Angora Shelter Deployment Report

AngoraFireEntrapment&FireShelterDeployment
AccidentPreventionAnalysisReport
PacificSouthwestRegionLakeTahoeBasinManagementUnit
January17,2008
TableofContents
ExecutiveSummary 3
Introduction 5
DescriptionoftheAngoraFire 7
NarrativeoftheAccident 9
LessonsLearnedbyPeers 35
Equipment,Environmental,andHumanFactors 39
LessonsLearnedAnalysis 40
KeyIssues,Decisions,andBehaviors 41
SummaryofAllRecommendations(#110) 57
EvaluationofLessonsLearned.............................................................................59
Summary 62
AppendixA,ChronologyofEvents 63
AppendixB,FireBehaviorSummary 73
AppendixC,BriefingPaper:AccidentPreventionAnalysis 91
AppendixD,PersonalProtectiveEquipmentReport 92
AppendixE,FireShelterTechTip 95
AppendixF,APATeamMembers 99
2
ExecutiveSummary
OnJune26,2007, twoForestServicefirefightersassignedtotheAngoraFirewereentrappedby
fireandforcedintotheirfireshelters.Fortunately,theywereuninjured.Thisreport tellswhat
happenedandexaminesthesocialandorganizationalcausesthatledtothisoutcome.In
conductinganinvestigation,thereviewteamlearnedofanotherstorythatof anear
catastrophictragedyfordozensofotherfirefighterswhowerewithinminutesofalsobeing
entrapped.Accidentsandnearmissessuchasthisareproofofthehighrisksofwildland
firefightingaswellasproofthatourfirefightingorganizationcouldbettermanagetheserisks.
ThereviewteamconsistedoftwolineofficersunderdelegationsfromtheChiefandRegional
Forester,apeersubjectmatterexpert(enginecaptain),localandnationalNFFErepresentation,
andexpertsinFireSafety,Information,Behavior,andPersonalProtectiveEquipment.
WiththeencouragementoftheForestServiceNationalDirectorofSafety,thisaccidentwas
investigatedusingthenewAccidentPreventionAnalysis(APA)Guide. Thisguideisanoutcome
oftheFoundationalDoctrineandrecognizesthatalearningcultureiscrucialtosafe,principle
centeredmanagement.TheAPAprocessguidesareviewteamtotreatanyincident,suchasthis
deployment,asanorganizationalaccident.Assuch,honesthumanerrorsarenotcausalfactors
theyaretheconsequencesoforganizationalandsocialfactors.APAsareconductedwithina
learningcultureandfeatureareportdesignedtobe,initself,alearningtool.
Inaneffectivelearningculture,mistakes,nearmisses,andaccidentsareframed,publicized,and
exploitedasopportunitiestolearn,focusingonthefactualandperceivedeventsintheeyesofthe
actualparticipants.Consequently,thefocusofthisinvestigationwasnot todocumentwhere
employeeswentwrong orwhoshouldbeheldaccountableforperformance,butinsteadto
understandanddisplaywhytheiractionsmadesensetothematthattime,giventheinformation
theyevaluated.Importantly,iftheirriskydecisionsmadesensetothematthetime,thesame
riskydecisionswillmakesensetootheremployees,givensimilarcircumstances.Thereview
teambelievedthat, giventhesamesetofinformation,anotherteamoffirefighterswaslikelyto
havethesameresponsesonfutureevents.Correctingthisresponsethroughalearningculture
willstrengthenfutureteamactionsandleadtoanincreaseinfirefightersafety.
3
Thankstotheopenandfrankdiscussionswiththoseinvolved,theinvestigationrevealed
numerousupstreamfactorsthatenabledthisunintendedoutcome.Unlessmitigated,thesefactors
willremainresidentandmayprovideapathwayfordisaster. Thereportconcludeswithten
recommendationsbelievedbytheteamtoaddresscomplexorganizationalissuessuchas:
illdefinedandconflictingriskmanagementprinciplesintheurbaninterface,
illdefinedstandardsforfitnessforcommandinkeyfieldleadershippositions,
interagencyrelationshipsbetweentheForestService, CALFIREandlocalfiredepartments
often strainedbyculturalandfinancialdifferences,and
aculturethatencourageshothandoffs(fastteamtransitions)between InitialAttack, T2
andT1IMTsduringeventswithrapidlyescalatingcomplexity,suchastheAngora
Incident.
4
Introduction
OnJune26,2007,twoForestServiceemployeesassignedtotheAngoraFireontheLakeTahoe
BasinManagementUnitwereentrappedbyfireanddeployedfireshelters.Nosignificant
injuriesweresustained,neitherindividualwashospitalized,andallfirefightersinthevicinity
weresafelyevacuatedfromthefire.Thisincidentqualifiesasanentrapment,accordingto
FSM5100,Chapter5130,section5130.3,whichstates,
entrapmentsaresituationswherepersonnelareunexpectedlycaughtinafire
behaviorrelated,lifethreateningpositionwhereplannedescaperoutesorsafety
zonesareabsent,inadequate,orcompromised.Anentrapmentmayormaynot
includedeploymentofa fireshelter.Thesesituationsmayormaynotresultin
injuryandincludenearmisses.
TheInteragencyStandardsforFireandFireAviationOperations(page192)statesthat
entrapmentswillbeinvestigatedutilizingtheSeriousAccidentInvestigation Process.Recently,
theForestServiceRiskManagementCouncilwroteandfinalizedanaccidentinvestigation
processthatmeetsthelegalintentofanaccidentinvestigationandisbelievedtosubstantially
enhancealearningculture.Thisprocess,calledAccidentPreventionAnalysis,incorporates
conceptsof21st centuryHighReliabilityOrganizingandNormalAccidentsTheoryintothe
reviewandanalysisofthehumanandorganizationalfactorsrelatedtoanaccident.(See
AppendixCForestServiceRiskManagementCouncilbriefingpaper,ExaminingUnintended
Outcomes.)
Accordingly,theWashingtonOfficedelegatedauthoritytothePacificSouthwestRegional
OfficetousetheAccidentPreventionAnalysisprocesstoinvestigatethisaccident.TheAccident
PreventionAnalysis(APA)Teamconsistedofateamleader,chiefinvestigator,union
representative,achiefsrepresentative,technicalspecialists,andapeer(enginecaptain)froma
similartypeofForestServiceengine.TheAPAprocessisdesignedtomeetthetechnical
requirementsofanaccidentinvestigation,whileproducingareportthatservesasateachingtool.
AnothersignificantdifferencebetweenaseriousaccidentinvestigationandanAPAisthatan
APAfocusesontheorganizationalandculturalfactorsthatcanbeidentifiedascausaltothe
accident.
5
ThisreportpresentstheresultsoftheAngoraFireshelterdeploymentreview,documentsthe
eventandassociatedcircumstances,andprovidesadiscussionofthefire,lessonslearned,and
recommendations.
ReviewObjectives
ObjectivesoftheAngoraFireEntrapmentandShelterDeploymentAccidentPrevention
Analysiswereto:
Evaluateemployeeperformanceundertheassuranceofalearningculture.
Evaluateorganizationalandculturalfactorscontributingtotheaccident.
Developrecommendationstocorrectorchangeorganizationalfactorsandculture thatmay
impedeorganizationalreliabilityorincreaserisktoemployeesafety.
Produceareportthatservesasaneffectivefirefighter andorganizationallearningtool.
Recommendactionsthataddressandmitigatetheorganizationalandculturalfactors
identifiedascausal.
6
DescriptionoftheAngoraWildlandFire
TheAngoraFirewaslocatedinCaliforniasSierraNevadamountainrangeontheU.S.Forest
ServicesLakeTahoeBasinManagementUnit(LTBMU)(seeAngoraFireLocation,Figure1).
TheinitialdispatchfortheAngoraFirewasat1423hoursonSunday,June24,2007.Thefire
wasstartedbyacampfireeastof
AngoraLakesintheLTBMU.During
theinitialsizeup,theInitialAttack
IncidentCommanderlocateda15 to
20acrefireburninginmaturemixed
conifertimberwithaminorshrub
componentandheavydeadanddown
fuelload.Thefireexhibitedextreme
behaviorandarapidrateofspread.
Evacuationsofnumeroussubdivisions
inthepathofthefirewere
immediatelyordered.Withinonehour
fromtheinitialsizeup,homeswere
destroyed.ByMondaymorning,June
25,theAngoraFirehadconsumed
237structuresandmorethan2,500
acres.
Duetocalmwindsandaggressive Figure1. AngoraFireLocation
suppression,efforts,thefirehadminimalgrowthonJune25.OnJune26,afternoonwinds
causedthefiretospotovercontainmentlinesandconsumeanadditional356acresbeforeitwas
containedthatevening(seeAngoraFireProgressionMap,Figure2).
7
8
Figure2. AngoraFireprogressionmap
StoryofthefirefighterswhodeployedontheAngoraFire
ForestServiceEngine34(E34)wasoneofmanyresourcesorderedtohelpfighttheAngora
Fire.Theyreceivedtheirdispatchcallatabout1730onSunday,June24,2007.Theengines
captainandoneofthefirefightersnormallyassignedtotheenginewerenotavailableforthis
assignment,sotheenginemodulewasstaffedbyaRedCardedenginebossfromadifferent
engineandafirefighterfromoneoftheforestswatertenders.Theenginemoduleconfiguration
forthisassignmentconsistedofanengineboss(GS07),anengineer(GS07),anassistantfire
engineoperator(GS05),andtwofirefighters(GS04andGS03).
ThemoduleleaderwhowouldserveastheenginebossforE34hadbeenservingastheengine
bossforadifferentlocalengineamonthearlier.Hehadcompletedhistaskbookfortheengine
bossqualificationthepreviousSeptember,sotheAngoraFiredetailwasagreatopportunityto
gainexperience.TheAngoraFirewouldbethefirsttimethisenginebosswouldtakeanengine
offtheforestforanassignmentandthefirsttimethisenginemodulerespondedtogetherasa
crew.HiscrewincludedthreememberswhowerenormallyassignedtoFSE34.Theyincluded
theassistantfireengineoperator,theengineer,andanapprenticefirefighterwhohadnotyet
beentotheWildlandsFirefightersAcademy.Thefifthmemberofthecrewwasafirefighter
normallyassignedtoawatertenderontheforest. ThesefivefirefighterswouldbethecrewofE
34duringtheirassignmenttotheAngoraFire.
E34leftitsstationat1900Sundaynightanddroveforthreehoursbeforespendingthenightata
hotelinWillows,California.OnMondaymorning,June25,2007, thecrewwasontheroadto
thefireat0630andarrivedattheIncidentCommandPost(ICP)inSouthLakeTahoeat1100.
Uponarrival,E34wasassignedtoenginestriketeam3630C,agroupof5federaltype3
enginesfromnorthernCalifornia.Striketeam3630CconsistedofoneU.S.FishandWildlife
Serviceengine,oneNationalParkServiceengine,andthreeForestServiceengines,includingE
34.Thestriketeamsmissionthatdaywastoclearthebrushfromamidsloperoad,knownas
the12N19road,locatednear thenorthernperimeterofthefireonDivisionD(seeIncident
ActionPlanMap,Figures3and4).
9
Figure3. IncidentActionPlanMap 10
Figure4. IncidentActionPlanmapshowingthe12N19road
ThewindsthatdrovethefiresrapidgrowthonSundaynightwerepredictedtoreturnlaterinthe
week,andtheroadthatenginestriketeam3630Cwasworkingonwouldbethelinethatwasto
beusedtostopthefirefromspreadingfurthertothenorthandthreateningahousingsubdivision
in SouthLakeTahoe.
Althoughtheysharedacommonmission,theenginesinthestriketeammainlyworked
independentlyalongtheirassignedsectionsoftheroad,astheywereseparatedphysicallyby
beingstrungoutalongthisroadsegment.Occasionally,thecrewofE34couldseethemainfire
11
backingdownthehillabovethemonthefareasternendoftheroadnearthelocalhighschool.
However,thewindswerelightandthefirewasmovingslowly.Duetothedensevegetation
alongtheroad,thefirecouldntbeseenatallfrommostofthelocationstheyworkedthatday
(seePicture1).
Allmembersofthecrewat thistimeindicatedthattheyfeltlikethiswasatypicalassignmentfor
anenginemodule.
By2200,E34completeditsshiftandreturned
totheIncidentCommandPost(ICP). Inall,it
wasaratheruneventfuldayonthisfire
perimeterroad.
Thenextmorning,Tuesday,June26,wasthe
thirddaysincethefirestarted.Tuesdaymorning
wasalsothefirstshiftfortheType1Incident
ManagementTeam(IMT),whichtransitioned
thenightbeforewiththeType2team,which hadbeenin Picture1.Fuelsalong12N19
commandsinceMondaymorning.Alongwith theirstriketeamleader,theenginebossforE34
attendedthemorningbriefingat0600.
Therewereapproximately1,000peoplepresentatthebriefing,includinglargenumbersof
reportersandcontractors.Itwasnoisywithalotof distractingsideconversationstakingplace.
Adjacenttothebriefingareawasalongsnakingfirefighterlineforbreakfastwithliterally
hundredsof peoplefilingthrough.Thebriefingthismorningemphasizedaredflagwarningfor
highwindsonWednesday.ThestriketeamleaderbriefedhisenginebossesattheICPandtold
themtoheadouttothe12N19road,wheretheywouldreceiveaspecificbriefingonsite.
ThetrafficatICP,alongwiththelinesforfood,delayedtheirdeparture,but,byabout0830, E
34andtheotherenginesofstriketeam3630Cwerestagednear12N19andwerereceivingtheir
onsitebriefingfromthedivisionsupervisorandtheirstriketeamleader.Thisbriefingindicated
thatthepreviouseveningsnightshifthadconductedaburnouttoRoad12N19(seeFigure4)
andthatadozerlinehadbeenconstructedfromthetopofTahoeMountaindowntoRoad
12
12N19.TheirmissionforTuesday wastoplumbahoselayalongthedozer lineandthenhold
thefireperimeteron the12N19roadadjacenttotheareathathadbeenburnedoutovernight.
TotheenginebossofE34,themorningsbriefingsindicatedsubstantialprogressovernightin
containingthefire.Theirobjectivewouldbetoholdontowhatwasdonethenightbefore.The
enginebosshadanIncidentActionPlan(IAP)andusedittobriefhiscrew.Theplanincludeda
FireBehaviorForecast,shownbelowinFigure5.
13
Figure5.FireBehaviorForecast
(Note:typicallyinCalifornia,IncidentMeteorologistsandFireBehaviorAnalystsdonotuseor
discusstheHainesIndex.TheactualHainesIndexforthatdayandlocationwasa4orlow)
FIREBEHAVIORFORECAST
FORECASTNUMBER:01 FIRE:ANGORAFIRE
OPERATIONALPERIOD:Day,Tuesday,June26,2007
DATEISSUED:06/25/2007 TIME:2100
UNIT:USFSLakeTahoeBasinMU SIGNED:/s/xxxxxxxxxxxFBAN
WEATHERSUMMARY:SeeattachedFireWeatherForecastfordetails.
1. HOTDRYCONDITIONSEXPECTTOSEEANINCREASEINFIREBEHAVIORTODAY
ASCOMPAREDTOYESTERDAY.IFOPENFLAMESARENOTCONTAINQUICKLYTHISCOULD
TRIGGERAFUELS/SLOPERUNWHERESLOPEASPECTANDFUELSAREALIGNED
MINRH: 1015%DOWN5%FROMMONDAY
MAXIMUMTEMP: 7780at6300UP5DEGREESFROMMONDAY
WINDS(20FT):E510becomingSW1015G22after1300STRONGERWINDS!
PROBABILITYOFIGNITION: 85%
WATCHOUTFORWEDNESDAYGUSTYWINDSSW35MPH
WATCHOUTFORTHURSDAY STEADYWINDS1520GUSTINGTO40!!
GENERALFIREBEHAVIOR:Lookforfirebehaviortoincreasetodaywiththewindsincreasingafter1300.
Whattowatchfortoday:
1Openflamethatcoulddevelopintoarunnearyou
2Torchingandspottingaswindspickupcouldspot1/4milefromthespottingsource.
SPECIFIC:
NORTHENDOFFIRE:Expectincreasingfirebehavioraswindspickupearlyafternoonandastheinversion
liftsearliertodaythanMonday.Uncontainedfireedgewilllikelydevelopintoshortcrownfirerunswithspotting
1/4ofamileinfrontofthespottingsource
WESTERNEDGE:Ridgelineshouldcontaintorchingandspotting.Lookoutofpotentialspotstothewestofthe
ridgethatcoulddevelopintoawinddrivenfire.
EASTERNEDGE:Aswindsbegintomaterializeearlyafternoon,torchingandspottingnearthefireedgecould
causefirebrandstolandinreceptivefuelbedsupto1/4milefromthemainfireedge.
SOUTHEND:Unburnedfuelswillcontinuetotorchandprovidefirebrandsthatmayspottotheeastgiven
enoughloftwithincreasingwindsbyearlyafternoon.
AIROPERATIONS:Windswillincreasetodaywithpotentialgustsupto22mphbeginningafter1300heavy
smokewilllingeruntiltheinversionbeginstolift.
SAFETY:Whenworkingondirectlineconstructionmakesureyouknowwhereallpotentialsourcesof
openflamecanoriginatefrom.Payparticularattentiontowhereafirecouldstartaslopeandfuels
14
drivenrun.
TheenginebossofE34recallsthatthemorningbriefingsemphasizedthehighwindspredicted
forthefollowingday.Additionally,thesafetyofficersmessageintheIAPstated,Todayisthe
daytogetitwrappedup,windpickinguponWed.thoughSat.
Astheenginesdrovealong12N19towardthedozerline,itwasobviousthattheareaalongthe
roadhadnotbeenburnedouttotheroadastheyhadbeenledtobelieve.Infact,alongtheentire
length of12N19,therewasnoevidenceofthepreviousnightsburnout.Someconfusionaroseas
planswerechangedbythedivisionsupervisors tomatchtherealityontheground,buttheengine
bossofE34understoodthathismissionwasstillvalid:plumbthedozerlineandthenhold
12N19.Whiletheonthegroundsituationdidnotmatchthebriefing,thefirefightersfelt
comfortablethat theoverheadwouldsortoutwhathadactuallyhappenedthenightbeforeand
thenrebriefthecrewsonwhatwouldhappenthatday.
Atapproximately0900,E34andthreeotherenginesfromthestriketeamarrivedatthewestend
of12N19wherethedozerlineconnectedtotheroad.Thewindswerecalm undertheinversion,
whichmadeforsmokyconditionsfortheirplannedwork.Thefourenginesintendedtobegin
layinghoseupthedozerlinefromtheirlocationatthebottomoftheline.Thefifthenginewas
assignedtoanareaeastofthe12N19roadnearalocalhighschool,whereitwouldpatrolthat
sectionofthelinefortherestoftheday.However,beforethestriketeamofenginesonthe
12N19roadcouldbegintheirwork,theyhadtowaitforhosetobedeliveredfromICP.
Astheywaitedforthehosetobedelivered,amemberoftheSierraHotshotscamedownthe
dozerlinetotheirlocation.TheSierraHotshotsandtheLagunaHotshotshadbeenassignedto
finishtheburnoutthatwasbegunthenightbefore. TheSierraHotshotsuperintendentmentioned
tothestriketeamleaderthathewouldbethelookoutforhisHotshotcrew duringtheburnout
operations.TheHotshotsuperintendentalsomentionedthatagoodescaperouteexistedbygoing
straightoutthe12N19roadtothenorthwest.Duringthisconversation,severalmembersofE34
werenearbyandlistenedtotheHotshotsadvice.Atthispoint,alloftheengineswerefacing
southeasttowardtheirprimaryescaperouteasplanned.
15
By1000,thestriketeamstillhadnotreceivedthehosetheyneededtoplumbthedozerline.The
striketeamleadercontactedICPandlearnedthatduetoashortageofdriversinlogistics,he
wouldgotothehighschooltopickuptheneededhose,fittings,andfoldatanks.Leavingthe
striketeam on the12N19road,thestriketeamleaderdrovetothehighschoolandreturnedwith
halfoftheneededsuppliesby1100.Theotherhalfofthesupplieswasdeliveredbyacamp
driverandwasstagedataparkingareaattheeastendofthe12N19road.
Asthestriketeambegantoplanitshoselay,thedivisionsupervisorsforDivisionsDandE
devisedanewplan,reevaluatingtheburnoutoperationandhowthedozerlineshouldbe
plumbed.ItwasagreedbetweenthetwoDivisionsthatathirdHotshotcrewfromDivisionE
wouldplumbthedozerlineandthatDivisionD,includingE34sstriketeam,wouldfocusupon
holdingthe12N19road. ThisdecisionmovedtheD&EDivisionbreakandgavetheentire
burningandholding
operationtoDivisionD
(seeFigure6,Mapof
revisedplan).
16
Figure6.Mapofrevisedplan
InorderforDivisionEsHotshotstoplumbtheline,thestriketeamleaderwouldneedtodrive
thehoseandotherequipmenttothetopofthedozerline.Beforeleavingtoshuttlethehose,the
striketeamleaderorderedhisfourstriketeamenginestospreadoutalongthe12N19roadand
preparetoholdtheroadforaburnoutoperation.Thestriketeamleaderthentooktheapprentice
firefighterfromE34withhimtohelpdeliverthehosetothetopofthemountaintothe
Hotshots.Thetriptookthestriketeamleaderapproximatelyonehour,andhereturnedtothe
12N19roadby1200.
Followingthestriketeamleadersordertospreadoutandholdtheroad,thecrewofE34headed
eastapproximatelyhalfwaydownthe12N19roadawayfromthedozerlineandtowardtheir
plannedescaperoute.E34wasthefurthestengineeastintheirstriketeam,and,liketheother
engines,theywerefacingeasttowardtheirprimaryescaperoute.Theengineswerespreadout
200300feetapart(seeFigure7,Map@1300).
ThismapdepictstheapproximatelocationofmajorresourcesassignedtoDivisionDat1300.
TheseresourcesincludeCALFIREenginestriketeams9271Cand9141CCALFIREhand
crewStrikeTeams9232Gand9273GSierraandLagunaInteragencyHotshotCrewsIron
Mountainhandcrew,andtheindividualenginesassignedtothefederalenginestriketeam3630
C.Thestriketeamleaderfor3630CisshownasSTENandtheDivisionD,Division
SupervisorisshownasDIVS.)
17
Figure7. Approximate
resourcelocationsat1300. 18
AsthecrewofE34satontheroad,theycould
hearontheirradiosthattheHotshotswere
beginningtheburnout operationabovethem.
However,theonlyevidenceoftheoperation
fromtheroadwasthesoundofanoccasional
treetorchingoutandradiochatterbetweenthe
twoHotshotcrewsandthelookout
(seePicture2).
Whiletheywaitedon12N19,theengineboss
andtheassistantfireengineoperatorwalked
Picture2.Aerialphoto lookingsouthwestatthemost
downtheroadtothesoutheasttotalkwiththe
easterlyportionofDivisionD.Smokeinthecenteris
otherforcesassignedtoholdtheroad.Inaddition
fromignitionbyLagunaIHC.TheIHCwas
totheirstriketeam,thereweretwoCALFIRE attemptingstripfiring sothatitcouldbebrought
striketeamsofhandcrews(9273Gand9232G) downevenlyto12N19.
spreadoutalongtheroadandtwoCALFIREstriketeamsofenginesontheroad(9271Cand
9141C),oneateachendof12N19.
TheenginebossforE34waskeepingtheassistantfireengineoperator closetohimduringthis
assignmentbecausetheassistantfireengineoperatorhadrecentlystartedhistaskbookfor
engineboss.Itwastheenginebosssintentiontohelptraintheassistantfireengineoperatorand
helphimgetafewthingssignedoffonhisnewtaskbook.Whentheyreachedtheeastendofthe
road,thetwofirefighterstiedinwithCALFIREenginestriketeam9141Candnotedthatthey
hadnotspreadoutalongtheroadliketheirownstriketeamhad.Whenaskedabouttheirtactics,
9141Csstriketeamleaderrepliedthathedidnotwanttoblocktheescaperouteonsucha
narrowroad.Followingthisconversation,thetwofirefightersreturnedtoE34towaitforthe
firetobackdowntotheirpositionontheroad.
By1200,E34sstriketeamleadertookupapositionsoutheastofE34alongthe12N19road
andthefirefighterhehadtakenwithhimwasbackatE34(refertoFigure7,Map@1300).As
thecrewwaitedon theroad,theycutholesthroughthebrushonthedownhillsideoftheroadso
19
thattheycouldseeintothebrushandaccesstheareaincasetherewereanyspots.Thefirefighter
whowasondetailtoE34fromhisregularjobasatacticalwatertenderdriverbegantaking
weatherobservations.At1200,thetemperaturewas70degreeswith32%relativehumidity,and
lightwindswereestimatedSWat02mph.Atthistime,theinversionstillhadnotlifted.
Duringthenexthourandahalf,the
inversionbegantoliftandthesmokewas
beginningtoclear.Crewmemberscould
heartheHotshotstalkingontheradioabout
theirburnoutoperations,buttheystill
couldntseetheburnoutfromtheirposition
on12N19(seePicture3).By1300,some
torchingwasobservedneartheridgeabove
them,butthesmokewasheadeduphillaway
fromthem.At1300,theweatherobserved Picture3.BurnoutoperationsonTahoeMountainabove
was72degrees,22%relativehumidity,and the12N19roadatapproximately1330.
estimatedwindsSWat02mph.
ThecrewofE34overheardHotshotstalkingabouttheirburnoutoperationbeingextremelyhot
andthatsomeofthetreesintheareawere torching.Additionally,thelookoutfortheHotshots
reportedthathewasobservingthedevelopingcolumnbattlingwiththewind.By1334,bothof
theHotshotcrewsceasedtheirburnoutoperations.TheHotshotcrewsreportedtoDivisionthat
theywereceasingtheirburn,sayingthatitwastoolateinthedayandthattheburnoutwas
increasingthetorching.
NotlongafterE34senginebossheardthattheHotshotshadceasedburning,heheardfromone
ofthestriketeamenginestohiswestthattherewasaspotneartheline,butstillwithinthe
potentialblacksideoftheline.By1400southwestwindsbegantodevelop,and,althoughE34
couldnotseeit,thefireontheslopeabovethe12N19roadwasbeingpusheddownhill.
Additionally,thewindsstartedtopushthecolumntowardtheNEoverthetopofE34andthe
