure that the family and coworkers of the fallen Crewmember were cared for.

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3. Background

On April 7, 2013, the Crewmember was assigned to the three-person Engine Crew on the Sacramento District of the Lincoln National Forest in south-central New Mexico. It was his first season with the U.S. Forest Service.

At 26-years-old, he was a U.S. Army veteran with 18-months of combat service with the 10th Mountain Division in Iraq and Afghanistan. He was discharged from the Army in February 2012.

Shortly after being hired by the Forest Service, he completed his basic wildland firefighting training, along with First Aid, CPR, Wildland Fire Chainsaws, and emergency vehicle operations training. In addition, on April 8, he completed his Work Capacity Test at the arduous level.

While he had no known medical history, he did smoke cigarettes—from one-half to a full pack per day— which he readily acknowledged that he needed to quit.

His fitness was characterized as adequate. He could maintain pace with the Engine Crew on hikes and runs during physical training (PT). The day of the incident was the last day of the pay period for the Crew before going on days off, and recent fire activity had been pretty low.

The Crewmember did not consume any caffeinated beverages or energy drinks prior to going on the patrol. He was not known to consume such beverages at all.

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Vicinity Map

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Proximity Map

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4. The Accident Narrative

Generally, Sunday was a day when District firefighting resources gathered to PT together and participate in joint training to develop and maintain inter-crew cohesion and ensure that ongoing training needs were consistent across the District.

However, this Sunday, the Duty Officer (DO) postponed PT and the training due to elevated fire restrictions and several abandoned campfires that had been discovered and extinguished the day before. These signs were indicators that the District could see some heightened fire activity that day.

Crew Background The Engine Captain was in his 13th season fighting fires, several of those seasons spent on an interagency hotshot crew. The Engine Operator had worked with the Captain the previous three years on the District. They had developed a strong working relationship. The third, new Crewmember on the engine was just finishing up his fifth week as a wildland firefighter. His “goofy sense of humor” had already endeared him to his compatriots.

The Engine Crew began its day at 8:30 a.m. with a morning briefing that included weather, SIT Report (the National Interagency Coordination Center Incident Management Situation Report), and a “6-Minutes for Safety” troubleshooting discussion tool that focused on stress and “We weren’t trying to kill fatigue (see Appendix A). ourselves.”

Last Day of Pay Period Engine Captain This was the last day of the pay period and the Engine Crew looked forward to a couple days off. After completing their timesheets and some other odds and ends, they gassed-up the Engine and headed down Sunspot Highway to the Monument Springs Trailhead where they ate lunch before leaving to patrol the area on foot.

It was a nice May day in the Sacramento Mountains. The sun was shining and temperatures hovered in the mid-sixties. The Engine Crew hiked off-trail for almost two hours, ascending to an elevation of over 8,000 feet, to a good vantage point on the ridgeline where they could look down onto the community of Timberon. From there, they headed back to the trailhead, eventually reconnecting with the Monument Springs Trail.

The Engine Captain set a leisurely pace as they enjoyed the beautiful day. They took a break at the bottom of a relatively steep incline and touched base with one another, making sure that everyone was doing okay. The Engine Crewmember responded: “I’m a little tired, but I’m good.”

Part way up the hill, the Captain stopped to catch his breath. He turned to his comrades with a sheepish smile at his own fatigue. The Engine Crewmember, only a few paces behind, suddenly stated that he felt dizzy—and collapsed.

The Engine Operator was immediately at his side, asking if he was okay and tapping him on the cheek. But there was no response. The Captain and Operator observed their fallen friend’s condition deteriorate rapidly to no breathing and no pulse. In less than one minute, he had become completely unresponsive. The Operator’s former experience as a combat medic with the U.S. Army provided him the confidence to act quickly and deliberately.

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Map of the accident site and proximity to the trailhead (approximately one mile in distance).

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They took off the Crewmember’s backpack and attempted to lay him flat on the trail—where they immediately began CPR.

We Need a Medevac Ship Realizing the urgency of the situation, the Captain attempted to call dispatch, but was unable to make radio contact.

In this remote area of the District, cell phone coverage is non-existent; the radio was their only potential communication link.

The Captain ran uphill about 30 yards, where the terrain opens to a wide flat bench: a suitable helispot. From this location, he was Location where Crewmember collapsed, looking downhill. Firefighter is able to establish radio positioned at the base of the slope. communication. It was 3:26 p.m. He notified the Alamogordo Dispatch Center that an individual collapsed while hiking, that they had started CPR, and that they needed a medevac ship right away.

“In my mind I went straight to Andy Palmer.”

