2008 Fireline Fatality Report

[ROOTSXROCKS]

about page 115

A decision was made to fall a large ponderosa pine (36.7” at the point of the cut). Downslope from the ponderosa pine was a 54” DBH sugar pine that had an uphill lean and a large cat face on the uphill side. When cut, the ponderosa pine fell downslope toward the sugar pine. It was contact with the sugar pine, or vibration from the ponderosa hitting the ground, that caused a portion of the sugar pine, approximately 120 feet long, to break off and fall upslope, hitting FC1 resulting in severe injuries.

Technical Assessment of Accident Site
Due to the lack of eye-witness accounts, a number of key facts are unclear; therefore actual events have been pieced together from interview statements and evidence at scene. FC2 and FC3 are the only surviving witnesses to the accident and they have not granted interviews to the Serious Accident Investigation Team. While it is impossible to determine at this time who actually fell Tree 1, it is possible for experienced observers to read the stump, the lay of the felled tree, and the felling area to determine how the felling of Tree 1 set into motion the sequence of events that lead to FC1 being injured.
Starting at DP 17, EM-CAPT proceeded east along the dozer line cutting an undetermined number of hazard trees. When the crew members reached the accident site one of them proceeded to fall Tree 1. Tree 1 was 36.7” at the point of cut. The ponderosa pine, when examined, appeared to be green with no readily apparent defects that would have required it to be felled as a hazard tree.
The first step in a procedural approach to felling is to survey the tree to be felled and the felling area for any hazards. Tree 2 would have presented a considerable hazard to anyone upslope from its base.The chainsaws EM-CAPT had with them had bar lengths of 28” and 32”; the diameter of Tree 1 at the point the cut was made was 36.7”. Regardless of which saw was used, the sawyer would have had to cut from both sides of the stump in order to complete the undercut. During this process, the sawyer experienced difficulty in obtaining a single plane, or hinge, across the diameter of the stump. This hinge is critical to the process that directs the tree into the undercut and the intended lay.
Closer inspection revealed that the sloping section of the undercut was not cleaned sufficiently as to provide a single plane across the diameter of the stump. The stump exhibits two distinct horizontal (gunning) cuts and two sloping cuts. Multiple Dutchmen that would have altered the holding wood were also present.
Due to the multiple horizontal (gunning) cuts and the multi-faceted sloping cut, it is impossible to accurately determine the exact intended lay of Tree 1; however it appears that the intended lay was to be downslope and to the left (looking downslope) of Tree 2 and 3. The sawyer made the decision that the undercut was completed sufficiently to direct Tree 1 into the intended lay, and proceeded with the backcut. As the backcut was initiated, it appears that the tree may have started to fall before the feller was able to get a sufficient amount of the holding wood cut.
The large amount of holding wood (16” wide) left on the stump can be attributed to Tree 1 starting to fall earlier than expected due to a heavy sidehill lean or a large amount of limb weight. Because of the interaction of the multi-faceted undercut, the Dutchmen present in the undercut and the heavy lean, the tree fell in a sidehill direction, possibly as much as 20 to 40 degrees to the right of the intended lay.

As Tree 1 fell, it is possible that it contacted Tree 3, breaking it off approximately 85’ from the ground. (Statement: CRWB1 [E-10]; MOI: FAL1[F-20] )
As Tree 1 continued to fall, it is possible that it contacted the bole or a limb of Tree 2.
It was this contact, or the vibration from Tree 1 hitting the ground, that caused an approximately 120’ section of the severely weakened Tree 2 to break off 16’ from the ground and fall upslope

It is highly probable that a large cloud of ash and dust was generated when Tree 1 hit the ground. This would have obscured any debris falling toward FC1. Based on the location of the broken pieces of Tree 2 and the known location of FC1 after the accident it was likely that a section of Tree 2, over 8’ in length and approximately 20” in diameter, impacted FC1, causing severe injuries.