restofthecrewsalongtheroad.
20
Thewindswerevariablebutstilllightalongtheroad.Theinversionwasliftingandtherewas
blueskyoneithersideofthecolumnabovethem.By1415asheswerefallingaroundE34.The
crewcontinuedwatchingthedownhillside(northeast)oftheroadforspots.Thedetailed
firefighteronE34noticedanemberdropinthebrushjustbelowtheengine,soheheadeddown
toit.Hepickeditupwithhisshovelandcarrieditbacktotheroad.Bythetimehereachedthe
roadwithhisshovelfullofgrass,needlesandtwigs,hehadashovelfullofopenflame.The
firefighterdroppedtheburningshovelloadontheroadandtheassistantfireengineoperatorand
anearbyhandcrewmemberwithabackpackpumpputitout.Theenginebosswasconcerned
aboutwhathehadjustwitnessedandbegantowonderhowmanymoreofthosewereinthe
greenbelowtheengine.
Withmoreandmoreashandembersfallingfromthesky,theenginebossofE34toldthethree
regularmembersofE34tostaywiththeenginewhileheandthedetailedfirefighterpairedup
andbegantogridforspotsbelowtheengine.ThisleftthethreepermanentmembersofE34on
theroadwiththeengineandthetwodetailedmodulemembersgriddingforspotsbelow(north
of)theengine.
Thecolumnabove12N19wasgettingdarker.Thewindsalongtheroadweregenerallycalm,but
occasionallygustswouldbattlebackandforth.Findinganotherspotnorthof12N19(belowthe
road)theenginebossandthefirefighterwerebusyandfocusedongettingitoutandlookingfor
more.Totheengineboss,thespotsbelowhisengineposedthemostsignificantthreattothe
safetyofhisengine.
AsthetwomembersofE34wereworkingon
spotsbelowtheengine(approximately800feet
fromtheroad),theassistantfireengineoperator
stoodatthesideoftheroad,communicatingwith
theenginebossbyradio,ashetriedtokeepthem
bothinsight.Theapprenticefirefighterclimbed
ontopoftheenginetohelpserveasalookout.
Picture4.Viewofthemeadowafterthefire
passedthrough.
21
Astheenginebossandthefirefighterventuredfurtherandfurtherintotheareabelow(north of)
theroadtoattackspots,theywerentalone.ACALFIREcrewcaptainandninefirefighterswere
alsointhesameareaworkingonspotfires.Atthesametime,thewindson theroadweregetting
verygusty,generallyblowingnortheast,towardthemainfire.Thecolumn,goingintheopposite
direction,wasflatteningoutandcastingabrownshadowoverDivisionD.TheCALFIRE
Captainandhisfirefighters,alongwithE34senginebossandfirefighter,droppedbelowa
benchbelowthe12N19roadandwerenolongervisibletoE34sassistantfireengineoperator.
Theassistantfireengineoperatorradioedthefirefighterandaskedhimtomovebacktowardthe
enginesohecouldkeepaneyeonhim.Asthefirefighterbeganmovingbacktowardtheengine,
theenginebossredirectedhimtohelpwithaspotfireheandthefirefightersfromtheCALFIRE
handcrewwereworkingonnearagrassyareatheywerereferringtoasthemeadow(see
Picture4).
Unknowntothefirefighterschasingspotsnorthof
12N19,thefirebehavioratthesoutheastendof
DivisionDwasincreasingdramatically.TheIron
Mountainhandcrew,assignedtopatrolthe
easternendof12N19,noticedbatsflying
overheadatabout1420,andseveralmembersof
theIronMountaincrewsawabearrunningaway
fromthemainfireacross12N19.Shortly
thereafter,theroaroftreestorchingoutandstrong
convectivewindsmadeitobviousthatthefire
wasabouttocrownacrosstheroad.TheIron
MountainCrewBoss,onanintracrewchannel,
orderedhiscrewtoevacuatetotheeast(see
Picture5).TheLagunaIHCcrewandtheDivision
DSupervisorwereinthesamevicinity.Theyboth Picture5. IronMountainHandCrew
notedthatspotswerecrossing12N19andboth evacuatingDivisionDatapproximately1430
realizedtheplantoholdtheroadwasrapidlybecomingimpossible.
22
AtthetimeIronMountainwasevacuatingtheline,thestriketeamleaderfor3630C(E34s
striketeamleader)wasnearoneoftheIronMountaincrewssquadbosses.Henoticedthatthe
handcrewwasmovingout,buthedidntknowwhy.Heaskediftherewasaspotor
something.Thesquadbossmaynothaveheardthequestionanddidnotanswer.Uponseeing
thehandcrewleave,thestriketeamleaderwasconcernedthathiseasternflankwouldbe
undefended.Hedidnotrealizethatthefirehadalreadyspottedacrosstheroadandthattheentire
easternendoftheirlinewasabouttobecompromisedbyacrownfire.
Withtheintentofprotectingtheeasternendoftheroadandtheirescaperoute,heorderedhis
enginestobumpdowntohislocationtowardthesoutheasternendof12N19.Twoofhis
enginesheardandrespondedtotheordertobumpdown.E34sassistantfireengineoperator
didnothearthestriketeamleadersorderbutnoticedtwoenginesfromhisstriketeamdrivepast
himtotheeast.Hewonderedwheretheyweregoingbutwasmoreconcernedwiththe
whereaboutsofhisenginebossand
firefighter.
AsIronMountainwasevacuatingto
theeastandthetwostriketeam
enginesweremovingsoutheastto
assistthestriketeamleader,E34s
enginebosstookamomenttolook
aroundandbegantounderstandthe
precarioussituationthathe,the
firefighterwithhim,andtheCAL
Picture6.Picturetakenfromahelicopteratapproximately
FIREfirefighterswerein.Theengine
1450showingevolvingspotfiresnearthelocationwhereE34
bosscouldseemultiplespotsaround enginebossandfirefighterwerelastworkingonspotfires.
himandcouldfeelthewindgusting,
buthecouldnotseehisengineorthe12N19road.Theenginebosscalledouttothefirefighter,
Wegottago!Hethenradioedbacktohisassistantfireengineoperatorthatthereweresix or
sevenspotsinthearea,buttheywereheadedbacktotheengine(seePicture6).
23
Thetwoenginesfromthewestendofthe12N19roadarrivedatthestriketeamleadersposition
atapproximately1440.Minuteslater,thestriketeamleaderrecognizedthatthefirewas
threateningtheroadattheeastend,cuttingoffthestriketeamsplannedescaperoute.Infact,
althoughthestriketeamleadercouldnotseeitfromhisposition,thefirehadalreadycrossedthe
road.Recognizingthattheirpositionontheroadwasnolongerdefendableandthattheengines
werenowfacingthewrongwayforegress,thestriketeamleaderorderedtheenginestoturn
aroundanddriveoutoftheareatothewest.ThestriketeamleadercalledhisDivisiontonotify
himthattheywereevacuatingtheline.Simultaneously,theDivisionSupervisorwasalready
orderingtheevacuationofthedivision(seeFigure8,Map@1438).
24
Figure8,Map@1438. Thismapdepictstheapproximatelocationofresourcesatthe
approximatetimethefirecrossedroad12N19.
25
Astheenginebossandthefirefighterstartedbackupthehilltowardtheirengine,theengine
bossheardhisstriketeamleaderontheradioorderingthestriketeamtoturnaroundand
evacuatethedivision.Meanwhile,theCALFIREfirefighters,withwhomtheywereworking,
alsoheardtheordertoevacuate.Astheenginebossandfirefighterlookedback,theysawthe
CALFIREfirefighterslinedupandrunningeastdownatwotrackroadtowardTallacVillage.
Althoughtheenginebossandfirefighterwereheadeduphilltowardwheretheybelievedtheir
enginetobe,theywerealsoheadedstraighttowardtheoncomingheadofthefire.Therewere
spotsinalmosteverydirectiontheylooked.Astheyranbackupthehill,theyscannedthe
hillsidefortheroadandtheirengine.Atthesametime,theassistantfireengineoperatorfromE
34waspacingalongthesideoftheroad,scanningtheareabelowforanysignofthetwo
firefighters.Althoughhehadheardtheorderfromthestriketeamleadertoturntheengines
aroundandheadout12N19tothenorthwest,hewasdeterminednottoabandonthetwo
firefighters.Theassistantfireengineoperatorsenttheenginesengineerandapprentice
firefightertodriveE34downtheroadtothesoutheast,tofindaplacetoturnaroundandthen
comeback.Theassistantfireengineoperatorradioedhisstriketeamleadertolethimknowthat
hewaswaitingfortwooftheenginesfirefighterstoreturntotheengine.
RightafterE34hadturnedaround,Engine2(drivingsoutheastdown12N19alsolookingfora
placetoturnaround)metE34headon.Fortunately,thepointwheretheenginesmetwaswide
enoughtopass.
BythetimeE34gotbacktotheassistantfireengineoperatorspositionontheroad,therewas
stillnosignoftheenginebossandthefirefighter.Theskynowwasdarkfromthecolumn.The
numberofspotfireswasincreasinginalldirectionsaswasthesoundoftreestorching.AsE34
waited,numerousCALFIREfirefightersonfootwerehustlingpastthemtowardsthenorthwest
andtheotherthreeenginesfromthefederalstriketeampulledinbehindE34 (seeFigure8).
Astheenginebossandfirefighterwererunninguphill,tryingtofind12N19,theyknewtheyhad
tohurryandgettotheirengineortheirenginewouldbeforcedtoleavewithoutthem.Asthey
climbedwhattheythoughtwasthelastbenchjustbelow12N19,awalloffirestoppedthem.
Theytriedtogoaroundbutwerecutoffby anotheremergingspotfire.Theenginebossradioed
26
backtohiscrewontheengine,Werecutoff!Wereheadingbacktothemeadow!The
assistantfireengineoperatoraskedhimiftheywereheadingbacktothevillage.Theengineboss
repliedaffirmative!
BecauseE34wasnowtheleadengineforthewesternegressfrom12N19,theywereeffectively
blockingtheroadaslongastheystayedtolookforthetwocrewmembersbelow.Themainfire
abovethelineofengineswasgettingmoreintenseasitpulsedwithgroupsoftreestorching
downthehillsidetowardthestriketeam.ThedriverofE34begantoidleslowlyalongtheroad
withitsthreecrewmemberslookingfortheothertwoin thewoodsbelowthem.Theotherthree
engineswerepressingbehindthem.Afterashortdistance,E34stoppedinawidespotandtried
towavetherestoftheenginesby,buttheywouldnotpass.Theassistantfireengineoperator
calledhisenginebosstolethimknowthattheyhadtoevacuatetheroadimmediately.Thereply
hereceivedfromtheenginebosswas,Wereokay!Yougoon!Leaveus!Hearingthat
messagefromhisengineboss,theassistantfireengineoperatordirectedhisdrivertoleadthe
evacuationnorthwestdownthe12N19roadandeventuallytoHighway89.
Theenginebossandthefirefighterwerenow
runningbackdownhilltowardthemeadowarea
wheretheyhadbeenworkingonspotswiththe
CALFIREhandcrew.Whentheygotdowntothat
location,theystoppedonatwotrackroad.Inevery
directiontheycouldseeonlyfireorheavysmoke.
Atfirsttheytriedrunningbacktowardtheeastto
reachthecommunityofTallacVillage,butasthey
raninthatdirection,spotfirescutofftheir
Picture7.Angoraplume,lookingsoutheastfromHighway
route.Theyturnedaroundandrantowardthe 89,shortlybeforetheestimatedtimeofdeployment.
westandendeduprightbackwheretheystarted.Thelocationwheretheywerestandingwasa
widespotonatwotrackroadwithgreengrassand1015yardsofspacebetweenthemandthe
nearesttree.Thefirefighterwasexhaustedandwantedtodeployatthislocation.Theengineboss
wantedtokeeprunning.Theybothrememberedfromtheirfiresheltertrainingthatyoushouldnt
27
keeprunningpastagooddeploymentsiteinhopeofpossiblyfindingabettersite.Theydecided
todeploytheirsheltersrightwheretheystood(see Picture7andFigure9).
28
Figure9. Thismapdepictstheapproximatelocationofresourcesatthetimeofdeployment.
29
Thetwofirefighterspulledtheirsheltersoutanddeployedasquicklyastheycould.The
firefightergotintohisshelterquickly,buttheenginebosswassurprisedbythedifficultyof
openinghisshelter.Hethoughttohimself,Thisishardertousethanthepracticeshelters.With
anxietyaboutthesituation,gloveswetfromsweat,andalackoffamiliaritywithanew
generationfireshelter,itseemedlikeminutestotheenginebossbeforehewasfinallyabletoget
inhisshelter.
Onceinsidetheshelter,theenginebossrepeatedlytriedtocallthestriketeamleaderandhis
assistantfireengineoperator,butheneverreceivedareply.Hesuspectedthathisbatterieswere
lowandyelledtothefirefighternexttohimthatheneededhisbatteries.Afterabattery
exchange,therewasstillnoreplyontheradio.Theflamefronthadyettoarrive,sohestuckhis
radiooutsideoftheshelterandcalledagain.Thistimehereceivedaquickreply.Theengine
bossannouncedovertheradio,Wehavedeployed.Someoneansweredhiscallandaskedifhe
wasgoingtodeploy.Loudlyandasclearlyaspossible,theenginebossrepeated,WeHAVE
deployed!Theenginebossdescribedhislocationasbeingonatwotrackroadnorthofthefire.
Hewasthinkingthattheroadtheywereonwouldnotshowuponmapsbutthatlocalpeoplein
theareawouldknowtheroadsystem,soheradioed,someonelocalwouldknowwhereweare.
Justthenitgothotterandtheenginebosspulledhisradiobackinsideandsealedhisshelterto
theground.
Approximately5minutesaftertheyenteredtheirshelters,ablastofhotgaswashedoverthem.
Theairinsidethesheltersgotextremelyhot,makingbreathingdifficult.Theybothdugintothe
dirtandburiedtheirfacesasfarintothegroundastheycouldmanage.Itseemedtothe
firefightersthattherewereatleastthreemoreflameorheatpulsespassingoverthem,andthenit
gotquiet.Theenginebosspeekedoutsideofhisshelter.Therewasaholeinthesmokeandblue
skydirectlyabove.Hecouldhearhelicopterscloseby.Heswitchedhisradiotoairtoground
andbegantryingtorelayhispositiontothehelicopterssotheycoulddropwateronthem.The
smokeandheatreturnedbuttheenginebosscontinuedtopeekoutsideofhisshelterwheneverhe
thoughtitwassafesothathecouldcommunicate withthehelicoptersandotherswhomaybe
tryingtorescuethem.Asheopenedandclosedhisshelter,hecouldseetreestorchingandfeel
theheatoftheoncomingflames.Atsomepointduringthedeployment,achipmunkpushed
30
underneaththeedgeoftheenginebosssshelterandnuzzledupnexttohim.Theengineboss
reacheddownandwithhisglovedhandheldtheanimal,butthechipmunkdiedwithinafew
minutes.
Atonepoint,thefirefighterpeekedoutof
hisshelter,butgotashelterfullofhot
smoke.Hedecidedthathewasntgoingto
openhisshelteragainuntilsomebodytold
himitwassafetocomeout.Ashelayon
thetwotrackroad,thefirefighterwas
worriedthatanevacuatingengineoran
overzealousrescuerwouldcome
barrelingdowntheroadandrunthemover.
Picture7.Aerialviewofthedeploymentsite.
Assoonastheannouncementthatthetwo
menhaddeployedcameacrosstheradio,rescueoperationsbegan.Withinabout5to15minutes
ofdeploying,helicopterswerescanningtheareafortheshelters.Itisestimatedthatwaterdrops
nearthesheltersbeganwithin15minutesofdeployment.FromHighway89,severalfirefighters
couldseethatthehelicoptersweredroppingwateronlyafewhundredyardsfromthehighway.
TwosafetyofficersandaCALFIREstriketeamleaderhikedtowherethehelicopterswere
droppingandfoundthedeployedfirefighters.
Oncetheywerefound,theenginebossandthefirefighterweregivenaquickhealthcheck.It
wasdeterminedthattheycouldwalkouttoHighway89,approximatelymileaway.When they
arrivedattheroad,EMTsperformedamorethoroughcheckonthehealthofthetwomen.Asa
precaution,bothcrewmembersweretakentothelocalhospital,whereitwasdeterminedthat
theyhadcomethroughtheirshelterdeploymentcompletelyunharmed.Intotal,theyhadspent
approximately30minutesinsidetheirshelters.
31
Epiloguealargerstory
TheAccidentPreventionAnalysisTeammissionanddelegationreviewedtheentrapmentand
shelterdeployment.TheentrapmentwasaveryclosecallfortwofirefightersassignedtoE34
andtenCALFIREfirefighterswhowereforcedtofleeintoTallacVillage.However,asis
clearlyshownbythemapsandalludedtointhestoryabove,theAngoraFirewasnearlya
catastrophiceventfortwostriketeamsofhandcrewsandastriketeamofenginesatotalof
nearly70firefighters.Withtheirprimaryescaperoutecompromisedbythemainfirenearthe
southeastendofDivisionD,fourtype3engineshadtoturnaroundandevacuate,andthetwo
striketeamsofhandcrewshadtoreachthewestendofDivisionDbeforethemainfirecutoff
theirescaperouteortheemergingspotsnorthofRoad12N19weredrawnintothemainfire.One
ofthelastpeopleout,the3630Cstriketeamleaderstated,Itwasprettysquirrelly.Thefirewas
rightonmytail.TheAPAteamestimatedthelastfirefightersescapedDivisionDonlyafew
minutesbeforetheywouldhavebeenentrappedbytheensuingcrownfire.Hadthewindspeed
beenhigherorvectoredmorenortherly,orhadanenginegottenstuckturningaround,the
outcomeofthiseventwouldhavebeentragicallydifferent.
ThefollowingfivepicturesweretakenbyacrewmemberinEngine65,thesecondtolastengine
out(seepictures9through13).
Picture9. Thoughblurry,thispicturevividly
showstheprofusespottingoccurringnear12N19
justaftertheenginehadturnedaroundandwas
beginningescapetothenorthwest.
32
Picture10. FireasseebyfromEngine65near
thecenterofthedivisionalong12N19
Picture11. Engine65behindEngine81anda
slowmovingEngine34.
33
Picture12. FireasseenfromEngine65on
12N19nearthelocationwheretheengineswere
bunchedbehindE34.
Picture13. FireasseenfromEngine65on12N19
nearthenorthwestcorneroftheDivision,close to
wherethedozerlineconnectswiththeroad.
34
LessonsLearnedbyPeers
LessonsLearnedbythosedirectlyinvolvedintheaccident:
TheAccidentPreventionAnalysisReviewTeaminterviewedpersonnel whoappearedtohave
hadasignificantroleintheAngorafireentrapmentandshelterdeployment.Attheconclusionof
eachinterview,allparticipantswereaskedaseriesofquestionsregardingwhattheyhavelearned
forthemselvesfromthisaccidentandwhattheybelievedthegreaterwildlandfirecommunity
needstolearnfromit.Thefollowingisalistoftheirresponses.Theseresponseswereeditedto
eliminateredundancyandpersonalreferencesandtoimproveclaritybutotherwisearenot
categorizedorprioritized.Acommentfromanoperationssectionchiefmayappearadjacenttoa
commentfromafirefighter.Thesecommentswereevaluatedbythereviewteamandconsidered
whendevelopingtherecommendations.
Thestatementsbelowarereal,candid,open,honest,andintheirownwords.Readingthrough
thesegivesthereaderagoodunderstandingofthepassionandthoughtsofwhatthosemost
directlyaffectedbytheaccidentperceiveaslessonsallfirefightersandfiremanagersneedto
learntopreventasimilaraccident.
Whatfirefighterslearnedforthemselvesfromthisincident:
Talktotheenginesoneithersideofyou.
Makesureyouhavelotsofplacestoturnaroundtheengine.
Thisyearsnationalrefreshertraining(putoutbytheBLM)videowiththeLittleVenus
firefighterinterviewsworkedwell.
Makesureyouknowthetriggerpointsfordisengaging.
CommunicateandcoordinatebetterwithCALFIREfolks.Wethoughtwewereintegrated
butweobviouslywerent.
Takebettercareoffellowfirefighters.
Watchthewatchoutscloser.
Talktotheteammembersindividuallyandaskiftheyarereallycomfortabletakingoverthe
fire.Thentalktotheoutgoingteammemberstoseeiftheyarecomfortablegivingupthe
fire.(commentmadebyaC&Gstaffmember).
Beespeciallyheadsupwhenmyhandcrewsaresplitup.
Myattitudeonthefirelinewillbe:weareallone,regardlessofwhichagencyweworkfor.
Whenthefirebehaviorisincreasing,dontletyourcrewmembersgetoutofsight.
35
Whennothingisgoingon,usethattimetoscoutandlearnthelandscape.
Actonthewatchouts.Whentheyarepresent,dosomethingaboutit.
Stopotherfirefightersfromgoingtoofarchasingspots.
Dontjusttellyourfirefighterstolookforspots.Bespecificintellingthemhowfartogo
andspecificallywhatthetriggersarefordisengaging.
Takethetimetoknowyourfirefighters.Especiallyunderstandtheirexperiencelevel.
Makesureyourhaveplentyofspacetomaneuverenginesaroundwithturnouts,passing
areas,etc.
Makesureyourothercrewmembersknowwhereyouare.
Payattentiontowhatthelookoutsaresayingtoothers.
Iftheteamtransitionfeelsrushed,takeactiontoslowitdown.(CommentfromaC&Gstaff
member)
MakesurethecommandfrequencyonthehelicopterworksbeforeItakeoff.
DoalotmorescoutingbeforeIstartworkingonspots.
Getmyquestionsansweredbeforeacceptingtheassignment.
Whenyourfirefightersstarttoask, Whichwayisthefiregoing?itstimetogetoutof
there.
Wontletmy headgetlostinchasingspots.
Knowwhoisinchargeofyou.
Ifyouhavehelicoptersavailable,usethemsoonerratherthanlater.
Empoweryourlookouts topulltheevacuationtrigger.
Atriggerpointthatismorespotsthanyoucanpickupisntclear.Itstoosubjective.
Scoutyourescaperoutes. Scout.Scout.Scout.
Alwaysletyouradjoiningforcesknowwhatyouredoing.
Dontcompromisesafetybytryingtoburngently.
Askoperationalfolks,Whatisyourfallback,whatisyourcontingency?
Timetheburnoutwiththeforecast.Ifyoucanttimeitright,dontdoit.
Knowingwhichwaytogowhenourescaperoutewascutoff wastheonethingIdidright.
Dontputtheleastexperiencedcrewinthemostriskyarea.
Whatthefirefighterssaidthegreaterwildlandfirecommunityneedsto
learnfromthisincident:
Trainingonfireshelteruseandselectingadeploymentsiteworked.
LCESworkedforthoseusingit.
Alwaysknowandevaluatetriggerpoints.Setvalidtriggerpointsfordisengagement.
Puttimeframesandtriggerpointsontheburningoperation.
Whendoingabigburnoutoperation,establishaburnorganizationwithaholdingboss,
lightingboss,etc.
36
Allfirefightersmustknow:youdontchasespotswithacolumncrankingaboveyou.
Culturallyitisnotokayforateamtosaytheyarenotreadytotakeoverafire.Weneedto
fixthatculture.
Dontallowimportantinformationtobediscussedoversquirrel(intracrewfrequencies)
channels.
Wehavesetupfirefightersbyteachingthemthatsomeoneelseisresponsiblefortheirsafety
(avictimmentalityifsomethingbadhappenstothem,theyarenotatfaultsomeoneelse
is).Wevetaughtthemthatsomeoneiswatchingoutforthem.Weneedtoteachfolksto
takeresponsibilityfortheirownsafety.
The10&18&LCESdoesntmeanalottosomeonewithoutexperience.Weneedto
appreciatethatfirefightershavetohaveseenenoughfireandfirebehaviortorecognizeand
understandawatchout,orafireorder.
Weshouldminimizeoverheadtransitions.
Weneedabetterwaytomanagethepress.Theywereahugedistraction.
TheFSs2to1andCALFIREs24hourshiftsandlocalgovernmentsanythinggoeson
shiftlengthsisnotonlyalogisticalnightmare,itstotallyunmanageable.Everyoneonthe
incidentmustbeonthesameworkschedule(itismeaningfultonotethatthiscomment
camefromC&GmemberoftheType1IMT).
Usethisincidentasatrainingexerciseorsimulationforenginebossesandstriketeam
leaders.
Everyonefromindividualfirefighterstoincidentmanagementteamsshouldbaseallactions
oncurrentandexpectedweatherandfirebehavior.
UsethisincidentfortrainingFBANSandinFBANworkshops.
Chasingspotsisseductiveitsreallyhardtoresist.Weneedatrainingmodulethatteaches
firefighterstoreactinstinctivelyandappropriatelytospotting.
Managersneedtobehonestandupfrontandfacethetruth.Whenstructuresareinvolvedwe
takemorerisks.Wegivelipservicetothecompanylineandsaywedontrisklivesfor
structures,butthatisntreal.
Useavailabletechnologytogetbetterintelonthefire.(Livelinkwasavailablebutnotused)
Weneedawaytobettermentorourfirefighters.Youngfolksarecomingintoleadership
positionstooquickly.
Ifleadershipdoesntchangewherewearegoingandcontinuetoignoreretention,work
forcedevelopmentandlowerbudgets,thisandworseaccidentswillcontinuetogetmore
frequent.
Weneedawaytoweedoutincompetentpeopleinleadershippositions.
Practicesheltersareeasytodeploy.Itsharderonarealfire.
Dontexpecttobeabletotransmitinsideashelter.Theydefinitelyinterferewithradiouse.
37
AdditionalIssuesRaised
Immediately precedingthisevent,Region5wasexperiencingrapidturnoveroffirefightersand
wasimplementingnewhiring,promotion,andretentionpolicies.Theseweretheissuesmost
oftenmentionedbythefirefightersinvolved.Whetherornotitistrue,inthemindsofmanyof
thesefirefighters,attritionandhumanresourcepracticesplayedaroleinthisaccident.The
majorityofthecommentsgiventothereviewteamwereredundantwiththefivelistedbelowand
thereforewerenotdisplayedindividually.
PaydifferencesbetweentheForestServiceandourcooperatorsare resultingin toomany