Engine Captain

Fresh in the Captain’s mind was the Andy Palmer Fatality, Dutch Creek Incident. He knew that he had to make it clear that they needed an air ship NOW. Luckily, the person on the other end of the radio was a familiar voice who had previously worked with the Captain on a hotshot crew. The Dispatcher recognized the insistence in his voice and wasted no time ordering the medevac helicopter: Estimated time of arrival (ETA) 20-25 minutes.

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The Captain and Operator continued to administer chest compressions and rescue breaths as they waited for what “seemed like forever” for the helicopter to arrive.

They took turns as one would tire, stopping to reassess the Crewmember’s airway and pulse, but never noting any encouraging change.

Several times, the Captain ran back to the bench to respond to Alamogordo Dispatch while the Operator continued CPR.

Crewmember’s Care Transferred to Flight Medics Approximately 30 minutes after the initial call to Dispatch, at 3:58 p.m., a medevac helicopter arrived on scene and was able to land on the bench—located approximately 100 feet from the Engine Crew (at the previously described helispot).

The flight medics joined Location on the trail where the Crewmember collapsed, looking up hill. the Engine Crew and resuscitation efforts were transferred to the medics, who performed AED shocks, CPR, and administered epinephrine shots—with no positive results.

Even though those on-scene had frantically done everything within their ability to save him, the Crewmember had now been unresponsive for more than one hour. With much heaviness, the flight medics relayed a request through the Dispatcher to terminate resuscitation, which was granted by the physician with medical control of the situation at 4:38 p.m.

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“That was the hardest. That was tough. Stopping CPR.”

Engine Operator

Arrangements Made to Transfer the Crewmember’s Body The now fragmented Engine Crew, trying to make sense of the rapid-fire turn of events that had just occurred, ascended to the top of the incline.

There they sat, not wanting to be there anymore: Waiting.

The flight crew and the recently arrived Timberon Volunteer Firefighters remained with the Captain and Operator until arrangements were made to transfer the body.

They stayed out on the bench for a long three hours as the protocol for body extraction was checked off by the New Mexico State Office of Medical Investigation, who had arrived on-scene at approximately 6:50 p.m. Helispot looking south. Snag in background is the approximate location where the Crewmember collapsed. The trailhead where the Engine was parked was approximately one mile up the sometimes steep and narrow trail. With the medevac ship still on-scene, approval was granted to extricate the body by air—rather than embarking on a potentially difficult and stressful journey up the trail carrying the deceased crewmember in a heavy and cumbersome litter.

Around 7:20 p.m., the Engine Crew helped load the Crewmember’s body onto the helicopter and they then hiked back to the trailhead.

“We helped put him in the body bag and load him up. The hardest part was the waiting to get him off the hill. Knowing he was just down the hill and trying to process what had happened.”

Engine Operator

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Profile view of the accident site and medevac helispot.

Meanwhile, back at the Mayhill Administration Site, the Duty

Officer had been in contact with Alamogordo Dispatch. He was up-to-date with the situation and was keeping a meticulous “I never thought communication log of all the information received and relayed. it was our own guy.”

At this point, however, he was not aware that the fallen “hiker” Duty Officer was actually a Forest Service employee. Even so, he knew that his Engine Crew might need some extra support after being the first responders to a potential fatality and performing CPR. Therefore, the Duty Officer had already initiated inquiries into a Critical Incident Stress Debriefing (CISM).

After his offer to respond was declined by Dispatch, the Duty Officer decided to remain at Mayhill rather than adding any confusion to the situation in the field by going out there.

Over the course of the incident, the Duty Officer kept the District Ranger and the Crew’s Supervisor regularly updated, never realizing that it was one of their own who had died. It was not until about 8:40 p.m. that evening when the Captain and Operator finally arrived at the Mayhill Administration Site that he was informed that the fatality was the Crewmember.

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Notifying the Next of Kin Immediately, the Crew Supervisor’s phone was ringing, as well as the District Ranger’s.

As the Duty Officer updated them that the Engine Crewmember was the individual who had passed away, a plan was made to determine protocol for the notification of the next of kin.

After consultation with the Forest Supervisor and Forest Fire Management Officer, it was decided that the District Ranger, the Crew’s Supervisor, and the Engine Captain would “The support received was huge; personally notify the next of kin, who lived in a nearby town. amazing.”

Engine Operator

Post Incident: Well-Defined Roles were Critical The days following the incident were chaotic and stressful for those involved in sorting through what to do next. Employees from the District, Supervisor’s Office, Regional Office, and the Washington Office were all actively engaged in their piece of the response— mentoring and supporting one another to the best of their abilities.

On the District, well-defined roles were critical to their forward momentum.