Tree 1 was a class C tree. The stump measured 36.7” in diameter at the point the cut was made.
The highest saw qualification of any of the crew members present was that of a faller B.
The undercut of Tree 1 was not cleaned sufficiently as to provide an adequate “hinge” to direct Tree 1 during the felling process.
The undercut of Tree 1 exhibits two distinct horizontal (gunning) cuts and two sloping cuts. Multiple Dutchmen that would have altered the holding wood were also present. (See photo 2)
Tree 1 fell away from its intended lay due to lean, possible limb weight, and an inadequately cleaned undercut.
Tree 1 appeared to have been a sound, green tree with no readily apparent defects that would have required it to be felled as a hazard tree.
FC1 had not completed First Aid/CPR training. First Aid/CPR training is a prerequisite for S-212 (Wildland Power Saws).
The JHA for tree felling provided by EM after the accident was not adequate for the activity of tree felling, additionally no evidence could be found to indicate the JHA had been reviewed by EM or a line supervisor. Recommendations:
Fallers must only fall trees that are within their qualification level, unless being directly supervised by a faller of appropriate qualifications.
Fallers must survey the cutting area for hazards and identify escape routes/safety zones before the felling operation can commence.
Fallers must retain control of the cutting area. (S-212 identifies the cutting area as two times the height of the tree being cut; OSHA Logging Standards 1910.266(h)(1)(iv) states: “No employee shall approach a feller closer than two tree lengths of trees being felled until the feller has acknowledged that it is safe to do so, unless the employer demonstrates that a team of employees is necessary to manually fell a particular tree.”)
Undercuts must be completely cleaned.
Techniques such as boring back cuts and quarter wedging should be considered on leaning trees

what is a boring back cut? I think I know but Im not sure I understand the principle.

[ROOTSXROCKS]

nevermind I continued reading

Boring Backcut: A felling method that utilizes a back cut where the chainsaw bar is inserted behind the holding wood area and the direction of cut proceeds away from the holding wood toward the back of the tree to fell. This is a particularly good method to use on leaning tress as it prevents the tree from pulling a large amount of holding wood and possibly barberchairing.

[techdave]

To the gentleman who initially said that prosecution would/will inhibit cooperation with investigation:

ONLY if you work with moral-less liars who see incorrect things done, do nothing to protect their crewmate, and seek to hide their culpability.

This is a perfect example, look at all the screw ups by the main members of he crew:

felling over certified class, lack of situatiuonal awareness at felling time, failure to administer first aid correctly, and refusal to cooperate with investigators. WT _ is this, the mob and OMERTA?

Philosophical objections to cooperation with investiagators are PROBABLY the sign of moral decay. In some cases, a tight mouth may be justified by some ex-officio consideration, but in general that arguement is BS!


If you cooperate and it turns out the death was from a crumbly piece of bole where holding wood should be, but it was not seen due to smoke and fatigue then maybe no one should be prosecuted or demoted or fired.

But this scenario is one were there was major contribution and cause from a violation of COMMONLY UNDERSTOOD and often followed rules.

I am not a fire guy, but a faller of B cpabilities, and bucker of unlimited size range and capability in off camber and tangled forest situations. I work in the saftey business.

Sorry for the crew buddies of the deceased, and their emotions and feelings, but that should not be a pass to hinder figuring out what happened and maybe saving others by communicating eh lessons that should be learned!

[newsawtooth]

You make some valid points. However, I would offer that in the case of Federally managed wildland fires the situation is complicated by the fact that fires are considered emergencies, orders and assignments are passed down through sometimes dozens of people, and the assignment of felling fire compromised snags is particularly unpredictable and dangerous. Unfortunately recent investigations conducted by people with no real understanding of the realities of wildland fires have become prosecutorial. The investigations are usually conducted without proper consul provided for those involved in the incident. At risk of being convicted for lying to investigators or worse it is advisable to remain silent and demand consul. More wildland firefighters are purchasing liability insurance for just such occasions. If the Feds are really concerned with learning from mistakes, they should conduct the investigations as such, not in a way that bolsters a case for prosecution. Logging and specifically felling timber is the most dangerous occupation in terms of injuries and fatalities in the US. Add to that the difficulty inherent in felling trees that are compromised by fire and the task is even more daunting. These seasonal firefighters had an assignment given to them by the Federal Government on a Federal Wildland Fire using Federal equipment that they were trained to use by the Federal Government. They were tasked with falling hazard trees, so crews with upwards of 20-40 people in that area were safer. That is quite a burden. I maintain that carrying out the work of the government, on government land, using government equipment, and trained by said government, the current trend towards investigations based on prosecution is inappropriate and detrimental to creating a safer work environment.

