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 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 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 other agencies “in the prevention and suppression of to reduce protection costs and increase availability of firefighting and prevention resources.”

An event that began on July 1, 2013 is fresh in the memories of residents in the greater Las Vegas area. In the midday heat, lightning struck a single tree and started the Carpenter 1 Fire. Despite an initial attack, the fire grew to 600 acres the following day. Three days later, fire spread had increased substantially to 14,000 acres and the incident had transitioned from a Type 3 to a Type 1 incident. People from the communities of Trout Canyon, Torino Ranch, Lee Canyon, and Mount Charleston had to evacuate their homes. All were displaced for an extensive period. The fire burned 27,883 acres before it was finally contained on September 18, 2013 at a total cost of $20,183,000. A subsequent programmatic and cost review noted that, although most of the burned acreage was within a wilderness area, private

Willow Peak Fire FLA Report, 7/2/2015 Page 3 land inholdings, high-value recreational developments, sensitive species habitat, heritage resources, and other values at risk narrowed the decision space of fire managers.

The area around the Willow Peak Fire has a long history of fire with numerous events recorded since 1948. Twenty-two of those have occurred since 1981. The small community of Cold Creek has been exposed to these threats since its establishment. Fires have occurred with such frequency that the community has its own volunteer fire department with volunteers operating from Clark County’s Cold Station.

The Willow Peak Fire started when lightning struck a ponderosa pine snag within a burn scar created by two overlapping fires. The Bonanza Fire burned 279 acres in late July of 1972. The area burned again in late June of 1981 when the Mack’s consumed 6,400 acres of vegetation. These two events have transformed the area above the Cold Creek community from heavy stands of ponderosa pine to a shrub community dominated by manzanita, bitterbrush, and snowbush and littered with the skeletal remains of burnt timber.

Willow Peak Fire FLA Report, 7/2/2015 Page 4 STORY t’s late Sunday evening when the assistant chief of the Cold Creek volunteer fire department calls Alex about a fire. It’s a single tree, with pretty good flame, on the mountain above the small Icommunity of Cold Creek. Alex, the Forest Service’s fire prevention technician, is used to hearing from residents directly. He’s a local guy who was once chief of the Indian Springs Volunteer Fire Department nearby, and he knows people in the area are twitchy about fire. Residents and travelers on Highway 95 have broad views of the Spring Mountains, and every smoke prompts multiple calls to Alex and dispatch.

Alex talks to Brett, the fire operations specialist, who confirms the smoke report. As he drives toward the location, Alex spots a flicker on the mountain. He also notices a storm had passed through with lots of rain. He ties in with Brett at the Bonanza pullout where the view is better and they call Daryl, the fire management officer (FMO), at home around 22:30. They know homeowners are concerned and volunteer firefighters have been out on ATVs to check out the smoke report.

Alex, Brett, and Daryl make a plan. Daryl asks Brett to monitor the fire since people will be calling all night to report it. They’ll put an engine crew on it early in the “”It was an eyesore. We could have morning. Alex calls dispatch at 23:38 with a rough size up, left it. But people were calling in. and then leaves for home around 01:00. Daryl goes to bed They could see the smoke.” but, after a few minutes, decides to set his alarm for 03:00. Although there’s nothing remarkable about this fire, he decides to be up early to check on it.

During the night, Brett watches the hill. He hears some chatter about the volunteer firefighters responding. He calls dispatch at 02:17 with an update (“single ponderosa burning 10-15 feet up the trunk”) and asks dispatch to tell the volunteers that people will be on it in the morning. At one point, it appears that the tree, or at least part of it, falls down. It’s too far away and too dark to see much detail.

* * * * *

onday morning, May 25, the crew of Engine 453 is up early, preparing to travel to Cold Creek. It’s early in the season, and the five firefighters are in good spirits and ready to work. M It will be a routine job—just a single tree—and won’t take long. Around 05:00, the crew leaves the new Kyle Canyon fire station. Their engine heads north on the Deer Creek Road, which winds through ponderosa pines and provides views of the broad valley below. They see the extensive Angel Peak fuel break around the Spring Mountains Youth Camp before turning down Lee Canyon Road.