The District Ranger dedicated his work time to the incident and tasked the Deputy District Ranger with regular business. A neighboring District Ranger, who had experienced a fatality on his unit in the past, offered immeasurable counsel and guidance.

The Crew’s Supervisor became the family liaison, and even though there was no time to read-up on his responsibilities as referenced in the NWCG Agency Administrators Guide to Critical Incident Management (PMS 926), he used the family liaison checklists for guidance. He also received internal support from others in the agency who helped him provide the family with the time and information that they needed.

A Critical Incident Stress Management/Peer Support Team (CISM) arrived in Cloudcroft, the District’s location, on the Wednesday following that fateful Sunday. The team hosted an all-employee District meeting. Team members also met with several groups of employees who had been directly involved in the incident.

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5. Monument Springs FLA Timeline Date Time Event 5/5/13 0830 Engine crew began shift at Mayhill Admin Site. They completed a morning briefing which included weather, SIT Report, and 6-Minutes for Safety (stress and fatigue). 1030 Refueled engine in Cloudcroft. 1230 Lunch at Monument Springs Trailhead. 1300 Began patrol in Area of Responsibility (AOR) by hiking west from trailhead to top of ridge. 1445 Began hike back to Engine. 1515 Stopped for a short break then continued hiking up relatively steep hill. Crewmember expressed that he was dizzy and collapsed. Captain and Operator assessed fallen Crewmember’s condition and began CPR. Captain made unsuccessful attempt to contact Dispatch then climbed hill approx. 30 yards and relayed information to Alamogordo Dispatch Center. Operator continued chest compressions and rescue breathing. 1526 Initial report to Alamogordo Dispatch Center for collapsed “hiker”, male 26, weak pulse, CPR started, requested Life-Flight right away. Captain and Operator continue CPR until Life Flight arrives. 1532 Alamogordo Dispatch requested MEDEVAC, ETA 20 minutes. 1535 Duty Officer notified by Dispatch that Engine Crew is responding to a medical emergency. 1545 Duty Officer notified by Engine Crew’s Supervisor and asked about protocol for Critical Stress Debriefing. 1558 Life Flight landed on scene; Flight medics received briefing, evaluated patient and took over care; airway was established, AED shocks were performed, IV and epinephrine were administered, and CPR continued. 1635 Flight medics requested permission to terminate resuscitation. Approved by medical control doctor. 1638 Crewmember pronounced dead. Timberon Volunteer Fire Department members arrived on scene with stretcher. 1850 Otero County Sheriff’s Office and NM State Medical Examiner’s Office arrived on scene. 1919 Life Flight departed scene with deceased Crewmember. 2030 Engine Captain and Engine Operator left Monument Springs Trailhead. 2041 Duty Officer met Captain and Operator at Mayhill and is informed that the fatality was a Forest Service employee. 2145 Crew Supervisor, Engine Captain, and District Ranger notified next of kin. 5/8/2013 1100 Critical Incident Stress Management/Peer Support (CISM) Team arrived in Cloudcroft and met with District administrators. 1300 CISM Team hosted an all-District meeting. 1430- CISM Peer Support met with several core groups (Engine and Dispatcher). 1630 5/14/2013 Monument Springs Fatality Facilitated Learning Analysis Delegation of Authority Letter. 5/15/2013 Facilitated Learning Analysis (FLA) Team arrives in Cloudcroft and begins interviews. 5/16/2013 District FLA informational meeting, interviews, and site visit. 5/17/2013 FLA closeout.

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6. Lessons Learned and Observations – Shared by the Participants

“Our training was spot-on.”

“Training for emergency response helped me stay calm.”

“Pay attention during training. Think that this COULD happen to me. You need to know what to do.”

A. Training The training and previous experience that the Engine Captain and Engine Operator brought to this incident prepared them well to be able to rapidly assess the patient’s condition and quickly decide to request a medevac helicopter.

 Both first responders were former hotshots; one was a U.S. Army combat medic veteran.

 First aid/CPR training is taught to firefighter resources every year by the Duty Officer. Having the training done by a peer was beneficial because this person understands the work and the environment.

 The Dutch Creek incident, where Andy Palmer was fatally injured, was reviewed in critical training this year. This strongly influenced their rapid decision making to clearly request a helicopter for evacuation.

 The Dispatcher was an injured hotshot crewmember who was well-versed in emergency protocol. This positively contributed to the Crew’s ability to communicate and get medevac procedures started quickly. The Engine Crew knew he would not take their request lightly.

“It never entered into my mind that it was one of our own.”