holesinleadershipandtoomanyvacancies.Aslongasthehugegapinpayexists,
leadershipholeswillcontinuetoexisteverywhere.R5needstobecarefulnot topromote
inexperiencedpeopletoleadershippositionstooquicklyinordertostaffmoremodules.
Ourrapidpromotionprocessissettingusupforanotherdisaster.
ThiswillhappenmoreandmoreifwedontaddressForestServicepay issues.
YoucannotretainexperiencedfirefightersinRegion5duetothepaydifferencesbetween
stateandlocalagenciesandtheForestService.
Topreventthisinthefuture,theForestServicemusthavethefollowingasitstopthree
priorities:
Recruitandhireonlyhighqualityemployees.
Rampupretentionincentivestoalevelwheretheyactuallywork.
Basepromotionpoliciesonlyonqualityperformanceanddemonstratedfitnessfor
command.
38
Equipment,Environmental,andHumanFactors
Equipment
Therewerenoequipmentissuesdiscoveredthatcontributedtothisaccident.Allequipment
performedasdesigned,andthefiresheltersusedwerelikelylifesavingpersonalprotective
equipment.TheonlyequipmentfailurenotedwasthattheOSC1(OperationsSectionChiefType
1)couldnottransmitoncommandnetfromhisobservationhelicopter.Thatfailurehadnoeffect
orinfluenceontheaccident.Therefore,theteamdidnotinvestanytimeinevaluatingthecause
ofthatcommunicationfailure.
Environmental
Theenvironmentalfactorsofsignificancearethosethatledtothevolatileandextremefire
behaviorconditionsontheafternoonofJune26th.Whilethefirebehaviorwaspredictable,it
wasneverthelesssounusualthatnumeroushighlyexperiencedfirefightersweresurprised.For
furtherdiscussiononthefirebehaviorseeAppendix B.
Human
Humanfactorsexplainhowhumanscometomakesenseofbehaviorsthatare,inhindsight,
unnecessarilyriskybehaviors.InanAccidentPreventionAnalysis,humanfactorsaredisplayed
inthelistingof CausalandLatentFactorsbelow.
39
LessonsLearnedAnalysis
Developmentofcausalfactorsandrecommendationsbasedonlessons
learnedandteamanalysisofKeyIssues,Decisions,andBehaviors.
Withperfecthindsight,someoftheriskmanagementdecisionsdisplayedbelowmayappearto
arisefromalackofskillorexperience.Minimumskillandqualityexperienceisclearlyanissue
ofconcerntothefirefightersinvolvedinthisincidentaswellasamajorfocusoftheAPAreview
team.
However,itisimportanttonotethateverypersoninterviewedforthisaccidentmetorexceeded
theagencysminimumqualificationsfor thatposition.Inotherwords,theagencycertifiedthat
everypersoninvolvedinthisincidentaccidentreviewhadthenecessaryknowledge,skill,and
experiencetoperformsatisfactorilyontheincident.Consequently,ifanemployeeserrorisdue
toalackofexperience,therootcauseofthaterrorisnttheemployeeslackofexperiencerather
therootcauseor causalfactoristhattheagencysstandardforqualifyingexperienceor
evaluationprocessmaybeinadequate.
Likewise,everyonedirectlyinvolvedappearedtobeappropriatelymotivated.Theteamfoundno
evidenceofbehaviorthatarosefromrecklessnessormaliciousintent.Thedecisions,whichin
hindsightmayseemunreasonabletothereader,seemedreasonabletothoseinvolvedatthetime
basedupontheirunderstandingofthesituation,theirexperience,theirtrainingandtheir
expectations.
IntheAccidentPreventionAnalysisprocess,thereviewteamcontinuouslyengagedina
substitutiontest.Asstatedintheguide,
Throughouttheinvestigativeprocesstheteamshouldbeperforminga
SubstitutionTest thisisasking:couldanotheremployee(orsupervisorofthe
activity)meetingtheagencysminimumcompetencystandardsmakethesame
decisionsandhavethesame(orworse)outcome?Iftheanswertothisquestionis
yes,thenitislikelyasimilarorworseaccidentwilloccuragainunlessthe
latentcausesareidentifiedandmitigated.
Inanalyzingeach ofthefollowingKeyIssues,Decisions,andBehaviors,thedeterminationof
thereviewteamwasYEStothesubstitutiontest.
40
I.Keyissues,decisions,andbehaviors
TheType1IMT(IncidentManagementTeam)acceptedmanagerialcontroloftheincident
soonafterarrival
beforesomekeyoperationalteammemberscouldtransitionwiththeircounterpartsonthe
Type2team.
beforeaccuratefirelocationinformationwasmappedorknowntocritical operational
leadership,causingpartsoftheplantobeinaccurate.
beforeOperationsandPlanninghadadequatelyevaluatedandpreparedforpredictedfire
behavior,mediacontrol,logisticalsupport,andcontingenciesforfailure.
Relatedelements
TheT2OSC2debriefedwiththeT1OSC1afterthe6/26dayshiftIncidentActionPlan
wasdeveloped.
TheorganizationoftheT1IMTwasnonstandard(explainedbelow).
Therewasonlyonebranchandthispersonsupervised8divisionsand2groups.
IncompliancewithnationalT1standards,theT1IMThadtwoqualifiedOperation
SectionChiefshowever,oneofthemoversawnightshiftandtheother,dayshift.The
personoperatingas(andlistedontheIAPas)PlanningOpswasanOSC1trainee.
DIVS Ddirectly supervisedatleast14resources.
DIVS DandEplannedtheburnoutoperationbutdidnotbelievetheyhadthetimeto,or
believeitwasnecessaryto,establishastandardfiringandholdingstructure.
Causalandlatentfactors
ThetimingofatransitionbetweenIMTsisaverycomplicatedriskmanagementprocess.
IncomingIMTsmustbalancetheneedtoassumecommandasquicklyaspossiblewiththeneed
toobtainenoughintelligencetobeeffective.Actionssuchasthoselistedabovemayhavebeen
theleastriskyoptionavailable,giventheexpandingandurgentneedforprotectionoflifeand
property.TheagencysexpectationforIMTsistotransitionasrapidlyasispossibletoreduce
existingrisktothefirefightersandthepublic.
Duringthefirstoperationalperiodoftheincident,theLakeTahoeBasinManagementUnit
(LTBMU)orderedaType2IMTtotakecommandoftheincidentondaytwo,andaType1
IMTtotakeovertheincidentondaythree.TherationalewasthattheType2wouldarrive
quicklyandbeabletorelievetheextendedattackICwithin12to24hours.TheType1IMT
41
wouldbescheduledtotransitionwiththeType2IMTandtakecommandoftheincidentonday
three.Itisbeyondthescopeofthisanalysistodetermineifthedecisiontoordertwoteamsat
oncewasappropriate.Nevertheless,thatdecisionresultedinthreeincidenttransitionsovera
threedayperiodandtheinevitableconfusionassociatedwiththose transitions.
42
Recommendations#12(of10)
1) TheRegionalForestershouldrequestthattheT1andtheT2IMT
workwiththeNationalFireOperationsRiskManagementOfficerto
facilitateasmallHighReliabilityOrganizing(HRO)workshop
surroundingandfocusedontheissuessurfacedinthisreport.In
particular,issuessuchas"hothandoffs"transitionculture,
transitioninformationstandards,protocols,andshadowingshould
beevaluatedunderdoctrinalandHROprecepts.Followingthis
workshop,theteamsshouldthenworkwiththeWildlandFire
LessonsLearnedCentertodisplaythelessonslearned,with
respecttoHighReliabilityOrganizing,otherIMTs,andthegreater
wildlandfirecommunity.Ifpossible,theworkshopshouldinclude
theteam'scommandandgeneralstaff,divisionsupervisors,
situationunitstaff,andthefirebehavioranalyst.Thereviewteam
believesthisrecommendationisthecornerstoneoflearningwithin
thisreportandthattheIMTisthebestqualifiedtoaddressthese
complexissues.Theteambelievesthisprocesswillstrengthenthe
incidentmanagementprocessandaddressanyinterteampolicies
oroperatingculturesthereviewteammaynotbeawareofwithina
learningframework.
2) TheRegionalForestershouldrequestthattheWashington OfficeFireandAviation
ManagementevaluatestrategiestoensureIncidentManagementLeadershipisordered
relativetotheexpectedandcurrentcomplexityandthatgeographicareacoordinators
continuetoprovideoversighttoForestSupervisorsfortheefficientandeffectiveteam
placementthatstrivestominimizemultiplerapidteamtransitions.
43
II.Keyissues,decisions,andbehaviors
Beginningat0600onTuesday,June26,2007,upuntilapproximately1300,highlyexperienced
operationalpersonnelthroughouttheincidentmanagementorganizationunderestimatedthe
expectedfirebehaviorandconsequentlytheriskstoassignedresourcesalongroad12N19atthe
headofthefire.
Itappearsthat,incrementally,virtuallyallleadershipinvolvedacceptedmoreandmorerisk.It
alsoappearsthatleadershipfromtheOSC1downtotheE34enginebossuniformlydidnot
adjustforthewideninggapbetweenwhatwaslikelytohappenandwhattheycoulddoaboutit.
ThenotableexceptiontothewidespreadnormalizationofincreasingriskwasbothoftheIHCs,
whichrecognizedatapproximately1330thattheirplannedmissioncouldnotbeaccomplished
andorderedtheirpersonneltowithdrawtoasafeareaonroad12N19by1400.
Relatedelements
TheFireBehaviorAnalyst(FBAN)fortheT1IMTwasnotutilizedinplanningtheholding
andburnoutoperation,norwastheFBANsfirebehaviorforecastadequatelyconsideredby
leadersorpersonnel inmitigatingsafetyhazardsforeitherDivisionEorD.
AninfraredthermalmappingflightwasnotorderedforMondaynight.
The215Adevelopedfor6/26didnotincludeanalysisoffiringoperationsinDivisionD.
WhenthedivisionbreakwasmovedandDivisionDtookcontroloftheburningoperations
fromE,theburningoperationdidnotcomplywiththerecommendationsstatedinthe215A
suchasawrittenplan,assignmentofaFiringBoss,etc.
Thenightshiftoperationalpersonnelreferredtothefireslocationnearajeeproad.Some
dayshiftoperationalpersonnelinterpretedjeeproadtomeanRoad12N19. Infact,the
jeeproadwasactuallyseveralhundredfeetupslopeofRoad12N19.
ContingencyplansforthefirebreachingRoad12N19werenotdevelopede.g.,Tallac
Villagewasnotevacuated.Thelackoftriggerpointsmayhavereinforcedthestandand
defendtacticandmustdomentalityofsomeholdingoperationsonDIVSD. Therewere
clearlyotheroptionsbelow12N19wheredramaticchangesinslopeandfuelsexisted.
TheordertoevacuateDivisionDwasgivenonlyafteritbecameevidentthefirehadorsoon
wouldcrossRoad12N19withahighintensitycrownfire.
Baseduponinterviews,fewfirefighters oneitherdivision appreciatedthesignificanceofthe
IHCsdisengagingfromtheburnoutoperation.
Whenasked,Whatwasyourtriggerforwithdrawing?mostofthesupervisoryfirefighters
assignedtohold12N19repliedwithindefiniteandvagueanswerssuchasIfwegotmore
spotsovertheroadthanwecouldcatch.
44
TheunderstandingofOSC1(t),OSC1,OPBD,andDIVSD&Eatthebeginningofthe
6/26/2007shiftwasthatthepreviousnightshifthadcompletedaburnoutoperationeffectivelyto
the12N19road(thismisunderstandingmaybepartlyduetothenightshiftreferencetothejeep
road,whichwaslaterinterpretedtomeanRoad12N19).Forexample,theIncidentActionPlan
statedthatDivisionDsmissionthatdaywastoImproveline,mopuparoundstructuresand
100infromtheline.WhenDivisionDresourcesarrivedontheirdivision,thelocationofthe
firewasentirelydifferentfromtheirexpectations.Theirbriefings,preparations,andplanned
actionswerenolongerrelevant.DIVSDandDIVSE,alongwithotherhighlyexperiencedand
skilledoperationalpersonnel,investedseveralhoursinobtaininganaccuratelocationofthefire
anddevisinganewplan.Thiswasfrustratingtomanybecausethecalmmorninghourswould
havebeenthebesttimetoconductaburnoutoperation.However,theycouldnotstartthe
burnoutuntiltheyweresuretheyhadaccurateintelligenceonthelocationofthefire.
Thenewplan,finalizedlatein themorning,changedDIVSDfromamopupandholding
operationtoaburnoutandholdingoperation.Importantly,basedonextensiveinterviews,the
striketeamleadersandtheIHCleadershipondivisionDfeltcomfortablewith,supported,and
concurredwiththenewplan.
Anappropriatequoteobtainedintheinterviewsrelatedtothesedecisionsandbehaviorsis:Its
likeeveryoneforgotwhatSundaywaslike.InfacteveryoneinterviewedfromDivisionD,
includingnumeroushighlyexperiencedfirefightersandinexperiencedfirefighters,shared
virtuallyidenticalexpectationsofsuccessupuntilapproximately1300.
WerelyonRecognitionPrimedDecisionmakingskillsofexperiencedfirefighterstoenable
themtomakerapid,safe,andtimecriticaldecisions.Thisskilldependsuponareasonablematch
ofapresentconditionwithapastexperience.Thefactthatsomanyhighlyexperienced
firefightersweresurprisedbytherapidescalationofspotfiresandtherapidchangeoffire
behaviorindicatesthatthisphenomenonmusthavebeenaveryrareevent.Inotherwords,the
pastexperiencesofoveradozenseasonedfirefightersonDivisionDat1300wereinadequateto
enablethemtoperceivetheriskstheywouldfaceanhourandahalflater.
45
Amongthereasonsforanunderestimationoffirebehaviorandaconsequentmisperceptionof
riskwere:
Thefirebehaviorofthepreviousdays(Monday)fireswasminimalandtheT2IMTmade
substantialprogressoncontainment.Forthemostpart,thoseT1IMTmemberswhohad
beeninvolvedinthetransitionhadseenonlyminimalfirebehavioronthisincident.
Astheinversioncleared,windswereinitiallylightandgenerallyupslopefavorablefor
continuingholdingoperations.
TherewashighconcernandfocusbytheT1IMTonWednesdaysforecastedhighwinds.
MessagesconveyedonTuesdaymorning,suchasTodayisthedaytogetitwrappedup,
(SafetyOfficersMessageintheIAP)servedtoovershadowtheaccuratelyforecasted
weatherforTuesdaysdayshift.
TheOperationalPlanforTuesdaysdayshiftwasbasedonmisinterpretedfieldintelligence
fromMondaysnightshiftincludingtheincompleteburnoutworkremainingabove12N19
road.Basedonthisintelligenceerror,themembersoftheT2IMTinvolvedinplanningfor
TuesdaysdayshiftbelievedthatDivisionD&Ewouldhaveasimplecleanupoperation
andthatthefirewouldbefullycontainedearlyinTuesdaysdayshift.Thisperception
helpedtocreateagroupmindset,pervasivethroughouttheleadershiponDivisionD,that
thetaskbeforethemwasclear:wrapupthefireinpreparationforWednesdayswinds.
Theirexpectationwasthattheirjobwasneithercomplicatednordifficult.Theirexpectation
ofwrappingupthefirewasreinforcedbytheiroriginalunderstandingofthefires
location.Gradually,overseveralhoursthatmorning,piecesofinformationandsignsof
inconsistencybegantocontradictleadershipsperceptionofreality.Lackingbigpicture
information,virtuallyallleadersinvolvedclungtothepreviousandcomfortablereality.It
wasntuntiltheIHCreportedthattheintensityofthefirewastoogreatfortheburnoutto
continue(about1330)thattherewassufficientevidencetoseriouslychallengetheir
optimism.
TheT2IMTonMondayandMondaynightinvestedconsiderableresourcesinpreparing
road12N19asafirebreakandholdingline(brushing,limbing,etc.).Abandoningthisroad
foramoreviablecontingencywouldhaverequiredafundamentalreevaluationoftheirplan.
TheNWCGsapplicationofIncidentCommandSystemplacestheFBANpositionasa
technicalspecialistunderSituationUnitLeader.ConsequentlytheabilityforanFBANto
influencePlanning,Operations,orSafetyislargelyafunctionofthesocialrelationships
betweenthesefunctions.
Therateofchangefrommoderatefirebehaviortoextremefirebehaviorwasarareevent.
TheDivisionSupervisorsofDandE,alongwithIHCleadershipandseveralstriketeam
leaders,investedhoursofworkdevelopingaplantoburnoutto12N19.Thiscouldhave
resultedinoneorallofthreecommondecisiontraps.First,therecouldhavebeenagroup
mindsetofoptimism.Thatis,asharedopinionthatwithsomanyexpertsinvolvedin
developingaplan,thattheplanmustbeverygoodone.Secondly,therearelegitimateand
subtlesocialpressuresagainstchangingplansthatinvolvenumerousresources.Becauseof
theeffortexpendedindevelopingthenewplan,advisingalltheresourcesontwodivisions
46
ofthenewplan,andformallyandpubliclyannouncingthenewplanovertheradiotothe
BranchDirector,theleadershiponDivisionEandDwerereluctanttomakeadditional
majoradjustmentstotheplanandwouldhavenaturallysoughtconfirmingevidenceofthe
validityoftheirnewplan.Finally,themindsetoftheleadershipwasfocuseduponholding
thefireonRoad12N19.ThismayhavepredisposedthegroupofdecisionmakerstoFrame
Blindnessinthatthenewplanhadtofitwithintheframeofholdingthefireon12N19.
Otheroptions,outsideofthisframe,werenotexplored.
Recommendation#3(of10)
ImplementRecommendation#1.Failuretoestablishmeaningfulandrelevanttriggerpointsfor
withdrawalisafrequentandrecurrentconcerninaccidentandnearmissincidents.TheHRO
workshopshouldfocusontriggerpointsastheyrelatetosituationalawareness. Agoalofthe
workshopcouldbetohelptheagencymovetoaculturewheresituationalawarenessisnotonly
constantlyreevaluatedbutalsowherefiregroundleadersroutinelymentallysimulate,game
play,orfantasizeaboutfailureandarticulateeventsorscenariosthatdemandafundamental
reevaluationofstrategiesortactics.Inthisparticularinstance,itisunhelpfulhindsighttosay
thattheDivisionDpersonnelshouldhavehadatriggerpointforwithdrawal. Rather,afocusof
theHROworkshopshouldbehowtosharethelessonslearnedheretofosteraculturewherefire
groundcommandersexerciseaproperpreoccupationwithfailure.
3) TheRegionalForestershouldrequestForestServiceFAMtoevaluatestrategiesfor
integratingFBANsintothescenariosofS420andS520totrainOSCsandFBANstoshare
criticalinformationandtohelpdevelopeffectiveworkingrelationships. TheRegional
ForestershouldrequestthattheNWCGreviewandevaluatethepositionoftheFBANwithin
theIncidentCommandOrganizationandrecommendchangesifappropriate.
III.Keyissues,decisions,andbehaviors
EarlyintheafternoonTuesday,theLineSafetyOfficerwasdivertedfrompatrollingDivisionD
&Eanddirectedtodissuademediaenteringthefireareafromthenorth.
TheOperationsSectionChiefhadnotyetseenthefirebutfeltcompelledtogiveaSenators
Aideanoverviewflightthatstartedapproximately1400thedayofthedeployment.TheOSC
47
relayedtotheteamthatthisdelayedhisearlierflightplansandreducedhispersonalSA
developmentfortheshift.
Relatedelements
None
DozensofreporterswereenteringthefireareafromHWY89andwalkingintowardtheheadof
thefire. Ahighrankingoperationsofficialevaluatedthesituationandreasonedthatthese
personsposednotonlyasubstantialrisktothemselvesbutalsotothefirefighterswho,inthe
eventofabreachincontainmentlines,wouldinevitablyrisktheirlivestosavethemedia
personnel. ThisofficialrequestedtheassistanceoftheDivisionD/ELineSafetyOfficerto
mitigatethisrisk. WhilethisrequestremovedtheLineSafetyOfficerfromtheholdinglines,it
didnotremovetheSafetyOfficerfromthegeneralvicinityofDivisionD,nordiditpreclude
communicationsbetweentheSafetyOfficerandeitherDivisionSupervisor.
TheOperationsSectionChieffeltcompelledtoflywithapoliticalVIPatacriticaltimeof
operations.ThisaerialtouralsodelayedtheobservationflightoftheFBAN.Theaerialrecon
wascriticaltotheOSCssituationalawarenessasneitherhenortheFBANhadseenthefire.
Recommendations
Implementrecommendation#1. ItisnotknowniftheIMTsunderestimatedtheamountofmedia
attentionthisincidentwouldgenerateandwasthusunpreparedtomanagethemediaorifthe
actionsofthemediawouldhaveoverwhelmedanyreasonablyprudentcontingencyplan. The
teamcanresolvethisquestionandsupplyrecommendationsinconjunctionwiththeHRO
workshop.
48
IV.Keyissues,decisions,andbehaviors
Overaperiodofapproximatelyonehour,theenginebossofE34andhissubordinatefirefighter
focusedincreasingeffortandattentiononsuppressingspotfiresnorthof Road12N19.At
approximately1415theywereworkingonaspotfireoutofsightandover800feetawayfrom
Road12N19.
Relatedelements
Thestriketeamleaderof3630Cdidnotrecognizetheexperienceleveloftheengineboss,had
novisualcontactwithhisstriketeamfromapproximately1100through1400,andwasengaged
inlogisticaloperations(haulinghose)fromapproximately1000to1200
A0.9acreparking/stagingareawasconstructedneartheDivisionC/Dbreak.OnJune26,2007,
atleastonepersonwithleadershipandsupervisoryresponsibilityunderstoodthistobeasafety
zone.SeveralpersonsinleadershiprolesassignedtoDivisionDreferredtotheareaasa
combinationofastagingareaandasafetyzone.Asafetyzoneinthisfueltype,underthese
conditions,andwiththenumberofresourcesinvolvedwouldneedtobe20to30acresinsize.
Duringandimmediatelyafterthedeployment,akeysupervisorwasaskedtwiceforaPAR.
ThissupervisordidnotunderstandwhataPAR(PersonnelAccountabilityReport)requestwas
butneverthelesstwicerepliedallwasokay.PARiscommonterminologyusedbyCALFIRE,
localfiredepartments,andothersworkingonstructurefires.
Although theenginebossmettheminimumnationalandregionalenginebossqualifications,this
washisfirstoffforestassignmentasanengineboss.Withlittlesupervision thatday,theengine
bossreliedonbriefingsthatmorning,hispastfireexperience,andhisobservationsofthefirethe
daybefore.ThebriefingsindicatedthatJune26th wasawrapupdayandthatthesignificant
threatwasthefollowingday.Hisobservationsoffirebehaviorthedaybeforecouldhave
reassuredafirefighterwithminimalexperiencethattheAngorafirewouldbehaveina
predictableway.Importantly,theenginebosswasnotalonesupervisorchasingspotsoutof
sightofhisengine.WorkingalongsidetheenginebossandhisfirefighterwasaCALFIRE
49
CaptainandnineCALFIREfirefighters.Thepresenceofotherfirefightersnodoubtprovided
confirmingreassurancethattheiractionswereappropriate.
Atapproximately1000onthedayoftheentrapment,theenginebossreceivedabriefingin
personfromthestriketeamleader.Boththestriketeamleaderandtheenginebossrecallthe
briefingincludinginstructionstopatrolandholdtheroad,butthebriefingdidnotcontain
specificorclearexpectationsonwhatwasmeantbyholdtheroadorwhatwasexpectedifspot
firesappearedacrosstheroad.TheenginebosswasinstructedtobriefhismoduleontheIncident
ActionPlan,althoughbythattimetheobjectivesofthedivisionhadbecomelargelyirrelevant.
Specifically,theIAPstatedtheirassignmentwasto:Improveline,Mopuparoundstructures
and100+feetinfromtheline.
E34spositionalongRoad12N19isolatedtheenginebossfromsightoftherestofthestrike
team.Communicationbetweentheengineboss,thestriketeamleader,andtherestoftheengines
onthestriketeamwasminimal.E34wassandwichedbetweentwoCALFIREhandcrews.
Eventhoughtheywereadjacenttoeachother,communicationbetweenthemodulemembersof
E34andtheCALFIREfirefighterswasminimal.
Thefirstspotseenbytheenginebosswasneartheengineandtheroad.Theneedtosuppressthis
spotwasobviousandthetaskwaseasy.Graduallyoveratleastanhour,additionalspots
appearedfartherandfartheraway.Withthegradualpassageoftimetheenginebossandhis
firefighterfoundthemselvesfartherandfartherfromtheroadandtheirengine.Theengineboss
hadreassurancethathisactionswerevalidasamuchmoreexperiencedCALFIRECrewBoss
wasalsoworkingwithninefirefightersfurtherandfurtherofftheroadinthesamevicinity.
By1415theengineboss,thefirefighter,nineCALFIREfirefighters,andtheCALFIRECrew
Bosswereallworkingtogetheronthesamelargespotfireapproximately800feetnorth (down
slope)ofRoad12N19.Theefforttocontainthisspotfirewassignificantandmoderately
difficult.Boththeenginebossandhisfirefighterdidnotnoticeorappreciatetheconsequencesof
thecolumndirectlyabovethemthatwasdroppingembersthroughouttheareatheywere
working.Noneofthefirefightersengagedinholdingactivitiesreevaluatedthechanging
conditionsandthereforedidnotadjusttheiractions.
50
Asthefirebehaviorbegantoincrease,sodidtheamountofradiotrafficontheassignedtactical
frequency.Thehighvolumeoftrafficontheradiomadeitdifficulttodiscernimportant
informationconcerningescalatingfirebehavior.
Whentheenginebosswasaskedhowitmadesensetohimtobesofarfromtheroadworkingon
spotfires,hereplied,Ifeltthegreatestthreattothesafetyofmyenginewasfirebelowthe
