CHIPS FIRE Hazard Tree Felling Accident Facilitated Learning Analysis USDA Forest Service Pacific Southwest Region Plumas National Forest Executive Summary On August 20 2012 at approximately 0945 hours, a limb fell from snag on the Plumas National Forest struck and injured a wildland firefighter faller. The faller’s mission was to remove snags from a section of line on Division G of the Chips fire. The faller was a contracted professional timber faller, with 18 years of experience. The faller was in the process of falling a 61 inch diameter at breast height (DBH), 163 foot tall Ponderosa Pine “buckskin” tree when a limb approximately 5 inches in diameter and 5 feet in length fell approximately 63 feet and struck the back of the hardhat being worn by the faller. The faller had completed the undercut. He walked around the tree to retrieve his falling axe and began using it to remove a small portion of the wedge section still left in the undercut. He struck this small section four times and on the fifth strike a limb fell vertically striking the faller’s hard hat. Emergency medical services were dispatched immediately. The faller lost consciousness for approximately 2-3 minutes. Emergency medical technicians (EMTs) at scene rendered care immediately removing the faller from the area and administered first aid. The faller regained consciousness and complained of head, jaw and hip pains. The medical evacuation of the patient took approximately 34 minutes from the time of the initial report until the patient was in Helicopter 407 and in route to the Enloe Medical Center in Chico CA. The faller received 18 staples in the back of his head and was released the same day. Several other firefighters witnessed the incident. The incident was also video-taped. A Facilitated Learning Analysis (FLA) was initiated on September 7, 2012 with the goal of identifying opportunities to strengthen the agency safety culture by identifying any lessons learned associated with the incidents and sharing those lessons with employees engaged in firefighting activities. The lessons learned through this process have applicability to any employee that routinely works in forested environments. The following report provides some lessons learned as well as recommendations that agency leadership should consider in an effort to minimize employee exposure to falling snags. More importantly, the recommendations in this report address several other issues related to the medical care of our employees injured in the line of duty as well as the extraction of those employees to the appropriate medical facilities. The objective is to focus on lessons learned that would enhance the overall safety and future management actions. Chips Fire Tree Felling FLA Page 2 Narrative – Telling the Story The Chips fire started on July 29, 2012 on the Plumas National Forest northwest of Quincy, California. The cause is still undetermined. A type 1 IMT assumed command of the fire on August 3rd, 2012. On August 19, 2012 a plan was being implemented on Division G to burnout a piece of line west of Yellow Creek along a dozer line. Crews worked on prepping the piece of line all day on the 19 th in preparation for burnout operations to begin when conditions become favorable. The prep work included falling snags along the line that had been identified as hazardous. The large pine snag which was involved in this accident was identified as needing to be removed on the 19 th , however a decision was made to not remove the snag and instead dig line around it to try and keep fire from getting into it. On the evening of the 19 th and into the early morning of the 20 th , the line was burned out by night shift resources. Burnout operations were completed during night shift and the area was turned back over to day shift on the morning of the 20th. At the morning divisional breakout briefing, the plan for the operational period was to mop up 200 feet from the line. Engine crews would install a hose lay along the line to aid in the mop up and the 4 fallers would mitigate any additional hazard trees within the area. Four fallers were assigned to Division G and they spread themselves out along the area to give each other room to safely fall snags and provide minimum safe distances for falling operations. Faller 1 went to the area where the large snag was from the day before and found that the engine crews were already plumbing the hose on the line. Faller 1 met with Engine Boss 1 who tells him, “If we are going to mop up 200 feet, that tree has got to come down at some point.” Fire had gotten into the large pine snag and it was now smoking and smoldering from the top as well as around the base of the snag. Chips Fire Tree Felling FLA Page 3 Faller 1 made his way to the large pine snag, and began to size up the snag and prepare to fall it. Engine crew members on the line continued to install hose but many stopped to watch faller 1 cut down the large snag. Several crew members decided to video faller 1 cut down the tree which provided a record of the falling operation from beginning up to the time that the accident occurred. Faller 1 stated that when he sized up the tree, he identified that it had a heavy lean. He used his falling axe to “sound” the tree by striking it 3 times and determined that the snag was sound. Fire had made it into the snag and it was burning in the top and much of the top of the tree was smoking and smoldering. Faller 1 stated that he identified the limbs in the top as hazards, but believed that because of the heavy lean of the tree, anything that might come loose and fall down would miss his location and fall away from him working at the stump. Faller 1 began his falling operation by installing an undercut into the snag. When he finished cutting his undercut, Faller 1 walked around the back of the tree and used his axe to knock the wedge section out of the undercut. A small corner portion of the wedge section remained in the undercut and faller 1 struck this small corner trying to knock it out. While attempting to knock the small piece of the wedge section out of the undercut, a large limb approximately 5 feet long and 4 or 5 inches in diameter was dislodged from about 63 feet above ground and fell. The limb tumbled through other limbs causing it to rotate toward the faller and the limb struck the back of the hardhat being worn by the faller. The faller was knocked to the ground unconscious and the hardhat was knocked approximately 30 feet away. Chips Fire Tree Felling FLA Page 4 Personnel from the engine strike team notified the strike team leader that “we have a faller down” and responded to the faller to render aide. A quick evaluation of the situation was conducted by Emergency Medical personnel at which point, Engine Boss 2 made the call to move the faller to a safe location for further treatment and evaluation. This decision was made because the site where the accident occurred was highly dangerous both to the patient and to the caregivers. Faller 1 had regained consciousness by this time and was moved several hundred feet away, where additional medical treatment was administered. He was confused, complained of head and jaw pain and had a large laceration to the back of his head. The local engine strike team possessed 10 EMTs within their ranks. Emergency medical equipment was present on their engines, therefore, a back board, cervical collar and straps were quickly brought to the site and the faller was treated with full C-spine immobilizations and carried to an area where he could be evacuated by medevac helicopter. A few minutes after the faller was carried to the site known as the pumpkin site, the medevac helicopter arrived overhead. A rescuer was dropped via the helicopter hoist. The faller was place into an extrication basket and hoisted into the medevac helicopter. The rescuer then joined him in the helicopter and the faller was transported to an area medical facility for further evaluation. Total time between the initial accident notification and the patient extraction was 34 minutes. The Faller was evaluated at a local medical facility. He was diagnosed with a concussion and was released to rest and recover at home. An After Action Review was conducted on the line by the Division Supervisor with all personnel involved in the treatment and evacuation of the faller. Division supervisor stated that “it was time to stop, take a break, and re-focus on the job at hand.” Several personnel from the incident management team convened at the accident site to gather information and found evidence that the faller had been struck on the hardhat by a limb 5 inches in diameter and 5 feet long. The hard hat showed signs of being impacted by the limb, however, no additional damage was evident. The suspension system seemed to be intact and the shell showed no signs of cracks or splits. After documenting the accident sight, another faller finished felling the snag and operations in the area were allowed to continue. Chips Fire Tree Felling FLA Page 5 Chronology of Events August 20, 2012 0900 – Faller arrives at tree to be felled and begins his size up. 0941 – Faller is completing the undercut on the tree.