The crew turns northwest on Highway 95, moving further away from the sprawl of Las “Everyone thought it would be a routine deal.” Vegas before cutting southwest on Cold Creek Road. The engine crosses BLM land,

Willow Peak Fire FLA Report, 7/2/2015 Page 5 passing Joshua trees and wild horses as it begins climbing toward the Spring Mountains and cooler temperatures.

The crew meets up with Brett at the Cold Creek Fire Station and they all drive to the Bonanza pullout for a briefing with FMO Daryl and Alex at 06:00. The fire is in the Mt. Charleston Wilderness and they receive approval to use chain saws. Forest Road 45601C, which ends at the edge of the wilderness, will get them within a 70-minute hike of the fire. The road is rocky, rough, and narrow so they leave their engine at the Bonanza pullout. Alex and Brett use their smaller vehicles to shuttle the crew and gear to the base of the ridge. Everyone is feeling good. On the ride in, Alex jokes with Derek, who’s in his third year as a chain saw operator. It’s Derek’s fifth season as a firefighter but his first with Engine 453. He’s looking forward to the hike and packing in his chain saw. It will be a chance for some more falling experience.

Finn, the engine captain, begins hiking around 07:00 about 15 minutes ahead of the crew. It’s an arduous climb on steep and rocky ground. He picks his way through hip-high bitterbrush and manzanita before arriving at the burning snag about 70 minutes later. Finn does a quick size up of the fire but doesn’t call it in. He’ll let Gabe, the senior firefighter who’s training as a Type 5 Incident Commander (ICT5), call in his own field fire report. This single-tree incident will be good training for Gabe and Harley, an engine boss trainee. It will also be an opportunity for Ian, who’s starting his second season, to get some more experience.

Ten or fifteen minutes later, at about 08:30, the other four firefighters join Finn. They’re in a large, 30-year-old burn scar with a few snags, rocky bluffs, scree, and a scattering of live trees. It has about 50% ground cover: bitterbrush, snowbrush, and manzanita but no grass. They see that the top half of the snag has fallen out. It’s burning but the The top had fallen out of the snag before the ground is wet and rocky so it’s not spreading. The standing crew arrived.

Willow Peak Fire FLA Report, 7/2/2015 Page 6 piece is on fire too. Gabe calls dispatch with a location at 08:43 and a size up at 08:58:

“Estimated size is a tenth of an acre with a 75% active perimeter. Fire investigator: no. Structures threatened: no. There are structures in the area though, three-quarters of a mile to the north. Fire potential is away from structures. Control problems: Steep slope. Spread potential is moderate. Character of the fire is smoldering and creeping. The slope at the head of the fire is 41 to 55%. Position on slope is upper third. Dominant fuel type is pondo [ponderosa pine]. Wind speed is 5 to 10 out of the southwest. Additional resources needed: no. Estimated containment date: today at noon. Control date and time is today at 15:00.”

The crew is concerned that burning material could roll down the hill so they agree to cut down the snag and secure it. As Derek takes off his pack and prepares his saw, Finn hikes on. Daryl had asked him to check over the ridge for other lightning strikes. He’ll also see if fire has spotted up the hill.