road.Whilethatstatementisgenerallycorrect,theenginebossandhisfirefighterlackedthe
experiencetorecognizetherisksoftheiractionsunderthechangingconditions,andlackedthe
supervisoryoversighttomitigatethelackofexperience.
Engine34wasnotabletofilltwokeyleadershippositionsforthisassignmentbecauseofseveral
vacanciesonthehomeunit.Thepositionswerefilledwithfullyqualifiedindividuals(thetwo
whodeployedtheirshelters)butwhohadminimalexperience,andwhohadnotworkedtogether
asamodule.Fromasafetystandpoint,thedifferencebetweenahighlyqualified firefighteranda
fully qualifiedfirefighter,particularlyinleadershippositions,canhardlybeoverstated.
Both theenginebossandfirefighterwhowereentrappedwerenotnormallyassignedtothis
enginemodule.Alackofcrewcohesion(thoughnotbelievedtobeanissuebythemodule
membersthemselves)wasreadilyapparenttotheAPATeamevidencedby thedelegationof
daily dutiesandthegroupingofcrewmembers.Otherenginesassignedtothe12N19identified
clearlydefineddutiesanddetaileddirectionregardingthesuppressionofspotfiresthatkept
themworkingasaunitthatday.
ThereisatrendofincreasedattritioninRegion5,whichleadstomoduleshavingalower
cumulativeexperiencelevelthanwasrealizedhistorically.TheAPATeambelievesthis
increasingtrendtobeapotentiallyserioussafetyissue.
CALFIRE,likemanynonfederalcooperatorsinCalifornia,sometimesusestheacronym
PARwhenrequestingaPersonnelAccountingReport. IfaTaskForceLeaderasksaCrew
BossforaPAR,forexample,therequestorisaskingiftheCrewBossknowsthatallmembers
ofthecrewaresafelyaccountedfor. ForestServiceemployeesthatdonottrain with orregularly
workwithCALFIREandlocal Californiacooperatorsareunlikelytohaveheardthatacronym.
Inthisincident,when theForestServicefirelineleadershipwasaskedforaPAR,henotonly
51
didnotknowwhatwasbeingaskedofhimbut, giventherapidlydeterioratingconditions,he
alsodidnothavethetimetofindout. Theuseofthisacronymisoneexampleofaproblem
arisingfromtheculturaldifferencesbetweentheForestServiceandnonfederalcooperatorsin
California.Inthewordsofonefirefighter,Wethinkthatwethinkalikebutwedont.Our
vocabularyandtacticsareverydifferent,especiallyinnorthernCalifornia.
4) TheRegionalForestershouldrequestthattheForestServiceFAMreviewandevaluatethe
existingprocessforassuringForestServiceemployeesinallfirelineleadershippositions
meetanappropriatestandardforcommandfitness. An evaluation processfocusedon
developingprinciplecenteredleadersanddecertifyingpersonsincriticalpositionswholack
thequalitiesofintegrity,experience,andskillisrecommended.FAMshouldconsider
simulationexercisesforallfirelineleadershippositions.
5) TheRegionalForestershouldrequestthattheForestServiceFAMevaluateiftheminimum
trainingandexperiencenecessarytoachieveenginebosscertificationisadequateand
appropriateconsideringtheincreasingcomplexityof thewildlandfireenvironment.
ImplementchangestoFSH5109.17asnecessary.
meetanappropriatestandardforcommandfitness.An evaluation processfocusedon
developingprinciplecenteredleadersandondecertifyingpersonsincriticalpositionsthat
lackthequalitiesofintegrity,experience,andskillisspecifically recommended.TheICT3
simulationandcertificationprocessmaybeamodelthatworkswelltoensureleadership
skillsarepresentinhighpressuresituationsforacriticalleadershipposition.
7) TheRegionalForestershouldrequestthattheForestServiceFAMconsiderincorporating
thisscenariointothetrainingforengineboss,striketeamleader,anddivisionsupervisor
positions.
52
V.Keyissues,decisions,andbehaviors
ThedecisiontoevacuateRoad12N19wasnotmadeuntilapproximately1430oraboutthe
timeDivisionDsprimaryescaperoutewaswithinminutesofbeingcompromised.
Manyfirefightersinterviewedstatedtheyacceptgreaterrisktothemselveswhenthefire
threatensstructures,ascomparedtowildlandonlyfires.
Relatedelements
TallacVillagewasnotevacuatednorwasthereacontingencyplanthatwasknowntoany
resourcesonDivisionDshouldthefirebreach Road12N19.
ThecommandfrequencydidnotworkinthehelicopterusedbyOSC1toscoutthefireat1435
(unclearifitwasduetomechanicaloroperatorerror).
ForestServiceenginebossesalong12N19werenotgivenclearinstructionsregardingtheir
assignmentoradequatedirectionconcerningtriggerpointsfordisengaging.
FromthephysicallocationofbothDivisionDSupervisorandstriketeamleaderof3630C,they
couldnothaveseenthespottingthatwasoccurringnearthecenterofthedivision.Whilethere
wassomediscussionofspottingacrosstheroadtothesefirefighters,theirresourcesdidnot
conveythatthespottingwasaseriousthreattoRoad12N19untilapproximatelythesametime
astheroadwasabouttobebreachedbythemainfire(about1430).
Thewinddirectionataround1430wasalignedwiththeslopeattheeasternheadofthefire.This
resultedinamomentaryhighintensityfirerunthatcrossedtheroadnearthelocationofthe
DivisionSupervisor(seeAppendixB,firebehavioranalystreport).
TheuseofMinimalImpactSuppressionTechniques(MIST)intheLakeTahoeBasin
ManagementUnitwasembeddedinthemindsofmanyfirefightersonthisincident. Inthewords
ofonehighrankingLTBMUfiremanager,MISTishowwedoitaroundhere,andeverybody
knowsit.Thisbiasinfluencedtacticaldecisions.Forexample,eventhoughtwodozerswere
available,theywerenotusedtocreatecontingencylinesorreinforcementholdinglineson
53
DivisionD.Also,burnoutoperationswereslowedinparttominimizeintensityandtree
mortality.Theletterofdelegation,however,clearlypermitsthefullrangeofsuppressiontactics
andencouragesaggressiveactionstominimizethesizeofthefire.Inthiscase,theleadersintent
didnotpermeatethroughtheincidentcommandstructuretothegroundlevel.Whenaskedwhy
dozerswerenotusedonDivisionDuntilafterthefireescaped,amemberofthecommandand
generalstaffreferredtotheneedtoprotectthevisualqualityofthearea,stating,Thepolitics
overruledthetactics.
Withrespecttothisparticularincident,allleadershipontheincidentknewthatifthefirejumped
Road12N19,thefirewasverylikelygoingtoenterTallacVillage.Inthewordsofone
firefighter,Weallknewtheconsequenceoflosingthisroadwasthathouseswouldburn.And
inanotherswords,Whenhousesareinvolved,thefirefightercandospritbecomesthemustdo
spirit.Weknowfromreviewthatthefirststatementwasoverstatedandtheperceptionwasnot
atruereflectionofallthetacticaloptionsavailable.
KnowingthatTallacVillagewasnotyetevacuated,therewasamindsetamongseveralofthose
interviewedthatthefirefightersalongRoad12N19weretheretostandanddefend,notonlyto
protectstructures,butalsotoprotecthumanlife.
Interviewswiththoseinvolvedrevealedasenseofresignationasifkeepingthefirefrom
jumpingthe12N19roadwassomethingthattheyhadtodoandtherewerenoothergood
options.
Manyofthosemostdirectlyaffectedbythisaccidentstatedintheinterviewsthat,ifgiventhe
samesituation,theywouldlikelytrytoholdthefireatthe12N19roadagain.Afterfurther
questioning,firefightersdiscussedtacticstheywoulddotoincreasetheirownsafetyandchance
ofsuccess(seetheindividuallessonslearnedsection beginningonpage35)butnoonedirectly
saidtheywouldnottrytoholdthatroadagain.Thisisremarkablebecauseashindsightclearly
demonstrates,holdingthefireon12N19wasamongthemostriskyoftheavailablestrategies.
Inmanyrespects,wildlandfirefightersshareasimilarculturewithcooperatingfiredepartments.
Theyworkandtraintogetheroften,readthesamepublications,andspeakthesamelanguage.To
54
thebroaderpublic,certainlythemedia,weareoneandthesame.Aswithstructuralfirefighters,
societyexpectsourpublicservantstorescueusfromthedangersoffire.Weexpectthese
soldierstohaveasenseofduty,whichincludesvaluesofselfsacrifice,courage,andpublic
service.Wereinforcevaluesofintegrity,whichincludevaluesofcompassionandselflessness.A
commonsayingapplicabletobothculturesis,Wegoinwheneveryoneelseisrunningaway.
TheindividualandpeerpressuresonthefirefightersonDivisionDtodoeverythingpossible
(includingacceptingadditionalpersonalrisk)toprotectthepropertyandperhapsthelivesof
TallacVillageinfluencedmanydecisionsthatday.
Lineofficersandmanyseniorfiremanagementleaders,includingincidentcommandersandtheir
staffs,areofteninsulatedfromthesepressuresandthustheydonotshareacommonparadigm
withthefirefightersfacedwiththedifficultriskmitigationdecisions.Upperlevelleadership
maydirectlinefirefighterstonotcompromisefirefightersafetytosavestructures.
However,thisdirectionisfilteredbyaculturethathasalwaysbeenexpectedtoandbepublicly
rewardedforrescuefellowhumansfromtheperilsoffire.
Ultimately,thevaluesoffirefightersonthelineconcerningthelevelofappropriaterisktaking
arenotinalignmentwiththeexpressedvaluesoftheirleaders.
Implementrecommendation#1.Theissueofappropriateriskandappropriateinvolvementinthe
urbaninterfaceisanationalissue.Becauseofthisaccident,thisT1IMTmayhaveinsightinto
nationalsolutions.
8) TheRegionalForestershouldensurethecompletionoftheongoingCaliforniaWildfire
CoordinatingGroup(CWCG)efforttoidentify theoperationalprinciplesforfiresuppression
forallwildlandfiresuppressionagenciesintheWildlandUrbanInterface(WUI).
55
VI.Keyissues,decisions,andbehaviors
Interagency personnel conflict,jealousy,anddistrustinterferedwithcommunications.
Interagencyrivalryandlowlevelsofintermoduletrustinterferedwiththefreeflowofcritical
intelligenceonthefirelineamongagencies.Unauthorizedchannelsusedtocommunicatewithin
moduleshamperedthesharingoffirebehaviorinformationthroughouttheentiredivision.
Thedegreetowhichalackoftrustandcommunicationbetween agenciesassignedtothis
incidentthatmayhavecontributedtothisaccidentisunknown.Nevertheless,amajority of
personsinterviewedintheconductofthisanalysisreferencedinteragencycommunications
outsidetheassignedcontrolstructureasaseriousproblem.
Itiswidelyrecognizedthatastandardforsafepracticesisintercrewcommunicationsand
maintainingcommunicationsbetweenadjoiningforces.Ininterviews,firefightersstatedthe
followingasreasonsorcausesforthelackofcommunicationsbetweenagencies:
Jealouslybetweengroundpersonnelregardingdisparityinpaybetweenagencies.
Differencesinworkingconditionssuchashotelsversustents,and16 versus24hourshifts.
Useofintracrewnetsorsquirrelchannelswhenpassingimportantinformation
ForestServicepromotionandhiringinR5fromadiminishingapplicantpool,coupledwith
highturnoverrates,hashadthepotential of selectingminimallyqualifiedapplicantswhere,
historically,candidatehiringlistsoncehadmoredepth.
9)TheRegionalForestershouldrequestthattheCaliforniaWildfireCoordinatingGroup
surveyandevaluatetodetermineifinteragencycommunicationsor theirculturalissuesare
significantlyaffectingsafetyand/orefficiency atthegroundlevel. Iftheseissuesare
significant,CWCGshoulddevelopstrategiesforresolution.
10)TheRegionalForestershouldrequestthatthe NWCGsafetyandhealthworkingteam
considerwaystoreinforcetheimportanceof sharinginformationcriticaltosituational
awarenessoncommandandtacticalfrequencies.
56
SummaryofAllRecommendations(#110)
1) TheRegionalForestershouldrequestthattheT1 andtheT2IMTworkwiththeNational
FireOperationsRiskManagementOfficertofacilitateasmallHighReliabilityOrganizing
(HRO)workshopsurroundingandfocusedontheissuessurfacedinthisreport.Inparticular,
issuessuchas"hothandoffs,"transitionculture,transitioninformationstandards,protocols,
andshadowingshouldbeevaluatedunderdoctrinalandHROprecepts.Followingthis
workshop,theteamsshouldthenworkwiththeWildlandFireLessonsLearnedCenterto
displaythelessonslearned,withrespecttoHighReliabilityOrganizing,tootherIMTsand
thegreaterwildlandfirecommunity.Ifpossible,theworkshopshouldincludetheteam's
commandandgeneralstaff,divisionsupervisors,situationunitstaff,andthefirebehavior
analyst.
2) TheRFshouldrequestthattheWOFAMevaluatestrategiestoensureIncidentManagement
Leadershipisorderedrelativetoexpectedandcurrentcomplexityandthatgeographicarea
coordinatorsfulfilltheiroversightroleofefficientandeffectiveteamplacementtoensure
onlytheresourcesnecessaryareorderedandteamtransitionsareminimized.
3) TheRegionalForestershouldrequestthattheForestServiceFAMevaluatestrategiesfor
integratingFBANsintothescenariosofS420andS520toencourageOSCsandFBANsto
sharecriticalinformationandtohelpdevelopeffectiveworkingrelationshipsTheRegional
ForestershouldrequestthattheNWCGreviewandevaluatethepositionoftheFBANwithin
theIncidentCommandOrganizationandrecommendchangesifappropriate.
meetanappropriatestandardsforcommandfitness. Ameaningfulanditerativeevaluation
process,focusedondevelopingprinciplecenteredleadersanddecertifyingpersonsincritical
positionswholackthequalitiesofintegrity,experience,andskill,isspecifically
recommended.TheICT3simulationandcertificationprocessmaybeamodelthatworks
welltoensureleadershipskillsarepresentinhighpressuresituationsforacriticalleadership
position.
57
5) TheRegionalForestershouldrequestthattheForestServiceFAMevaluatewhetherthe
minimumtrainingandexperiencenecessarytoachieveenginebosscertificationisadequate
andappropriate,consideringtheincreasingcomplexityofthewildlandfireenvironment.
ImplementchangestoFSH5109.17asnecessary.
6) TheRegionalForestershouldrequestthattheForestServiceFAMengageNWCGto
evaluatetheENGB,CREW,STCR,STEN,DIVS,OPBD,andOSC1/2taskbooksfor
neededupdatesthatreflecttheincreasedcomplexityofmodernurbaninterfacewildland
firefighting.Also,evaluatetheneedforindividualsingleresourcebosstaskbookstoreplace
thecurrentcombinedtaskbooksystem.
7) TheRegionalForestershouldrequestthattheForestServiceFAMconsiderincorporating
thisscenariointosimulationbasedtrainingforengineboss,striketeamleader,anddivision
supervisorpositions.
8) TheRegionalForestershouldensurethecompletionoftheongoingCWCGefforttoidentify
theoperationalprinciplesforfiresuppressionforallwildlandfiresuppressionagenciesinthe
WUI.
9) TheRegionalForestershouldrequestthattheCaliforniaWildfireCoordinatingGroupsurvey
andevaluatewhetherinteragencycommunicationsortheirculturalissuessignificantlyaffect
safetyand/orefficiency atthegroundlevel. Iftheseissuesaresignificant,CWCGshould
developstrategiesforresolution.
10) TheRegionalForestershouldrequestthattheNWCGsafetyandhealthworkingteam
considerwaystoreinforcetheimportanceof sharinginformationcriticaltosituational
awarenessoncommandandtacticalfrequencies.
58
Evaluationoflessonslearnedrelativetoprinciplebased
decisionmakingandtheForestServiceFireSuppression
Doctrine
TheReviewTeamanalyzedthelessonslearnedbythefirefightersinvolvedinthisincidentand
evaluatedthemrelativetotheOperationalEnvironmentandFiveKeyAreasfoundinthe
FoundationalDoctrineGuidingFireSuppressionintheUSForestService.Thisevaluation
servesasthisReportsLessonsLearnedAnalysisandisintendedtofurtherthedoctrines
understandingandapplicationinwildlandfiremanagement.
TheOperationalEnvironment
AsstatedintheDoctrine,Tosucceedandsurvive,theagencysfirefightersmustfirstperceive
thesecomplexities,thenthink,plan,managerisksandengage.Thefirefightersinvolvedin
DivisionDwereactivelymitigatingtheriskstheybelievedwerepresent.Inhindsighthowever,
virtuallyeveryoneonRoad12N19seriouslyunderestimatedthefirebehaviorandfailedto
perceivetheincreasingcomplexitiesresultinginafailuretoreevaluatetheiractions.
Mission
Themissionofthefirefighterstoprotectlifeandproperty,andtokeep thefiresouthofHwy89
andeastofFallenLeafLakeRoadandtheWildernessArea,wasappropriate.However,the
ambiguityoftheagencysresponsibilitiesforfiresuppressionwithintheurbaninterfaceresulted
intheacceptanceofgreaterriskbythefirefighters.
LeadershipandAccountability
TheDoctrinestates,Leadersintheorganizationmustbecapableofindependentintelligent
action.Itgoesontostate,Leadersdemonstraterespectby knowingandlookingoutforthe
wellbeingoftheirsubordinates.
Demonstratedfitnessofcommandisarequirementforleadershippositionsassociatedwithfire
suppression.Inthissituation,apartiallyinadequateplan,basedonbadintelligence,waschanged
inthefieldtoadequatelyreflecttheremainingworktobecompletedthatday.Leadersatall
levelsfromtheIMTtothetwoemployeeswhodeployeddidnotrecognizethechanging
59
conditions,reevaluatetheiractions,ormaintainahighlevelofsituationalawarenesscausing
themtomakepoordecisions
RolesandRelationships
TheAgencyAdministratorsintentwasclearlystatedattheinbriefingand
intheletterofdelegation.However,theculturalunderstandingthatthe
politicsintheLakeTahoeBasinweresocriticalthatthoseperceptions
drovesomeofthetacticaldecisionsandtheFireLeadershipsperception
ofacceptablesuppressionimpact.TheCommandersIntenttoholdthe
roadbecametheonlyfocusuntilitwasnecessaryforfirefighterson
DivisionDtoquicklydisengage,andforthetwoemployeesofEngine34to
deploytheirfireshelters.
Operations
Thedivision,IHC,andstriketeamleadersonDivisionE&Dwereempoweredtotakeinitiative
andmakeoperationaldecisions.Theseleaderswerecreativeanddecisiveindevelopinganew
planthatmatchedtheupdatedintelligenceofthefireslocationandwasgearedtoward
accomplishingtheirleadersintent.However,sincetheyunderestimatedtheexpectedfire
behavior,theychoseahighriskstrategyandtacticsthatplacedmultiplecrewsofenginesand
handcrewsinasituationwheretheywouldeventuallybeforcedtoretreatwithgreaturgency.
Acriticallessonlearnedfromthisincidentisthatrareeventfireswillbehaveinwaysfar
outsideoftheexpectationsofexperiencedfirefighters.Basingriskmitigationdecisionson
experiencedbasedfirebehaviorestimatesaloneisinsufficienttoensureasafeworking
environment.InadditiontosoundjudgmentandanemphasisonSituationalAwareness,
adherencetobasicsafetyprotocolsspecificallyLCES,the10StandardFirefightingOrders,
andthe18situationsthatshoutWatchOutwillmitigatesubstantialrisksassociatedwith
humanerror.Additionallookoutscouldhavebeenposted,intermodulecommunicationscould
havebeenimproved,andadequatesafetyzoneswerenotdeveloped.ThefactthatDivisionD
resourceshadanalternateescaperoute narrowly precludedatragedy.Throughoutthehours
leadinguptotheincident,manyactionsweretakenbasedonincorrectassumptionsofthe
potentialfirebehavior.Forexample,theweatherforecastpredictedincreasingwindsat1300,but
mostfirefightersweresurprisedwhenthewindspickedup.Therewasonlyonelookout
60
assigned.Therewerenotadequatesafetyzones.Theinstructionstocatchthespotswerenot
clear.
RiskManagement
FoundationalDoctrinerecognizesthat,unlikeatypicalworkplace,whichcanbeengineeredto
besafe,thewildlandfireenvironmentisinherentlyandinvariablyhazardous.Becausesafetyina
typicalworkplacereliesonmanagerialcontrols,theenvironmentissafeuntilhumanbehavior
makesitunsafe.Inthewildlandfireenvironment,safetyreliesonemployeecreativity.We
dependonwildlandfirefighterstocreatesafetyinanunsafeenvironment.Inotherwords, the
doctrinerecognizesthatwildlandfiresafetyisnotan endstate itiscontinuousemployee
creativityinresponsetoubiquitousrisk.
Thefirststepinriskmanagementistosecureaclearunderstandingofthemissionandgoal
(commandersintent)oftheoperation.Thisincidentshowsthegoalofholdingthefireat12N19
waspoorlyunderstoodatmultiplelevels.Fromunderstandingthetacticaldecisiontoholdthe
road totheAgencyAdministratorsintenttofightthefireaggressively,upthroughtheranksto
understandingtheagencysmissioninthewildlandurbaninterface,thecommandersintentin
thissituationwaspoorlydefinedandpoorlyunderstoodbytheleadershipandfirefightersof
DivisionD.
Thesecondstepinriskmanagementisincorporatingjudgmentandexperiencewithstandard
operatingprocedurestoreduceriskstoacceptablelevelsrelativetothemissionathand.This
incidentdemonstratesthat,duetoconditionsofheavyfuelsanddrought,pastexperiencealone
couldnotbereliedupontoestimatefirebehavior.Basicstandardoperatingprinciples,including
establishinglookouts,communications,multipleescaperoutes,andlegitimatesafetyzones,
shouldbeimplementedregardlessoftheperceptionofrisk.
61
Summary
Highreliabilityorganizingisfundamentallyaboutdevelopingalearningculturewhereweare
constantlyimprovingourunderstandingandperceptionofriskbyconstantlylearningfromour
pastmisunderstandings.Inalearningculture,accidentsandnearmissesarefullydisclosed,
framed,andexploitedasopportunitiestolearn.
Theindividualandpersonallessonstobelearnedfromthisaccidentarenumerousfor
firefighters,agencyadministrators,enginebosses,striketeamleaders,divisionsupervisorsand
incidentmanagementteams.Sharingthisreportanddevelopingtraininganddialogueexercises
usingthisscenariowiththewidestpossibleaudiencewillenhancethesafetyandreliabilityof
manyfirefighters.Evenmoreeffectivelearningwilloccurifthisreportisdevelopedintotraining
exercisesorstaffrides.
Anotherkeytraitofhighreliabilityorganizingisembracingaccidentsandnearmissesas
warningsoflatentpathogenswithinthesocialorganizationofwork. Theanalysisofthisaccident
hasyieldedseveralwarningsfortheAgency.Thesearenotproximalrootcausesoftheaccident.
Theyare,however,thebacklayersofcheeseintheswisscheesemodelofaccidentcausation,
andthey signalnormalizingdevianceintheorganizationalaccidentmodel.Warningsaddressed
bythe10recommendationsinclude:
ambiguousandconflictingresponsibilitiesandriskmanagementprinciplesfortheForest
Serviceintheurbaninterface,
nocurrentstandardsforfitnessforcommandinfieldleadershippositionssuch asengine
boss,
enginemoduleswithcumulativelowexperiencelevelsandcohesion,
interagencyrelationshipsandthelackofcommunicationandtrustbetweenagencies(the
ForestService,CALFIRE,andlocalfiredepartments)thatarestrainedbynumerous
culturalandfinancialdifferencesatthegroundlevel.
aculturethatencourageshothandoffs(fastteamtransitions)betweenT2andT1IMTs.
lackofsituationalawarenessandtheabilitytorecognizeandreacttochangingconditions
andrisks,and
poorcommunicationbetweenresourcesontheline.
62
AppendixA
Chronologyofevents(alltimesareapproximate)
Date Time Event
06/24/2007 1423 InitialattackdispatchedtoAngoraFire
1600 TypeIIIMTorderedtoreporttoincident,TypeIIMTordered
tostageinSacramento
1700 E34dispatchedtoAngoraFire
06/25/2007 0600 InbriefingforTypeIIIMT
0800 TypeIIIMTtakescommandoftheAngoraFire
1100 E34arrivesatICPandisassignedtointeragencystriketeam
onDivisionD.Missionforthedayisbrushremovalalong
12N19road.
1600 InbriefingforTypeIIMT
2200 E34offshiftandbackatICP.
06/26/2007 0600 Type1IMTtakescommandoftheAngoraFire.
BriefingatICP.
0730 4enginesmovetointersectionof12N19andthedozerline.
0900
63
0800 WeatherobservationsonDiv.E:60,37%RH,lightwindsout
ofthewest,locationwas300updozerline.
0900 WeatherobservationsonDiv.E:61,37%RH,lightwinds
fromthewestandsouthwest,6000elevation.
0915 CALFIREhandcrewpairedup100apartalongroadtowatch
forspots.
06/26/2007 0900 DivEHotshotsuperintendentdiscusseswith STENand