[outofmytree]

I don't see the grey area here. The work was done outside the quals of anyone on site. The tree was not a hazard, the type of cut was unsuitable for the job and was executed badly. And someone died.

If I dropped a tree the wrong way in town and killed someone I would be prosecuted and ditto if one of my employees did the same. The fact that the job those fellers were doing is high risk does not mean that they are excused from the simple human requirement of taking responsibility for their actions.

One other item I havent seen raised and that is why was there no team member with higher felling credentials on site? That seems like a glaring oversight on the part of management to assume that every hazard tree would be within the capabilities of this crew. If there is to be changes made to protocol to avoid a repeat of this tragedy then ensuring teams are always comprised of at least 1 highly qualified feller should be an obvious start.

[newsawtooth]

Originally Posted by outofmytree

I don't see the grey area here. The work was done outside the quals of anyone on site. The tree was not a hazard, the type of cut was unsuitable for the job and was executed badly. And someone died.

If I dropped a tree the wrong way in town and killed someone I would be prosecuted and ditto if one of my employees did the same. The fact that the job those fellers were doing is high risk does not mean that they are excused from the simple human requirement of taking responsibility for their actions.

One other item I havent seen raised and that is why was there no team member with higher felling credentials on site? That seems like a glaring oversight on the part of management to assume that every hazard tree would be within the capabilities of this crew. If there is to be changes made to protocol to avoid a repeat of this tragedy then ensuring teams are always comprised of at least 1 highly qualified feller should be an obvious start.

You're absolutely right. I agree that there does not appear to be any gray area except this situation involves the Federal government. The problem with prosecutions involving our Federal Government is that prosecutions are directed towards the lowest possible level in order to limit the liability of the agencies. We are presented with an opportunity to make cultural changes in order to make the work safer. Instead the government seeks to blame an individual for the mistakes of an agency and policy. That is the fundamental difference between the scenario you presented in which one of your employees makes a mistake and you, the employer, is held accountable. It is apparent that appropriate oversight was lacking in this case. But this likely would not be addressed in a trial as it has not been in the past. Furthermore, we do not know who was cutting the tree and why. There is a 33.3% percent chance that the deceased was cutting the tree or a combination of fallers.

I maintain that the most important change that can be made is streamlining medical protocols to be simply: Evacuate injured parties to a higher standard of care as quickly as possible. It is not for someone in the field attending to the injured to worry about which trauma center can best handle the injuries or which agency can facilitate an evacuation. The back of a rural ambulance staffed by volunteers would have been preferable to medical interventions on a dozer line 3/4 of a mile from a road.

[137cc]

Originally Posted by outofmytree

One other item I havent seen raised and that is why was there no team member with higher felling credentials on site? That seems like a glaring oversight on the part of management to assume that every hazard tree would be within the capabilities of this crew. If there is to be changes made to protocol to avoid a repeat of this tragedy then ensuring teams are always comprised of at least 1 highly qualified feller should be an obvious start.

These guys were out "sport falling" and not following directions. In camp before they went on the line a branch director reminded the module to stay within there limitations (he knew their actual falling credentials). When the engine module members got to the line they told their division/group supervisor that they were "C" qualified. So there are rules and regulations in place to prevent workers from doing jobs they are unqualified for. These guys lied about their qualifications, that's part of how they got through.

Originally Posted by newsawtooth

Furthermore, we do not know who was cutting the tree and why. There is a 33.3% percent chance that the deceased was cutting the tree or a combination of fallers.

Very unlikely the deceased was cutting, this was his FIRST fire assignment. He was most likely watching and unaware of the dangers that were present.

[smokechase II]

There is almost no chance the deceased was cutting the tree. Maybe one in a thousand with the first two cowboys letting him do the back-cut. Maybe.

============

The failure to hold people accountable for their actions also indicates the level of moral decline at the management level.

An interesting bit of trivia is that the Park Service was involved in a near miss burnover event about a dozen years ago where the crew boss there also went outside his experience/certification level. This was in regard to the use of a backfire but burn injuries did occur and this was very close to a fatality event.