Ian and Harley swamp as Derek cuts shrubs for escape routes and an area for the snag to fall into. Derek eyes the snag. It’s about 12 feet tall, still burning, and charred with pockets and cavities. The top is jagged with two tall “ears” that begin about 6 or 7 feet above the ground where the bowl has hollowed out. He limbs off the ears and then makes the gunning cut. He begins a sloping cut. The ground isn’t hot but the tree is, and the saw is throwing flames as chips exit the back of the saw. Derek tries a second sloping cut. The cut is taking some time. Harley takes a big swig from his water bottle and spits water on it, causing steam to rise from the hot surface. It doesn’t help much. The saw is hot so Derek cuts the engine, steps away, and sets it on the ground. While it’s cooling, the firefighters clear more brush downhill. Finn is still scouting out the area uphill. Derek makes a gunning cut and sloping cuts on the snag * * * * * before setting the saw down to cool.

ith the crew shuttled in, Alex leaves to check on another smoke report. Brett and FMO Daryl remain at the base of the ridge, watching the crew through binoculars. It’s pleasant there: Wsilent except for the intermittent, distant sounds of the chain saw and an occasional jet above. They can see the expansive valley below and the mountain ranges beyond. The loose arrangement of homes and other structures at Cold Creek are to the north.

* * * * *

Willow Peak Fire FLA Report, 7/2/2015 Page 7 bout ten minutes after setting down the chain saw, Derek prepares to cut some more brush. He’s about 10 feet downhill and to the side of the burning snag when he picks up his saw and Apulls the cord. It won’t start. He tries several more times. No luck. Thinking it’s out of gas, he stops and, using his leg to prop up the saw, turns it on its side. He twists the tool-less cap. Suddenly, like a geyser, a stream of gas and a cloud of mist shoot out of the tank into Derek’s face and toward the burning snag. In that stunned moment, there is a miniscule pause . . . a frozen second as the firefighters’ brains process what they’re seeing. Derek spits gas out of his mouth just as a trail of flame races from the burning snag toward him. Approximate positions of firefighters just before the accident. Photo taken 5/29/2015.

* * * * *

fter determining the crew has the situation under control, FMO Daryl asks Brett to drive him to his rig. They’re about 50 yards downhill when Finn radios: “We’ve got third-degree burns. We Aneed a hoist!” Daryl and Brett, sensing the injury’s severity in Finn’s voice, look back through the rear window. They can see that something frenzied is going on. Brett immediately turns his rig around as Daryl gets more information. Daryl calls dispatch at 09:11 to request a hoist-capable helicopter from Las Vegas Metropolitan Police Department Search and Rescue. He calls dispatch twice more to request a paramedic on the Metro ship and, anticipating the need for advanced care, for an air ambulance to respond. The plan is to have Metro hoist Derek off the hill and meet the air ambulance, Care Flight 12, at the Cold Creek Fire Station for additional medical care and transport to a burn unit.

Alex is in Willow Creek where he had issued a citation to campers for an illegal campfire. He had helped put it out and was making sure it was cold when he thinks he hears “short haul” on the radio. He calls Daryl, who tells him to hang on, so he radios Finn. Finn asks about a landing zone and Alex recommends the Cold Creek Fire Station. He drives there to help prepare it and calls volunteer firefighters to assist with a roadblock.

Willow Peak Fire FLA Report, 7/2/2015 Page 8 The crew of Engine 451 is at their station near Cold Creek when they get the call around 09:20 to relieve Engine 453 on the Willow Peak Fire. On their way, they hear something about an injury but they don’t know who it is or how serious it is.

* * * * *

ack on the mountain, just after they extinguish the fire on Derek with water from a water bottle, crew members begin to administer first aid. Finn had heard the commotion and raced down from the ridge, leaping several feet down over a rock bluff. He radios Daryl and Brett about the injuryB, knowing that Daryl has cell phone coverage and clearer communications with dispatch.

Finn calls dispatch at 09:19 for an ETA on the Metro hoist ship. It arrives over the accident site at 10:05 and lowers After the fire reached Derek, he ran two medics who provide care to Derek and prepare him to uphill. Gabe grabbed him, pulled be hoisted. With Derek and the medics on board, the him to an area that wasn’t as Metro ship leaves at 10:34. The other four firefighters stay brushy, and tackled him to the on scene for about an hour, monitoring the fire to make ground. Crew members used their sure the helicopter’s rotor wash did not blow embers and gloved hands to pat the flames out start spot fires. on Derek’s clothes but it was difficult to extinguish the fire on his At 10:45, the Metro ship is on the ground at the Cold Creek face and neck. There was little dirt Fire Station and transferring Derek’s care to Care Flight 12. on the rocky slope so Harley The Care Flight medics continue the advanced life support grabbed his bottle and doused care and prepare Derek for flight. Care Flight 12 is en route Derek with water, which succeeded by 11:05 to the University Medical Center in Las Vegas, the in putting out the flames. regional burn unit.