1000 enginestheplan workedoutforburnoutofthehill.Engine
STsLearnofadditionalescaperoutesandsafetyzonetothe
west.
1000 9273GStrikeTeamLeaderBriefsCaptainsthenleavestoget
lunches.
STENleavestostagingtopickuphose,fittingsand2folda
tanks.
WeatherobservationsonDiv.E:65,34%RH,lightwesterly
windsalmostcalm,6300elevation.
1100 SenatorsAidetoICPforreconflight.
AgreementbetweenDivisionsDandE,andSTEN,thatthe
KlamathHotshotswouldplumbdozerline.Meanwhile,
DivisionDwouldholdtheburnoutalong12N19whilethe
LagunaHotshotsandSierraHotshotswouldconductthe
burnoutjointly.
64
STENordershis4enginestofaceeastandspreadoutalong
12N19forholding.
STENtakesFFTfromE34tohelphimshuttlehosetotopof
TahoeMountain.
WeatherobservationsonDiv.E:65,29%RH,02mphwind
WSW
06/26/2007 1130 HotshotsoneastsideofTahoeMountainstartburning.
1145 E34cutskeyholesalongroad.
9273GStrikeTeamLeadercompleteslunchdelivery.
1200 STENandE34FFTreturnto12N19.STENpositionshimself
eastofE34alongtheroad.
E34takesweatheron12N19road.70dryblub,52wetbulb,
32%RH,estimatedwindwas02SW.
AirAttack Smokestartingtoclearout.
WeatherobservationsonDiv.E:68,30%RH,13mphwind
WSWoccassionalgustfromNEalsoswitchingfromNW,
mileupdozerline.6678elevation.Smokecrossingdozerline
occassionally.
1215 SierraIHCtestburn.Burnwashotandthecrewdetermined
theycouldntrunstripsandwouldonlyapplyfireindots.
65
1218 Divisionconfirmswithoperationsthattheyhavemovedthe
divisionD/Ebreak.
1230 SierraHotshotsbeginburninginthesoutheastcornerof
DivisionD.
1300 AirAttackadvisedDiv.D/Efireactivityispickingup.Minor
torching,blacksmoke,intensityincreasing.Windpicksup.
06/26/2007 1300 E34takesweatheron12N19Road.72drybulb,50wetbulb,

