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Willow Peak Firefighter Burn Injury Facilitated Learning Analysis

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Willow Peak Firefighter Burn Injury Facilitated Learning Analysis United States Department of Agriculture Forest Service Willow Peak Firefighter Burn Injury Facilitated Learning Analysis Spring Mountains National Recreation Area, Humboldt-Toiyabe National Forest “Most people don’t think they can get hurt on a single-tree fire.” Incident Date: May 25, 2015 Report Date: July 2, 2015 Willow Peak Firefighter Burn Injury Facilitated Learning Analysis Contents EXECUTIVE SUMMARY .................................................................................................................................. 1 INTRODUCTION ............................................................................................................................................. 2 BACKGROUND ............................................................................................................................................... 2 STORY ............................................................................................................................................................ 5 ONGOING TECHNICAL REVIEW ................................................................................................................... 10 LESSONS LEARNED ANALYSIS ...................................................................................................................... 11 Culture .................................................................................................................................................... 11 Full Suppression vs. Monitoring .......................................................................................................... 11 Normalization ...................................................................................................................................... 12 Training ................................................................................................................................................... 13 Learning .................................................................................................................................................. 13 Emergency Response .............................................................................................................................. 13 RECOMMENDATIONS ................................................................................................................................. 14 APPENDIX A: TIMELINE ............................................................................................................................... 15 APPENDIX B: PERSONAL PROTECTIVE EQUIPMENT REPORT ...................................................................... 16 Helmet and Chin Strap ............................................................................................................................ 16 Flame-Resistant (FR) Shirt ....................................................................................................................... 18 Gloves ...................................................................................................................................................... 19 Conclusion ............................................................................................................................................... 19 APPENDIX C: FIRE HISTORY ......................................................................................................................... 20 Facilitated Learning Analysis Team Joseph G. Alexander, Team Leader Godot Apuzzo, Subject Matter Expert Jose Castro, Team Leader Shadow Randy Draeger, Lead Facilitator Mike Erickson, Subject Matter Expert Dirk Netz, Union Representative Richa Wilson, Writer/Editor, Documentation Specialist Cover photo: The Willow Peak Fire began when lightning struck a single tree late on the night of May 24. This is how the tree appeared when the Engine 453 crew arrived on scene the following morning. EXECUTIVE SUMMARY “We’ve got third-degree burns. We need a hoist!” Finn radios Daryl from the Willow Peak Fire in southern Nevada. After crewmembers tackle Derek and extinguish flames on his upper body and face, they begin to administer first aid. Daryl, the fire management officer who was on the road down below the fire, calls dispatch to initiate a medical response. It was May 25, 2015, and Derek had been cutting a burning snag. After noticing the chain saw was getting hot, he set it aside to cool. It would not start when he returned to saw operations ten minutes later. In an attempt to troubleshoot the problem, he raised the chain saw and twisted the tool-less cap of the gas tank. The tank was pressurized, which caused gas to spew out as a shooting stream with an associated vapor cloud. The gas saturated him and established a path of fuel that led to the burning snag. Derek sustained second- and third-degree burns on his face, upper torso, arms, and airway. Daryl, understanding the urgency, requests a hoist-capable helicopter from the Las Vegas Metropolitan Police Department’s Search and Rescue unit (“Metro”). He also asks for a medic and an air ambulance (Care Flight 12). Metro hoists Derek off the hill and transfers him to the Care Flight 12 medics who have arrived just below the fire at the Cold Creek Volunteer Fire Station (Clark County Station 82). They initiate advanced life support measures and prepare Derek for flight to the University Medical Center’s burn center in Las Vegas. The Regional Forester of the Intermountain Region commissioned a Facilitated Learning Analysis (FLA) Team to review and analyze the circumstances surrounding Derek’s burn injury. The Team’s charge included identifying opportunities to strengthen our safety culture, without fear of reprisal and with the focus on learning, which is vital to accomplishing our mission safely and successfully. Preliminary information gathered by the FLA Team indicated the need for additional technical review of pressurized gas tanks as experienced on the Willow Peak Fire. The U.S. Forest Service National Technology and Development Program will assist with the technical review and prepare a report for future distribution. After considerable review of the incident, including the leadership, qualifications, interagency cooperation, fuels, weather, incident management response, and local policies, the FLA Team concluded that the firefighters and overhead involved in the Willow Peak Fire performed within the leaders’ intent and scope of duty. The Team did not find any reckless behaviors or actions. Willow Peak Fire FLA Report, 7/2/2015 Page 1 INTRODUCTION This report presents a story, derived from interviews, of the events leading up to and surrounding the burn injury. The present-tense narrative provides the perspectives of those involved as those events unfolded. The purpose is to place you in their shoes with the information they had at the time, and to provoke you to view the situation as they did. Names have been changed to protect the privacy of interviewees. The intent of this report is to spur discussion and learning at all levels. Quotes and sidebars are scattered throughout the report to inspire dialogue, not because they point to any causes of the accident. In fact, this accident could have occurred on almost any fire, to almost any firefighter. The analysis portion of this report focuses on conditions that were present at the time of the incident. We address those conditions because they offer learning opportunities to the firefighting community. Numerous studies have shown that, by focusing on learning, we can improve our safety culture. BACKGROUND The Spring Mountains National Recreation Area (SMNRA) is approximately 316,000 acres and is part of the Humboldt-Toiyabe National Forest. Better known to locals as Mount Charleston, it is just 30 minutes from downtown Las Vegas. The SMNRA ranges in elevation from 3,000 to 11,918 feet at Charleston Peak, and the slopes are extremely steep. The terrain is some of the most rugged found in the western United States. Firefighters can expect to work in a broad range of conditions and vegetation types. The surrounding area averages 120 initial attacks per year with 30 to 40 occurring within the SMNRA boundaries. It is estimated SMNRA that 55% of these fires are caused by human activity with lightning strikes starting the remainder. The SMNRA hosts four Type IV engines, with one each stationed in Indian Springs, Lee Canyon, Kyle Canyon, and Mountain Springs. Three fire prevention technicians also work on the SMNRA and, in Willow Peak Fire FLA Report, 7/2/2015 Page 2 addition to fire suppression duties, help educate local communities. A fire operations specialist, an assistant fire management officer, and a fire management officer work with these resources and neighboring agencies to manage fires on the SMNRA and adjacent land. Those agencies include the Bureau of Land Management, US Fish and Wildlife Service, National Park Service, Nevada Division of Forestry, and the Clark County Fire Department. The SMNRA, surrounded by highways and heavy air traffic, is a highly visible “sky island” to the large population of the greater Las Vegas area. The Las Vegas Interagency Communications Center (“dispatch”) often receives numerous calls on the same report of smoke from residents who have high expectations for an immediate response and complete fire suppression. Duty officers often pursue a suppression response (confine, contain, or control) as outlined in the Forest’s fire management plan. The plan includes a prescription for the Mt. Charleston Wilderness to coordinate with
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