* * * * *

n their way up the mountain, the crew from Engine 451 Omeets the Engine 453 firefighters who are hiking down. Engine 451 receives tactical control of the fire at 12:53 and, after a short discussion, continues uphill to suppress the fire. Their sawyer cuts down the burning snag and the crew contains the fire at 15:30. They begin hiking out at 16:50 after it's controlled.

Willow Peak Fire FLA Report, 7/2/2015 Page 9 ONGOING TECHNICAL REVIEW Analysis of pressurized gas tanks that can occur during chain saw operations is ongoing. More information will be available later in 2015.

During the Willow Peak Fire, a firefighter received burns after opening a fuel tank that had become pressurized. Multiple conditions including heat, altitude, and evaporation can pressurize a fuel tank, and one can reasonably expect all fuel tanks to be pressurized at any time. The hazard is not limited to environments or to chain saws. Pressurized tanks on lawn tools, vehicles, and boats have expelled fuel geysers and/or vapor mists after they were opened.

This report addresses the hazard of pressurized gas tanks during chain saw operations while suppressing wildland fire. Analysis of the hazard is ongoing and it will include an evaluation by the U.S. Forest Service National Technology and Development Program and the ANSI 175.1 committee which includes representatives from several chain saw manufacturers, the Occupational Health and Safety Administration, and the Consumer Product Safety Commission.1

Review of potential changes in equipment and practices will require time. In the interim, the following mitigation measures are recommended:

 Review the equipment manufacturer’s owner’s manual and recommended maintenance schedule. Manuals for Stihl and Husqvarna chain saws, the two brands most commonly used in wildland firefighting, are available at:

o http://www.stihlusa.com/manuals/instruction-manuals/#chainsaws o http://www.husqvarna.com/us/support/download-manuals/  Recognize and include the risks associated with pressurized gas tanks in tailgate sessions and Job Hazard Analyses.  Allow chain saws to cool down when they become hot.  Expect a pressurized gas tank situation when opening the gas tank.  When opening a gas tank:

o Move to an appropriate distance from ignition sources. o Place the chain saw on bare ground or other type of non-combustible surface. o Allow the saw to cool for at least five minutes. o Follow the owner’s manual instructions for opening the cap. o Deliberately aim the tank opening away from yourself and toward a safe direction. o Slowly open the cap to release all the pressure. o When reinserting the cap, make sure it closes completely.

1 ANSI B175.1 is the American National Standards Institute’s standard for Outdoor Power Equipment –Internal Combustion Engine-Powered Hand-Held Chain Saws – Safety and Environmental Requirements.

Willow Peak Fire FLA Report, 7/2/2015 Page 10 LESSONS LEARNED ANALYSIS The Lessons Learned Analysis is the FLA Team’s examination of the relevant facts and lessons learned from the participants. The aim is to overcome hindsight bias and understand the conditions that may have contributed to the outcome. Those conditions relate to the people involved and the systems within which they operate: how they perceived and interpreted the risks they encountered, and how they made choices that they made. The conditions fall into four categories: culture, training, learning, and emergency response.

Culture

Full Suppression vs. Monitoring The Forest Service has a long history of fully suppressing wildfires. In recent years, the agency has started to view fire differently and allow some fires to play their natural role. While the Forest “If this fire was back further out of sight over the Service has come a long way in recognizing the hill deeper into the wilderness, we could have need for fire in the landscape, the public talked about just monitoring it. But it wasn’t ...” frequently expects full suppression, particularly in the wildland-urban interface.