22%RH,estimatedwind02SW.
WeatherobservationsonDiv.E:75,25%RH,12windswith
gustsof4.WindsbattlingNE&NWwindsaloftoutofSW.
6148elevation.
Somepeoplealongthe12N19roadnoticetorchingnearridge.
1315 AirattacktellsDiv.EthatFallenLeafLakehaswhitecapsand
highwindsheadedhisway.
1330 Hotshotsuperintendentreportsviaradiothatthecolumnis
battlingthewind.
1334 HotshotsceaseburnoutoperationsonTahoeMountain.
1330 Hotshotsuperintendent/lookoutreportsthatthecolumnis
1345 startingtolayover.
1345 Airattackadvisedhecouldnotseeundersmoke.
66
Severalenginebosseshearreportsofasmallspotfireoverline
atDiv.D/Ebreak.
1400 E34takesweatheron12N19Road.75drybulb,54wetbulb,
28%RH,estimatedwind3mph,East.
WeatherobservationsonDiv.E:77,26%RH,gustywinds,
significantwindincrease,WNWandshiftingfromtheNE.4
6mphwithguststo10mph.Elevationwas6650.Windsaloft
outoftheSW.
06/26/2007 1400 HotshotsonnorthwestendofDivisionDobservesignificant

torchinguphillalongdozerline.
Airattackordersleadplaneandairtankers.
Flamesshiftdownhillfromslopedriventowinddriven.
DivisionD/ElinesafetypatrollingHwy89formedia.
E34crewobservesanemberfallnorthofroad.FFTpicksitup
withshovelandcarriesopenflameuptoroad.
CALFIREhandcrewcallsinspotsbelowroad.E34engine
bossandFFTareactivlyworkingonspots.Later,theysee
spottingbelowthebench&gotheretoworkwiththehand
crew.
Hotshotson12N19andnearD/Ebreak.Theynotethatthe
CALFIREstriketeamisrepositioningtopointtheirengines
northwest.
67
ColumnisdroppingashesonE34.TheAFEOcatchesafew,
buttheyarecold.
1415 CALFIREhandcrewgoesdownbelow12N19roadtowork
onspots.
E34AFEOnoticeswindspickingupandhearsHotshotson
radiotalkingaboutbattlingwinds.
1420 OPStakesoff inhelicopter toreconwithSenatorsAide.
06/26/2007 1420 ForestServicehandcrewateastendof12N19reportsbatsand

abearexitfromfireareaandcrossroad.
1424 WeatherobservationsonDiv.E:77, 26%RH,steady4mph

windoutofN,switchingNEgustingupto12mph.Column
buildingwindspushingfromtheSW.
1430 STENcallsfortwoenginestocomedowntohislocation.
OPSseeswhitecapsonFallenLeafLake.OrdersfirstPAR
alliswell.
OPShelicopterlandsandunloadsSenatorsAide.
CALFIREhandcrewCaptaincallsfortherestofhiscrewto
gobelowbench.TheCALFIRESTCRstopsthem.
1435 OPShelicoptertakesoffagainwithFBAN.
68
EnginesrespondtoSTENsrequesttobumpdown.Engine65
&81pairupandslowlydriveEast.E34staysput. Engine2
drivesafewhundredfeeteastandstops.
1435 EnginebossandFFTabandonthespottheyareworkingon
1445 belowthebenchandbeginmakingwaybacktoengine.
1438 Div.DtoBranch Reportoffirecrossing12N19
1443 IronMountainhandcrewcompletingegresstoeastalong
12N19.
1445 Div.Dordersallresourcestosafetyzones.
06/26/2007 1445 STENordershisresourcestoturnaround&headwesttoHwy.

89.
E34hearsfromSTENthatescaperouteblocked.Theydrive
east100yardsorsoandturnaroundtofacewest.
1448 BranchtoDiv.DpossiblyneedtocloseHwy.89.
1449 CHPclosesHwy.89.
1455 OPSseesspotnorthofHwy.89.
OPSattempts4timestocontactDiv.and2timesBranchon
Command.Helicopterradionotworking.
69
OPSorderspilottolandduetonocommunications.OSC1(T)
observesfireonbothendsof12N19road,intensefire,and
columnbendingovertoNE.
1500 Theenginebossandfirefighterbelievetheyarecutofffrom
theengine&telltheAFEOtogoon.NineCALFIRE
firefightersandaCaptainruntoTallacVillage.
Enginesarefacingwestandevacuatingtheroad.E34isgoing
slowlookingfortheircrewbelowtheroad.E34triestostop,
butisforcedtokeepgoingbyenginesbehindit.
CommandNetandTAC3trafficintensifies.
1505 OSCshelicopterlands.
Branch getsconfirmationof2nd PARallclear.
06/26/2007 1505 EnginebossandFFTrunbackdowntothe2track, thendown

1515 the2tracktotheeasttotryandreachthecommunity.
EnginebossandFFTdecidetoruntowestinsteadbecause
escapetovillagetoorisky.
EnginebossandFFTreachgrassyopeninganddiscussshelter
deployment.
1515 EnginebossandFFTdeployandentertheirshelters.
1515 OPSlearnsofdeployment.
1520
70
1520 FFTsaysthattheygotablastofhotair,then2moreblasts.
1544 The3rd soundedlikeafrieghttrain.
Enginebossgiveshelicopterincorrectcardinaldirections
tryingtodirectthemtohislocation.
1520 DIVSDfloodedwithrequestsfromOPSforhisresources.
RadioTraffic:Branchtounknown Shelterdeploymentof2
firefighters(Communicationslog).
SierraHotshotsreturn to12N19roadtoassistwiththerescue
andseehelicopterdroppingwaterbelowtheroad.
1522 CellphonecallfromOSC1(T)toICthatBranchreceived
notificationofshelterdeployment.
06/26/2007 1523 Branchtounknown HelicopterdroppingwateratDivs.D.