B. Communication and Privacy Concerns The only method of communication was the Forest Service radio system, which is often monitored by the public through the use of scanners. Therefore, the first responders never mentioned over the radio that the patient was an employee.

While this confidentiality was crucial for preventing the potential spread of rumors and misinformation within the local communities, it also resulted in a delay in the notification of Agency Administrators and the family.

 In the event of any medical emergency involving Forest Service employees as first responders, overhead support could be provided if an agency representative or liaison automatically responded to the scene— unless confirmed they are not needed.

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“Don’t have some ‘Joe Blow’ notify the family.”

“The support meant a lot to the family. They think the world of the Agency.”

C. Personal Notification Personal notification by agency personnel and providing an agency family liaison that was consistently available to the family through the entire process was very beneficial to the family.

 The Engine Captain coordinated with the Sheriff’s personnel on-scene that the Forest Service would make notifications to the family.

 The deceased Crewmember’s next of kin lived locally and were notified in person by the District Ranger, the Crew’s Supervisor, and the Engine Captain.

 The Crew’s Supervisor continued on as the family liaison and was present at the funeral service.

“Being with the family was important for closure. It really helped me; I will be forever grateful.”

“Sending the involved parties to the services was really appreciated; it should always be an option.”

D. Agency Support to the Family The Captain, Engine Operator, Crew Supervisor, and District Ranger all accompanied the Crewmember’s body via commercial airline to the off-unit burial location. The agency’s presence at the funeral services was beneficial to both the family and the employees.

 The family was heard to say this was their worst day and their best when they realized the support from the agency.

 The presence of the Honor Guard and the Washington D.C. (National) Office representative at the funeral was a powerful statement of support to both the family and employees.

 Other veterans present at the funeral took note of the agency’s support to the family and approached the participants to express interest in a career in wildland fire with the Forest Service.

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“The support to District staff, starting with the CISM, was really important.”

“The support received was huge, amazing.”

“Mentoring from peers with experience was very valuable.”

E. Be Prepared for a Line-of-Duty Death The services provided to the District by the Critical Incident Stress Management/ Peer Support Team (CISM), the Regional Office, and peers within the agency were extremely beneficial to the employees.

 Leadership made the choice to be engaged with the CISM so that others would also be engaged.

 We need to recognize that it can be an emotional event when it comes to informing District employees about the death of a fellow employee.

 Well-defined roles were critical, but sometimes we had to tag-team. We worked to each other’s strengths.

 You need people that can talk and understand the language. Fire to Fire.

 Agency Administrators could be provided training to be better prepared for a line-of-duty death.

 Cast a wide net so that employees at every organizational level have access to the support needed.

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7. Organizational/Process Improvements – Lessons Learned

Administrative Process: Frustrating and Inefficient The agency’s administrative process for dealing with a line-of-duty death was frustrating and inefficient.

1. There is no agency policy that could be referenced for line-of-duty death. This caused roadblocks with Human Resources.

Recommendation: Finalize policy or develop a “Line-of-Duty Death Guide” that contains “what to do” forms to complete, agency roles and responsibilities, and policy references.

2. Access to Personally Identifiable Information (PII) was critical for “SHIPS” (the Forest Service’s “Safety and Health Information Portal System”) entry and to obtain information regarding the autopsy and body transportation. Safety Managers and local units do not have access to this information without a signed release form from the employee.

3. “SHIPS” does not produce a CA-6 (Report of Fatality – Official Superior's Report of Employee's Death). A hardcopy must be completed by the supervisor.

4. Because this incident did not occur on a fire, there was no mechanism for funding an interagency CISM team to travel and support this incident.

Recommendation: Establish a multi-agency agreement for CISM support for the Southwest Coordination Group, or parties in the Southwest area.

5. Ensure that new employees understand and have the time to fill out all benefit forms before starting work. These forms include—but are not limited to: beneficiary, next of kin, health benefits, life insurance, and long-term care.

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8. Facilitated Learning Analysis Team Members

Margrett Boley Forest Supervisor National Forests of Mississippi

Helen C. Graham Deputy Fire Staff Officer Tonto National Forest

Joseph W. Domitrovich Exercise Physiologist Missoula Technology and Development Center

Ruth E. Spradling Safety Manager Grand Mesa, Uncompahgre, and Gunnison National Forest

Ana G. Parada Alternative Dispute Resolution Program Manager, Human Resource Specialist Southwestern Region, U.S. Forest Service

9. Process Coach Ivan Pupulidy Human Performance Specialist USFS

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Appendix A – Six Minutes for Safety: Fatigue/Stress

This is the “6 Minutes for Safety” discussion that focused on stress and fatigue that the Engine Crew participated in during their May 5 morning briefing—the day of the incident.

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