As illustrated in Appendix C, the SMNRA has a long history of wildland fire. The 2013 Carpenter 1 Fire and subsequent flooding of the damaged landscape has local communities very nervous about any fire. Records dating back to 1948 show that the Cold Creek community has been exposed to these threats

View from the Willow Peak Fire area toward the small community of Cold Creek.

Willow Peak Fire FLA Report, 7/2/2015 Page 11 since its establishment. A 2005 risk assessment rated it and its 72 homes as a high-hazard area.2 The Willow Peak Fire was in plain sight above Cold Creek and to travelers on Highway 95. Fires in this area draw numerous calls until the public sees aggressive action taken to extinguish them.

The Humboldt-Toiyabe National Forest’s Fire Management Plan, approved in 2012, provides direction for specific areas of the Forest. For the SMNRA, the plan states, “All wildfires will receive suppression response (confine, contain, or control).” Specific Management Area Prescriptions for the Mt. Charleston Wilderness include direction to “coordinate and cooperate with the Nevada Division of Forestry, the BLM, and local agencies in the prevention and suppression of wildfires to reduce protection costs and increase availability of firefighting and prevention resources.” Consistent with the Forest’s fire management plan, the District FMO directed appropriate suppression action on the Willow Peak Fire. On fires like this, firefighters typically do not have the discretion to monitor a fire once they are dispatched to suppress it.

Normalization

Working with Gasoline and Fire Firefighters often operate in high-altitude, high-temperature environments, and they have used gasoline in a variety of firefighting applications for decades. They use chain saws in very close proximity to fires, sometimes even touching flames with the saws. They commonly carry Sigg bottles (containers for chain saw gas) in their packs and operate around open flames. Fueling from Sigg Bottles or Dolmars (two- compartment fuel containers) often occurs near burning materials.

These practices are common in the fire community but may not make sense to an outsider. Gasoline is highly volatile and most people understand the associated risks. Firefighters have a job to do and it is time sensitive, often to a high degree. Shortcuts become normal over time if there are no consequences. Just because an accident does not occur, it does not mean that a practice is safe or prudent. When everything is aligned, a shortcut or unsafe practice eventually can have undesirable outcomes if other factors align.

The FLA Team reviewed how firefighters commonly use chain saws and handle gasoline. In doing so, it became apparent that firefighters, in general, may be “normalized” to the dangers of gasoline. It is a well-established fact that normalization occurs when people who are exposed to certain risks over time and without incident become less attuned to those risks.

Small Fires Several people involved with the Willow Peak Fire characterized it as a routine, single-tree, initial attack fire. The tragic and severe outcome surprised them—it was nothing they expected. Several of them expressed a lesson learned: no fire is routine and even small fires expose firefighters to a great deal of risk. For additional information on this discussion point, search for single-tree fire incidents on the Wildland Fire Lessons Learned Center’s website (http://www.wildfirelessons.net/irdb).

2 Resource Concepts, Inc., “Nevada Community Wildfire Risk/Hazard Assessment Project,” June 2005, http://www.rci-nv.com/reports/clark/index.html, accessed June 24, 2015.

Willow Peak Fire FLA Report, 7/2/2015 Page 12 Training The wildland fire community has a tradition of learning, teaching, mentoring, and training employees to increase proficiency. Fires provide opportunities for training and gaining experience, which builds practical skills in real-world settings. The FLA Team concluded that the Willow Peak Fire, a small and simple incident, was such an opportunity. The burning tree was about six feet tall with a 20-inch diameter breast height (DBH). A typical 20-inch DBH tree is much taller with limbs and other hazards. Additionally, it was burning on a rocky slope with minimal fuels in the area.