(Commlog).
1525 LineSafety(Division)andtheIMTsSafetyOfficerstart
lookingforcrew.
UnitFMOarrivesatHwy.89toassessthreatstostructures.
1532 Branchcontactsenginebosstomakesurehewasokay andlet

himknowhelpwasontheway.
71
1544 DivsSafety,Team Safetyand9232GStrikeTeamLeaderfind
firefightersatthedeploymentsite.Theyperformedaprimary
surveyonthefirefighters.Deploymentsitewasflaggedand
photographed.
1547 Communicationsoverheard:noinjuriesattemptingtoget2
firefightersouttosafetyzone.
1430 WaterdroppingonDivisionDfrom14301600by H516,

1600 H780,H720,H718 dropa total of 59,850gallons.
1610 Deployedfirefightersdepartedinambulancetoemergency
room.
ResourcesfromDivisionDregroupinvillagetodostructure
protection.
72
AppendixB,FireBehaviorSummary
FireEnvironment
ThissectionisasummaryofthefireenvironmentoftheAngorafireontheafternoonofJune26,
2007.Itdiscussesthetopography,conditionofthevegetationorfuelsinthearea,andthe
weatherrelatedfactorsthatinfluencedthefirebehavior.
Topography:TheAngorafirewasinmountainoustopographywithslopesrangingfrom0%at
thenorthendofthefireto90100%onthesouthwesternflankofthefire.Elevationsranged
from6246to7290feet.Thetwoshelterdeploymentswereonaroadwheretheterrainwasflat
at6315footelevation.Justuphilloftheroadtheterrainslopeduphillfrom20to40%toward
TahoeMountainat7249 feet.
ThemostprominenttopographicfeatureaffectingthefirerunonJune26wasTahoeMountain.
Itclearlyillustratestheinfluenceofterrainonlocalwinds,whichisdiscussedintheweather
section.
Photo 1. TopographyofthearealookingtotheSouthwithStateHighway89
intheforegroundandTahoeMountaininthebackground.Theshelter
73
deploymentsiteisindicatedwithayellowcircle.
Fuels:Multistoriedmixedconifertimber
wastheprimaryfueltypeduringtheJune
26th firerun.Heavyfuelloadingsand
significantladderfuelsexisted.Herbaceous
andwoodylivefuelswerepresentbutwere
notasignificantcontributortofirespread.
Liveanddeadfuelmoistureswereatcritical
levelsand1to2monthsaheadoftypical
moisturevaluelevelsforthatdate.NFDRS
1000hourfuelmoisturesof9%atnearby
Photo 2.Aerialviewoffuels.Arrowsindicatefirespread
MeyersRAWSstationarethelowestvalues directionontheafternoonofJune26,2007
recordedforthatdateinthepast10years.
Photo 3.Surfacefuelsabovethe12N19roadnear
intersectionwithdozerlineonthewestend.Surface
fuelloadingsrangedfrom4060+tonsperacre.
Photo 4.Unburnedfuelsbetweenthefiresedge
belowTahoeMountainandthe12N19road.Photo
wastakenbyanIHCcrewmemberintheareathey
planned toconductfiringoperations.
74
Weather:The20062007winterandspringseasonintheLakeTahoeBasinareawasdrierthan
normal.Droughtconditionsexistedintheareapriortothefireduetoslightlyabovenormal
temperaturesandbelownormalprecipitationforthe20062007wateryear.TheMay1st snow
packinthearearangedfromnearzerotoabout49%ofnormal.
TheweatherpatternforTuesday,June26,2007wasoneoftransition.Higherpressureoverthe
GreatBasinandlowerpressureoverCaliforniaonMondayreversedearlythatafternoon.Asa
result,lightnortheastwindsduringthemorninghourswithacooler,moisterLakeTahoe
influencebecameadriersouthtosouthwestwind.Thewindsswitchedaround1400hourswith
sustainedwinds815mphat20feetwithpeakguststo25mph.Temperaturesalsowarmedin
theafternoonintotheupper70swith relativehumiditydroppingtonear20%duringthelate
morninghoursandrisingslightlyto25%inthemidafternoon.
Neartheshelterdeployment,terrainplayedalargerole.Observationsfromthefirelineindicate
thattheareajustuphillfromthedeploymentsitehadsustainednortheastwindsat46mphwith
guststo12mphat1424onanorthaspect.Furthersouth,onasouthaspectofTahoeMountain,
windsweresouthat1015mphwithguststo25mphat1400. Bothsitesindicatedwinds
increasingrapidlyaround1400.DuetothesteepnorthaspectofTahoeMountain,thesouth
windswerenotabletosurfacerightawayandlikelyremained200500feetabovethesurface.
Asaresult,arotorcirculation (eddyeffect)developedwherethewindswillreverseatthebottom
ofthecirculation.ThusgeneralsouthwestwindsoverTahoeMountainresultedinnortheast
windsonthenorthaspect. Theseconditionslastedthroughapproximately1530hoursbasedon
thebehaviorofthesmokecolumn.Afterthistime,windslighteneddramaticallywitheyelevel
southwindsbecominglessthan3mphby1700hourssouthofTahoeMountain.
Thefireweatherforecastfromthe6/26/2007IncidentAction Planisattachedonpage76. It
shouldbenotedthattheforecastedweatherverifiedwellwithactualweatherconditions,
especiallythewindsandtimingofwhentheinversionwouldlift,whicharesomeofthemost
challengingweatherelementstoforecast.
75
FireWeatherForecast
FORECASTNO: 2 NAMEOFFIRE:Angora
PREDICTIONFOR:Tuesday SHIFT Day UNIT:CATMU
SHIFTDATE:6/26/0606002000 SIGNED:XXXXXXXXXXIncidentMeteorologist
TIMEANDDATEFORECASTISSUED:21006/25/06
***FireWeatherWatchforGustyWindsandLowHumidityWednesday***
WEATHERDISCUSSION:LowpressureovertheGulfofAlaskawillslowlymovetowardstheTahoeBasintoday
andthroughtheweek.Windswillbelightnortheastinthemorningwithafternoonsouthtosouthwestwinds
developingby1400.ItwillbealittlewarmeranddriertodaythanMonday.Thenextbigwindeventisexpectedto
beginWednesdayandlastintotheweekend.

