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Monument Springs Fatality Facilitated Learning Analysis Lincoln National Forest Sacramento Ranger District Monument Springs Fatality – Facilitated Learning Analysis Page 1 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 Monument Springs Fatality – Facilitated Learning Analysis Page 2 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. Monument Springs Fatality – Facilitated Learning Analysis Page 3 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. Monument Springs Fatality – Facilitated Learning Analysis Page 4 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. Monument Springs Fatality – Facilitated Learning Analysis Page 5 Vicinity Map Monument Springs Fatality – Facilitated Learning Analysis Page 6 Proximity Map Monument Springs Fatality – Facilitated Learning Analysis Page 7 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. Monument Springs Fatality – Facilitated Learning Analysis Page 8 Map of the accident site and proximity to the trailhead (approximately one mile in distance). Monument Springs Fatality – Facilitated Learning Analysis Page 9 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.

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