Learning While reviewing this accident, the FLA Team checked with staff of the Wildland Fire Lessons Learned Center (www.wildfirelessons.net), and they identified three reports about similar but less serious incidents involving pressurized fuel tanks. The Team initiated an informal survey of firefighters in the agency and found these events to be more common than first thought. This unscientific outreach identified a frequency of about 1 to 3 occurrences each season amongst saw operators on 20-person crews. This raises questions: “Is the firefighting community adequately aware of this hazard?” “What do we pay attention to and why?” Key conditions related to answers are:

 We continue to learn the hard way. There is a lack of recognition within the firefighting community of prior incidents. A report of a fatality or serious injury can intensify the circulation of knowledge more than a “near miss” report. For example, the combined downloads for reports on the three previous incidents numbered less than 500. On June 2, 2015, the Lessons Learned Center posted a “Rapid Lesson Sharing” document that provided information about the Willow Peak Fire injury and pressurized gas tanks. It had over 3,000 downloads in three days.

 After accidents and near misses occurred, no changes were made to the curriculum that instructs or refreshes chain saw operations. It appears there is no clear process for the Short Haul vs. Hoist A short haul is used to firefighting community or any of the lead agencies in fire transport one or more people to evaluate and make recommended changes from these suspended on a fixed line safety reviews. beneath a helicopter. The intent is to carry people a  Seasoned veterans have knowledge of pressurized gas short distance, normally from tanks but it appears less experienced sawyers are less a limited or inaccessible aware of the hazard. location to a safe landing area. Emergency Response As shared by those involved with the incident and as understood A hoist-capable helicopter has by the FLA Team, several actions were key to a successful a permanently mounted cable winching device that can emergency response. These actions included previous medical lower or raise people and fly a response training, the actual evacuation and medical care of the patient directly to a hospital injured firefighter, and identification of a liaison. or a location to meet other medical transport.

Willow Peak Fire FLA Report, 7/2/2015 Page 13 Gaining experience with emergency responses, whether through exercises or real events, increases familiarity with equipment, improves capabilities, and reduces response times. About five months before the accident, SMNRA employees had practiced with an air medical transport helicopter at the Kyle Canyon Fire Station. District fire personnel work with the Metro hoist helicopter frequently due to a high volume of incidents involving the public on the SMNRA. Familiarity with available resources facilitated the ordering of a hoist-capable helicopter to get the burned firefighter off the remote hillside as quickly as possible.

Medical training of a crew member, the request for medics on the hoist ship, and ordering an air ambulance allowed the firefighter to receive immediate care followed by more advanced life support care and transportation to a burn center.

Immediately following the injury, the acting ranger appointed an individual as a liaison. The liaison assisted the family and served as a link to the human resources/workers’ compensation staff at the Albuquerque Service Center. Those involved reported that this arrangement worked very well and helped make a stressful situation more manageable.

In summary, this incident teaches us that we can respond quickly and appropriately to emergencies by simulating emergencies, discussing what has worked during past emergencies, and identifying how responses can be improved. Specific preparations include the following:

 Have a plan, know what it is, and practice it.

 Ensure nonstandard radio frequencies such as those used by county and other cooperators are accessible.

 Be clear on medical protocols for firefighter burns.

 Identify a liaison and the role that person will play (e.g., hospital liaison, family liaison)

RECOMMENDATIONS  Revise the curriculum for S-212 Wildland Fire Chain Saws to address pressurized fuel tanks and fuel handling.

 Identify the hazard associated with pressurized fuel tanks in Job Hazard Analyses and tailgate safety sessions.

 Provide information on how to extinguish a fuel fire on a person.

 Create “6 Minutes For Safety” topics to identify the hazards on a regular basis.

 Disseminate this report through email, social media, and other digital sources.