WEATHERFORECAST:
WEATHER:Sunny.Smokythrough1200.
TEMPERATURES:MAX7780at6300feet.7376at7200feet.Up5degreesfromMonday.
HUMIDITY:MIN1015%allelevationsdown5%fromMonday.RHwilldropbelow25%around1100.
20FOOTWINDS:
RIDGETOP(7500feet)East510mphbecomingsouthwest1015mphwithguststo22mphafter1300.
SLOPELightbecomingnortheastaround0800thensouthsouthwest610mphwithguststo20mpharound
1330.
LAL:1 CWR:0%
STABILITY/INVERSION:Stronglowlevelinversionaround500feetAGLliftingaround1200.
OUTLOOKFORTUESDAYNIGHT(1800TO0600):Clear.Windssouthwest510withguststo20mph
becomingdownslope35mphafter2100.Mintemperature3646.MinRH6070%valleyto3040%ridges.
EXTENDEDFORECAST(Windsareforaverageafternoonconditions):
WEDNESDAY6/27 THURSDAY6/28
WEATHER: Sunny. WEATHER: Partlycloudy.
TEMP: Max:7580 RH: Min:1015% TEMP: Max: 7176 RH: Min: 1420%
Min:3747 Max:3550% Min: 4050 Max: 3245%
WINDS:Slope:SSW1016mphwithgusts30mph WINDS: Slope:SSW1420mphgusts35mph
Ridgetop:SW1220mphgusts35mph Ridgetop:SW1724mphgusts40mph
LAL: 1 CWR:0% LAL:1 CWR:0%
OBSERVEDWEATHER6/25/07Dayshift:
MeyersRAWS6310ft:MAXTemp:74.MAXHumidity:16%.WindsNE35mphguststo10mph.
DLBlissSt.ParkRAWS6942ft:MAXTemp:75.MAXHumidity:15%.WindsNE35mphguststo10mph.
SouthLakeTahoeAP(6263feet):MAXTemp:73.MAXHumidity:18%.WindsNE35mph.
Figure1:Griddedwindsimulation
Thisgriddedwindsimulationhelpstoillustratetheinfluenceoftopographyonlocalwinds.It
describeswindspeedanddirectionfora200degreesouthsouthwestwind.Notehowwindspeeds
increasealongtheridgetoponTahoeMountainandhowthewindstheneddyaroundthesidesof
themountainchangingdirection180degreeswhiledecreasinginspeed.Whilethissimulation
modeldoesnotattempttoforecastwindsorrepresentonsitewindconditions,thisinformationis
veryusefulforplanning,firebehaviormodeling,andgraphicallydisplayingthecomplex
interactionsofterrainandwind.Thelightbluecircleindicatestheshelterdeploymentsite
FireBehavior,General
ThefirebehavioronJune24and26couldbecharacterizedasextremefirebehaviorbutisnot
uncommongiventhehighwinds,lowfuelmoistures,heavysurfacefuelloadings,significant
ladderfuels,andcontinuouscanopyfuels.Giventhesimilaralignmentofthesecommon
environmentalconditions,firescanquicklytransitionfromasurfacefiretoahighintensity,fast
spreading,activecrownfire.
June24 WindDrivenSpreadandExtremeFireBehavior
WhentheAngorafirestarted midafternoononSunday,June24,itquicklytransitionedfroma
surfacefiretobothpassive(torching)andactive(dependent)crownfirewithsignificantshort
andlongrangespotting.Windswerereportedtobe2030withgusts to40milesperhour.The
firehadaforwardspreadofapproximately3milesina4hourperiod.Itburnedover2500acres
andconsumed237residences.
June25 ModeratedFireBehaviorwithDecreasedWinds
OnMonday,June25,thefirebehaviorwasstill activeonthenorthendofthefirebutthewinds
haddecreasedsignificantly.Aconsiderableamountofuncontainedfireperimeterexistedonthe
northnortheastaspectofTahoeMountain.Thefirewasnowbackingonashelteredandshaded
northeastaspect.Whilebackingspreadrateswerelow,thefireburnedwithhighintensityand
intermittentlytorchedindividualtreesorsmallgroupsoftrees. ItwasdescribedbyAirAttackas
beinginaprotectedbowlandnotmarchingupslopeordownslope.Thenightshift(18000600,
6/256/26)workedonfiringunburnedfuelsbetweenthefiresedgeontheupperslope,northeast
aspectofTahoeMountainandthe12N19road.The12N19roadwaslocatedjustbelowmidslope
andwastheplannedcontrollineatthenorthendofthefire.Thenighttimeburningprogressed
slowlyinthetimberunderstoryduetohighintensityburningcreatedfromtheheavyfuel
loadings.Criticallylowliveanddeadfuelmoisturesmeantallsizeclassesoffuelswere
availableforconsumption.
78
June26 AfternoonWindDrivenandPlumeDominatedFireSpread,ExtremeFire
Behavior,EntrapmentandFireShelterDeployment
OnJune26th,increasedsouthsouthwestwindsintheafternooncausedarapidincreaseinfire
behavior.Thestrongwindscombinedwithheavyfuelloading,extremelylowliveanddeadfuel
moistures,andcontinuouscanopycoverallowedforquicktransitionfromaslowbackingsurface
fireinthemorningtoarunningheadfirewithtorching,crowning,andsignificantshortandlong
rangespottinguptomileintheafternoon. Thefirespreadapproximately.8milesin2hours
andconsumedanadditional356acresbeforeitwascontainedthatevening.
OnthemorningofTuesday,June26,thefiresedgeonthenortheastaspectbelowTahoe
Mountainwasfreeburningandwasacriticalpartofthesuppressioneffortfortheday.Thenight
shifthadburneddownhillonestablishedcontrollinesonthewestandeastflanks.Thislefta
largehorseshoeshapedareaofunburnedfuelsbetweenthefiresedgeandthe12N19road(see
Photo5).Approximately140acresremainedtobeburnedout.Manypersonnelonthedayshift
werebriefedthattheburninghadalmostbeencompletedandthemajorfocuswouldbeon
holding.Thefirehadreachedportionsofajeeptrailapproximately1500feetabovethe12N19
road.Thismayhaveledtomisunderstandingontheamountoffiringleft,becausesomereferred
tothe12N19roadasthejeeptrail.
08001200Hours:Temperaturesstartedoutat60andincreasedto70andrelativehumidity
decreasedfrom37%to29%.Windswerecalmtolightfromthewest,southwest.Firebehavior
wasreportedasactiveevenwiththepresenceofanighttimeradiationinversionoverthefire.Air
Attackwasoverthefireat1035andreportedstableconditionsandpoorvisibility.Asouthwest
flowhadtrappedsmokeinthebowlonthenortheastsideofTahoeMountain.TheLagunaIHC
crewbeganburningontheeasternsideofthehorseshoeonDivisionDatapproximately1130.
Thecrewusedonlyonedriptorchandlitstrips15feetaparttokeepfireintensityaslowas
possible.Theirplanwastoevenoutthefiresedgebyburningdowntothejeeptrail.Whenthat
wasaccomplished,anotherIHCcrewwouldassisttheminburningoutfrom thejeeptrailtothe
12N19road.
79
12001330Hours:AirAttackreportedthesmokebeginstoclearoutatabout1200.Asthe
inversionlifted,eyelevelwindsontheDivisionEdozerlinebegintochange.Windswere13
mphfromthewestsouthwestwithoccasionalgustfromthenortheastandintermittentlycome
fromthenorthwest.Thiswinddirectionchangecausedsmoketocrossoverthedozerline
occasionally.Temperatureswentfrom70to75andRHdecreasedfrom32%to25%during
thistimeperiod.
At1215,theSierraIHClitatestfirenearthedozerlineonthenorthwestendofDivisionD.The
burnwashotandtheydeterminedthattheycouldnotrunstripsrathertheywouldtrytobring
firedownfromTahoeMountainalongthedozerlineto12N19.Theybeginburningat1230and
progressedveryslowlyduetothehigh
intensity.Bothhotshotcrewsceased
burnoutoperationsapproximatelyone
hourlaterat1330.Theywere
concernedwiththehighintensity,the
amountoftreetorchingtheburning
wascausing,andthetimeofday.
At1300hoursAirAttackadvised
DivisionsDandEthatfireactivity
waspickingupwithminortorching,
blacksmoke,andincreasingintensity.
Photo 5.Takenfromahelicopterlookingsouthatapprox.
Around1315headvisedDivisionE 1224hours.Photoshowsthehorseshoeshapedislandof
unburnedfuelsabovethe12N19road.TheTahoeMountain
thatFallenLeafLake(approx.mile ridgelinerunsacrosstheupperpartofthephoto.Thesmoke
indicatescalmtolightsurfacewinds,moderatefireline
westofAngoraFire)hadwhitecapson intensity,andanunstableatmosphere.
itandwarnedthemthatwindswould
beheadedtheirway.
13301430Hours:At1330hoursahotshotsuperintendentservingasalookoutreportedonthe
radiothatthesmokecolumnwasbattlingwiththewindandapproximately15minuteslater
80
reportedthesmokecolumnwasbeginningtolayover.At1345thefirespreadhadincreased
significantlyandAirAttackwasunabletoseeunderthesmoke.
Around1400hoursonthesouthaspectofTahoeMountain,windsweresouthat1015mphwith
guststo25mph.At1424thenortheastaspectofTahoeMountainhadsustainednortheastwinds
at46mphwithguststo12mph.AnalysisfromtheIncidentMeteorologistindicatesthatDue
tothesteepnorthaspectofTahoeMountain,thesouthwindswerenotabletosurfacerightaway
andlikelyremained200500feetabovethesurface.Asaresult,arotorcirculation(eddyeffect)
developedwherethewindswillreverseatthebottomofthecirculation,thusthenortheastwinds
onthenorthaspect.
Duringthistimeperiod,fire
behaviorincreasednoticeably
asthepredictedsouth
southwestwindssurfacedon
thefire,causingincreased
torchingofindividualtreesand
smallgroupsoftreesonthe
upperoftheslope.Awell
developedconvectioncolumn
formedandthesouth
southwestflowaloftcarried
embersacrossthecontrolline.
Theemberscausednumerousspot
Photo6.Burnoutoperationneardozerline(westflank)at
firesastheylandedinthehighly approximately1348.Photowastakenabout15minutesafter
crewceasedburningoperations.
receptivefuelbedoftimberlitter
withheavyfuelloadings,criticallylowdeadfuelmoistures(seeFigure2),andpunkylogs.The
flamingfronttransitionedfromabackingfiretodownhillwinddrivenheadfirespread.
81
Figure2:CalculatedDeadFuelMoisturesforAfternoonBurningPeriodonJune
26,2007.Rangesaredisplayedastheyvarybyaspect,elevation,andshading:
FuelMoistureTimelagCategory 1Hour 10Hour 100Hour 1000Hour
SizeClass 01/4 1 13 38
FuelMoistureContent 35% 57% 57% 810%
82
Photo 7.Lookingnorthtoward
TahoeMountainandincreased
firebehavioronnortheastaspect
ofTahoeMountainasSSW
windsincreasedaround1400
hours.RefertoFigure1fora
modeledrepresentationofthe
surfacewinds.
14301510Hours:Firebehaviorduringthisperiodcanbestbecharacterizedasactive
crowning,wherefireinthetreecrownsisdependentuponthesurfacefire.Astorchingintrees
occurs,embersareloftedintothewelldevelopedconvectioncolumnandlandaheadofthemain
firetothenorth.Asspotfiresbecomeestablishedinthesurfacefuelsandgrowtogether,they
increaseinintensityandpreheatthecanopyfuelstoignitiontemperature,andanotherpulseof
torchingoccurs.Firebehaviorisnowpredominatelyinfluencedbyconsiderablespotting,active
crowning,andastronglydevelopedconvectioncolumncreatingitsownwinds.Severalspotfires
developednorthofHighway89,indicatingspottingapproximatelymilefromthemainfire
front.
At1438hours,DivisionDadvisedBranchthatthefirehascrossedthe12N19road.At1445
DivisionDorderedallresourcestotheirsafetyzones.Atthesametime,aspotfirewasreported
northofHighway89,whichwasclosedapproximately5minutesearlier.
83
Photo 8.Increasingfirebehaviorat
approximately1430withsmoke
layingover12N19roadontheeast
sideofDivisionD.
Photo 9.Increasedfirebehavioron
upperportionofslopeat
approximately1445hours.Smoke
indicatesrapidcombustionandhigh
intensityfirebehavior.
84
Photo 10.Picturetakenfroma
helicopteratapproximately1450
showingevolvingspotfiresnear
thelocationwhereFSE34
enginebossandfirefighterwere
lastworkingonspotfires.Clear
airnearthefiresedgeindicates
surfacewindindraftsintothebase
oftheconvectioncolumn.Figure
1alsoprovidesinsightintothe
surfacewindsatthistime.
85
FireBehaviorEstimatesat1300,1438,and1515
Figure3:Fireprogressionestimatesarebasedonwitnessstatements,
photographs,andburnindicators.Coloreddotsindicateapproximatespot
firelocations.Estimationsaresubjecttosomeuncertainty.Yellowcircle
indicatestheshelterdeploymentsite.
86
FireBehavior,DeploymentSite
15101545Hours:Frequentspottingandhighlyreceptivefuelbedsledtonumerousspotfires
intheareawheretheengineboss,firefighter,andCAL FIREhandcrewwereworkingtocontain
spotfires.Thenumerousintense,
rapidlyspreadingspotfires
preventedtheenginebossand
firefighterfromgoingbackuphillto
the12N19roadwheretheirengine
waslocated.Windsintheareawere
gusty,erratic,andstrongly
influencedbyindraftsintothebase
oftheconvectioncolumn.
Atapproximately1515hours,the
twofirefightersdeployedtheirfire
Photo11.Picturetakenatapproximately1523of
sheltersonatwotrackroadbelowthe helicopter(indashedcircle)droppingwaternearshelter
deploymentsite.
12N19road.Theyreportedreceiving3
separateblastsofhotair.Helicopters
begandroppingwatershortlyafter
Operationsreceivednotificationof
deployment.Thewaterdropsmost
likelyreducedthefireintensity,but
itisimpossibletoquantifyhow
much.AsshowninPicture13
(AppendixB)andPicture8(inthe
mainreport),therewasunburned
grassdirectlyaroundtheshelter
deploymentsite.Oneofthesafety
Photo12.Atapproximately1530hoursthewinds
officersfirstonscenetoassistthe lighteneddramatically.Firepersonnelobservedthatthe
smokecolumnshiftedfromahorizontalprofiletoa
verticalprofile.At1700hourseyelevelwindswere
southatlessthan3mphjustsouthofTahoeMountain. 87
firefightersreportedthatthesurroundinggrasswasdamp.
Therewasasignificantchangeinvegetationstructurethatoccurredattheshelterdeployment
site.Thetimbertransitionedfromadensermixedconiferstand(Jeffreypine,Pinusjeffreyi,
WhiteFir,Abiesconcolor,andIncenseCedar,Libocedrusdecurrens)toamoreopenJeffrey
pine(Pinusjeffreyi)dominatedstand.Fuelloading,ladderfuels,canopyclosure,andtreedensity
alldecreasedsignificantlyintheJeffreypinestand,whilethecrowntobaseheightsincreased.
Thechangeinfuelcharacteristicsandarrangementallowedthefiretodropfromthetreecrowns
backtothesurface.Thisreducedthefireintensitytothetwofirefightersintheir
shelters.
Photo13.Shelterdeploymentsiteindicatedbyyellowcircle.
Arrow indicatesdirectionoffirespread.Notestriking
changeincrowningandscorchdirectlyabovesitein
comparisontothedeploymentsiteandsurroundingarea
88
89
90
AppendixC:Briefingpaper:AccidentPreventionAnalysis
ExaminingUnintendedOutcomesGainingtheGreatestBenefit
FireOperationsRiskManagementCouncil USDAForestService
Safetyisnotagoalthatanorganizationcanreach. havebeencompromisedorlostbythequick,
Safetyisnotanendstate.Incontrast,safetyis convenientandpracticallymeaninglessconclusion
continuousemployeecreativityinresponseto intheaccidentinvestigationreportofhuman
ubiquitousrisk.Thiscanbeachallenging error.
paradigmbutithasimmenseimplicationsforhow
In2004theForestServiceFireOperationsSafety
weshouldvalueoperationalaccidents.
Councilbegantofocusintentlyatlearningfrom
Afoundationalprincipleofhighreliability accidentsandespeciallyfromhumanerror.The
organizingisacommitmenttocontinuous NuttallandthentheI90fireentrapmentsprovided
learning.Learningfromsuccessisessentialbut excellentopportunities.Usingalearningapproach,
learningfromfailureiscrucial.Infactakeytrait ratherthanahuntforemployeeerrorapproach,we
ofreliableorganizationsisapreoccupationwith foundthatmanyemployeeswereeagertoshare
failure.Rarelydoweexperienceaserious behavioralinformationwithaccidentinvestigators.
nonrandomunintendedoutcome.Butwhenthis
In2006amoresophisticatedapproachwasusedto
doeshappen,theoccurrenceprovidestangible
investigatetheBallsCanyonandLittleVenus
evidencethattherearelatentflawsinthe
entrapments.Referencing21stcenturysafety
organizationofourwork.Becausetheeventsare
professionals,theseinvestigationsassertedthat
rare,theinsightstheyprovideintoorganizational
employeeerrorsaremoreeffectivelyviewedas
deviancearealsorareandthusenormously
organizationalfailures.Seeingthevalueofthis
valuable.Fidelitytoourvaluesdemandswetreat
approachforpreventingfutureaccidents,theFire
accidentsandnearmissesaspreciouslearning
DirectorsorderedtheCounciltodevelopaguide
opportunitiesandexploittheirfullvalueto
forconductinglearninginvestigations.The
enhancingsystemreliability.
AccidentPreventionAnalysisGuideistheproduct
Humanerrorisimplicatedin7080%ofall ofourexperiencewiththesefourinvestigations
accidents.Learningfromhumanerrorshouldbe combinedwithadditionalresearchintohuman
amongthehighestprioritiesformanagers errorandrefinementsfromcritiquesof
committedtohighreliabilityorganizing.The professionalsinthedisciplinesofpsychology,
ForestServicehasnotdonewellinthisregard. sociology,safety,lawandemergency
Overwhelminglyinfact,ForestServiceaccident management.
investigationsterminateuponfindingsof
In2006theForestServiceFoundationalDoctrine
employeeerror.Errorsarethenconstructedtobe
wassignedbytheChief.Underthisleadership
thecause(s)ofaccidents.Infactfordecades,
direction,employeereliability(safety)ismanaged
essentiallyallinvestigationshaveconcluded,An
throughalignmentwithprinciplesandvalues.This
employeedirectlyengagedinoperationsmadea
placesadditionalandcrucialimportanceon
faultydecisionorfailedto......Inotherwords:
learningfromunintendedoutcomes.Under
Anemployeecaused theaccident.Accident
Doctrine,ifthereisagapbetweenoperationsas
preventionactionsstemmingfromsucha
imaginedandoperationsasdone,thenathorough
conclusioninvariablyaredriventorecommend,
understandingofthisgapiscriticaltocultivatethe
additionalspecifications,rulesorproceduresto
continuousriskmanagementcreativityofour
guideemployeedecisions.Afterhalfacentury
employees.ThisguideprovidesLineOfficerswith
laboringunderthisparadigm,wehavethreeclear
toolstheycanchoosetouse(inlieuoftheSerious
results:1.)employeesfeardisclosingtheirerrors
AccidentInvestigationGuide)toinvestigateand
because(ethicallyornot)theirerrorswillbe
learnfromunintendedoutcomes.
labeledasacausalfactoroftheaccident2.)we
havegeneratedsomanyrulesthatinaggregate
theyarereducingemployeereliability3.)dozens
ofopportunitiestolearnfromseriousaccidents
91
AppendixD
PersonalProtectiveEquipmentReport
AngoraFireShelterDeployment
Thisequipmentreportisbasedonbothinspectionofequipmentandinterviewsofthe
firefighterandenginebosswhodeployedsheltersonJune26,2007attheAngoraFire.
Equipmentinspection,firefighterinterviewsandfollowupinterviewsoccurredbetween
June28andJuly18,2007.
PersonalProtectiveEquipmentAccordingtointerviews,bothfirefighterswere
appropriatelyequippedwithpersonalprotectiveequipment.
ClothingTheclothingshowednosignsofheatandperformedasdesigned.
TrainingAccordingtothefirefightersredcardsandinterviews,bothfirefightershad
firesheltertrainingwiththeNewGenerationFireShelter.Eachhadwatchedthetraining
videoandpracticedshelterdeploymentswithpracticeshelters.
FireSheltersandFireShelterBagsThefireshelterswereinspectedatthe
deploymentsiteonJune28and29andatMTDConJuly18.Theywereexaminedfor
signsofheatandotherstructuraldamage.
Thesheltersshowedverylittlesignsofheat onlyafewisolatedspots,lessthan
1inchindiameter,ontheshellofeachshelter.Thesespotsweremostlikelyfrom
hotembersdirectlycontactingtheshelters.
Theconditionofthesheltersindicatedthatthecombinationofradiantand
convectiveheatwasnotsufficienttoraisethetemperatureofthematerialabove
500degreesF.
EngineBossShelter:
NewGenerationFireShelter,RevisionC
Manufacturer WeckworthManufacturing
DateMfgLabelnotfound
Size:Regular
o Labelsewnintofloorseamsmissingduetofloorseamtears.
o Structuraldamagetheinsidecornerseamsoftheflooraretorninvarying
lengths:2,6,8and10inches.
FirefighterShelter:
NewGenerationFireShelter,RevisionA,Retrofit,GSA
Manufacturer AnchorIndustries
DateMfgAugust2003
Size:Regular
o Floormaterial,physicaldelaminationoffoilon1/3ofthefloorarea
o Floormaterialtoreawayfromreinforcementatoneendacrossthewidth
ofshelterthereinforcementremainedinplace.
o Holewornintofloormaterial 6X6inch.
92
Thefireshelterbagswerealsoinspected:
Bothbagswerefoundatthedeploymentsite.
Bothbagshadafew,lessthaninch,meltmarks,mostlikelyfromhotembers.
DiscussionThefiresheltersandbagsperformedasdesigned.Theamountofwear
observedon theenginebossshelterisasexpectedundertheconditionsofthis
deployment.Thefirefightersshelterhowever,showedconsiderabledelaminationofthe
floormaterial,muchmorethanexpectedundertheconditionsofthisdeployment.In
neithercasedoesitappearthedegradationofsheltersaffectedperformance.The
unexpectedamountofdelaminationwaslikelycausedbythesubstantialmovement,
shifting,crawling,etc.ofthefirefighterwhilehewasinsideoftheshelter.
ShelterExperienceBelievingallviableescaperoutescutoffandafterashort
discussion,bothfirefightersdeployedtheirfireshelters.
Thefirefightersreportedthetemperaturesinsidetheshelterwereveryhot.They
foundituncomfortabletobreathe,sotheybothdugsmallholesandcuppedtheir
handsaroundmouthandnoseinordertobreathemorecomfortably.
Thefirefighterpouredwaterinthesmallholehedug.
Afteraholedevelopedinthefloorofhisshelter,thefirefightertuckedthefloor
materialunderhimselfandreceivednoadditionalsmokeorheat.
Theenginebossmovedwithhissheltertogetbatteriesfromhispackandlifted
hissheltertocommunicateontheradioandobservethefireseveraltimes.
DiscussionThedeploymentsitewasinasmallgreenmeadowinanareatransitioning
fromclosedcanopytoopencanopy.Justsouthofthedeploymentsitealmostalltree
crownswereconsumedandjustnorthofthesite,almostallcrownsremainedafterthe
firepassed.(Seefirebehaviorreport)Ultimately,itwasthecombinationofanadequate
deploymentsite,thebucketdropsfromhelicoptersandtheperformanceofthefire
shelterswhichresultedintwouninjuredfirefighters.
Thegrassyareachosenfortheirdeploymentsiteofferedsufficientprotection
fromdirectflamecontact.
Bothfirefightersusedtheirtimeatthedeploymentsitewiselyanddeployedwith
timetosparebeforetheinitialheatwavearrived.
Bothfirefighterstossedtheirpacksclearoftheshelters.
Theenginebossreportedhehaddifficultyunfoldingtheshelterfordeployment.
HeperformedapracticedeploymentwitharealNewGenerationFireShelter
severaldaysafterthedeploymentandwasabletodeployquicklyandefficiently
withnoproblems.
BothreportedthattheredtearstripoftheshelterPVCbagdoesnottearawayas
easilyastheredVelcrotearstripofthepracticeshelterPVCbag.
Bothfirefightersbroughtwaterintotheshelterswiththem.
Thefirefighterreportedthatpouringwaterintothesmallholethathehaddug
cooledtheairthathewasbreathing.
93
Bothfirefighterscommentedthattheywereabletoobtainagoodsealwiththe
shelterfloorandtheshelterhelditsvolumeandshapewell.
Radiotransmissionswerehamperedwhileinsidetheshelter,theengineboss
neededtopartiallypeekoutofthesheltertotransmitwithhisradio.
Afterafewminutesofbeingdeployed,thefirefightersreceivedwaterdropsfrom
thehelicopters.Thewaterdropshelpedcooltheareamorequickly.
Bothfirefightersparticipatedin sheltertraining,butstatedtheyneverthoughtthat
theywouldeverneedtodeployafireshelterduringtheirfirecareers.
Bothfirefightersbelievethefireshelterssavedtheirlives.
DeploymentSite:
SizeApproximately1600squarefeet,triangleshape,shortgreengrasswitha
twotrackroadonthenorthend.
Mostareassouthofthedeploymentsiteburnedinahighintensityfirethatburned
mostofthetreescrowns.
Northandwestofthedeploymentsitethefiretransitionedtomostlyaground
fire.
RecommendationsandReminders:
Ifatallpossible,firefightersshouldtimetheirdeploymentsotheyareinsidetheir
sheltersbeforetheflamefrontarrives.
Firefightersshouldbringwaterbottlesintotheshelteronlyiftimepermits.
Currentfiresheltertrainingwarnsagainstbreathingthroughwetbandanas.
AtthistimeitisNOTrecommendedtopourwaterintothedirtnearbreathing
areas.Furtherevaluationofdifferentwayswatercanbeusedduringadeployment
isneeded.
Firefightersshouldpracticeshelterdeploymentsinahighstressenvironment,
withtimeconstraintsandindifferentpositions(standing,kneelingandlying).
Inadditiontopracticingdeploymentswithpracticeshelters,firefightersmayneed
todopracticedeploymentswithanactualNewGenerationFireShelterinorderto
becomeasproficientaspossible.
Firefightersshouldreviewthe2003MTDCFireTechTipFireSheltersWeaken
RadioTransmissionsFromHandHeldRadios.
TheNewGenerationFireShelter:
Thisisthefifth knowndeploymentoftheNewGenerationFireShelter.
Informationlearnedfromthisdeploymentwillbeusedtocontinuedevelopment
workontheNewGenerationFireShelter.
__/s/TonyPetrilli___________ __August8,2007___
TonyPetrilli Date
EquipmentSpecialist
MissoulaTechnologyandDevelopmentCenter
94
AppendixE,FireShelterTechTip
95
96
97
98
AppendixF
AngoraFireEntrapmentandFireShelterDeploymentAccident
PreventionAnalysisTeammembers:
RayHaupt,KlamathNationalForest, DistrictRanger(APATeamLeader)
DeborahAustin,LoloNationalForest,ForestSupervisor(ChiefsRepresentative)
JoeDuran,LosPadresNationalForest,ForestryTechnician,NFFERepresentative.
RandyMeyer,PacificSouthwestResearchStation,NFFEPresident
MikeSimmons,LTBMU,EngineCaptain.
LarryHood,PacificSouthwestRegionalOffice,FirePlanner.
AnthonyPetrilli,MissoulaTechnologyandDevelopmentCenter,FireShelter
Specialist.
JayKirchner,PacificSouthwestRegionalOffice,PublicAffairsSpecialist
SteveHoldsambeck,IntermountainRegionalOffice,FireOperationsSafety
Manager.
RandyDraeger,RegionalHealthandSafetyManager,IntermountainRegion
GISandDocumentationSupportprovidedbyKurtTeuber(LakeTahoeBasin
ManagementUnit)andGaryChase(ShastaTrinityNationalForest).
99

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AngoraFireEntrapment&FireShelterDeployment

Duetocalmwindsandaggressive Figure1. AngoraFireLocation

PaydifferencesbetweentheForestServiceandourcooperatorsare resultingin toomany

Date Time Event

06/24/2007 1423 InitialattackdispatchedtoAngoraFire

06/25/2007 0600 InbriefingforTypeIIIMT

06/26/2007 0600 Type1IMTtakescommandoftheAngoraFire.

06/26/2007 0900 DivEHotshotsuperintendentdiscusseswith STENand

06/26/2007 1130 HotshotsoneastsideofTahoeMountainstartburning.

06/26/2007 1300 E34takesweatheron12N19Road.72drybulb,50wetbulb,

06/26/2007 1400 HotshotsonnorthwestendofDivisionDobservesignificant

1420 OPStakesoff inhelicopter toreconwithSenatorsAide.

06/26/2007 1420 ForestServicehandcrewateastendof12N19reportsbatsand

1424 WeatherobservationsonDiv.E:77, 26%RH,steady4mph

1438 Div.DtoBranch Reportoffirecrossing12N19

06/26/2007 1445 STENordershisresourcestoturnaround&headwesttoHwy.

Branch getsconfirmationof2nd PARallclear.

06/26/2007 1505 EnginebossandFFTrunbackdowntothe2track, thendown

06/26/2007 1523 Branchtounknown HelicopterdroppingwateratDivs.D.

1532 Branchcontactsenginebosstomakesurehewasokay andlet

1430 WaterdroppingonDivisionDfrom14301600by H516,

PREDICTIONFOR:Tuesday SHIFT Day UNIT:CATMU

FuelMoistureTimelagCategory 1Hour 10Hour 100Hour 1000Hour

FuelMoistureContent 35% 57% 57% 810%

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