Willow Peak Fire FLA Report, 7/2/2015 Page 14 APPENDIX A: TIMELINE

Willow Peak Fire FLA Report, 7/2/2015 Page 15 APPENDIX B: PERSONAL PROTECTIVE EQUIPMENT REPORT Prepared by U.S. Forest Service, National Technology and Development Program

On May 25, 2015, a wildland firefighter chain saw operator received severe burn injuries from a chain saw fuel fire. Pressurized fuel from the chain saw’s fuel tank sprayed onto the firefighter’s face, torso, and arms, and ignited. The firefighter attempted to smother the flames on his face with his gloved hands. It took the efforts of several firefighters to extinguish the flames.

The following report is based on a site visit, interviews with firefighters, and visual examination of recovered personal protective equipment (PPE). The site visit was conducted at the incident location on May 29, 2015. Interviews were conducted at the Kyle Canyon Station on May 30-31, 2015. The injured firefighter’s PPE was examined on June 1, 2015 at the Las Vegas Helibase.

Helmet and Chin Strap Make: Bullard Wildfire Series Fire Helmet with Chin Strap

Model: FH911H

Date of Manufacture: April/2013

Certifications: NFPA 1977 Standard on Protective Clothing and Equipment for Wildland Firefighting, 2011 edition; ANSI/ISEA Z89.1-2009, Type 1, Class E&G.

Condition: The helmet’s polycarbonate shell has black soot marks that continue around the circumference. The brim area of the shell appears to have reached ignition temperature. The chin strap shows dye sublimation and charring, which is concentrated at the chin strap lugs on the shell. (Figures 1 & 2)

Willow Peak Fire FLA Report, 7/2/2015 Page 16

Back Front

Right side

Figure 1. Helmet shell detailing right-outside view. Circles show areas of high temperature.

Chin Strap Dye Sublimation Left side

Front Back

Right side

Figure 2. Helmet shell, bottom of brim-inside view. Circle shows area of high temperature.

Willow Peak Fire FLA Report, 7/2/2015 Page 17 Flame-Resistant (FR) Shirt Make: Forest Service Specification 5100-91E Manufacture Date: November 1992 Condition: The shirt shows areas of dye sublimation (encompassed by circles) on the front and back. (Figures 3 and 4)

Figure 3. Firefighter’s FR Shirt, front view

Figure 4. Firefighter’s FR Shirt, back view

Willow Peak Fire FLA Report, 7/2/2015 Page 18 Gloves Make: The gloves look like they are Forest Service Specification 6170-5.

Manufacture Date: Label missing.

Condition: The fingers of the right glove appear to be slightly shrunken by heat. (Figure 5)

Figure 5. Firefighter’s gloves

Materials: Conditions and Corresponding Temperatures

Approximate Material and Characteristic Temperature (°F) Skin: Second-degree blister 131 Human Survivability: Air Temperature 300 Polycarbonate Helmet: Softens 325 Leather Glove: Shrinkage 10% 350 Flame-Resistant (FR) Aramid Cloth: Dye-Sublimation 400 Flame-Resistant (FR) Aramid Cloth: Char 824 Polycarbonate Helmet: Ignites 1000

Conclusion Wildland firefighter PPE is not designed for chain saw fuel flame source. The Flame-Resistant clothing and leather gloves did not contribute to the severity of the flames and most likely lessened the burn injury area.

Willow Peak Fire FLA Report, 7/2/2015 Page 19 APPENDIX C: FIRE HISTORY

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Large fires have occurred throughout the history of the SMNRA. Most were relatively close to areas most likely to have high human activity (e.g., roads, homes, campgrounds). Although the information available is incomplete, records show that nearly 93,000 acres have burned and re-burned in the mountainous terrain around the communities and settlements between Las Vegas and Pahrump. Some houses have been lost at times.

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Index No. Fire Name Year Acres 1 Willow Creek 1948 289 2 Willow Creek 1953 0.2 3 Willow Pass 1961 estimated 8,992 4 Buck Springs 1962 97 5 Bonanza 1972 394 6 Wheeler Burn 1981 291 7 no name recorded 1981 5,000 8 Mack’s Canyon 1981 8,389 9 Buck Springs 2000 2,047

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