Rather than pick on the Park Service I would suggest that the problems manifested in this fatality and limited investigation are part of all the Federal Fire Services and many of the State Agencies.

==============

1) Train
2) Certify
3) Supervise
4) Investigate
5) Prosecute
6) Terminate employment

As needed on the last three.
Always on the first three.

==========

Don't think of this level of incompetence as a complete indictment of all wildland firefighters.
However, as you may have noticed a decline in the quality of fireline work over the last couple decades and as you may notice a further fall in coming years, understand that this all starts with management.

[fyresq]

Originally Posted by superfire

[/color]

what my basic point all along has been if personnel on a fire line have to use a saw then the must be required to be certified and registered. if the IC needs trees removed they would call out
Faller-Fighters not regular firefighters. Faller-Firefighters would be like hot shots trained to do the more dangerous hazard tree work.

Well as a person who was on that fire but in a different area (former firefighter for the USFS and an all risk Firefighter in Lake Tahoe) I will agree that the mentioned party should not have been cutting that tree. That said I have a few points to make

1st. Wildland firefighters are rquired to be certified to cut trees starting with the basic s-212 to having the c faller hazard cert. Any hazard trees are supposed to be fallen by c class hazard fallers, especially any tree over 24" dbh
2nd. Knowledgeable fallers are called out all the time. They are single resource c class hazard fallers. I can't armchair quaterback the decision too much, but a better approach would have been to use a dozer or keep people out of the area until proper personnel could arrive rather than using b fallers (who aren't supposed to cut hazard trees or anything over 24" dbh)
3rd. When we have big hazard trees in our local area, we have personnel trained to wrap det cord and fall them (cut them by explosive) by remote with no one standing within 100yds. IMHO this is the smartest way to fall a hazard tree that isn't threatening property. It was my understanding that this is a red card qualification and training is out there to do this type of falling and fireline construction using det cord.
4th. Timber fallers in general have no knowledge of fire or fire behavior or other extremely important factors such as the ICS system, communications, safety, etc.. Most firefighters killed in the line of duty on wildland fires (other than exertion and aircraft) are from being overun by fire. So what certification do timber fallers have for working around a major wildland fire?

With that said, I think the fire service can always do better than it has and injury/death reviews are extremely important. I do believe that people should be held responsible for actions or inaction.

[fyresq]

Originally Posted by newsawtooth

I maintain that the most important change that can be made is streamlining medical protocols to be simply: Evacuate injured parties to a higher standard of care as quickly as possible. It is not for someone in the field attending to the injured to worry about which trauma center can best handle the injuries or which agency can facilitate an evacuation. The back of a rural ambulance staffed by volunteers would have been preferable to medical interventions on a dozer line 3/4 of a mile from a road.

Agreed, I think people aren't realizing that most wildland fire/seasonal agencies such as the FS and PS often only have EMT basics who don't have the training, knowledge or equipment to deal with most emergencies. A local agency that had paramedics or a heli evac should have been intitiated immediately. Taking 2 hours to call in a Coast Guard helicopter is ridiculous at best. At the very least the FF could have been carried in the scoop or taken by patrol truck to the nearest suitable rendezvous in way less than two hours.

[superfire]

my point has beenthat there is three basic failures in this case.

1: Untrained sawyers
2: Failure on the part of the IC on scene
3: Failure of on site medics in three areas
A: Not doing a proper head to foot evaluation
B: Trying to use an air ambulance instead of the faster ground transport
C: Failure to use local resources

[techdave]

Hi NST, thank you for your reasoned response to first post, which had a tad too much of a damn the torpedoes to it.

Having just re-read Fire on the Mountain, about the West canyon Fire on Storm king mountain, I see better where you are coming from.

USING IT AS AN EXAMPLE

Blaming Mackey for cutting line downhill trying to hook the fire at the end of ridge is missing teh bigger picture because:

Since among other things, neither he nor Blanco should have been left in charge as the fire and crew grew, the bickering higher up denied them logistic and air attack support that would have changed the outcome. Also no one did anything to make sure the crews were briefed onlocal weather patterns, fuel conditions (Gambrel Oak when dry), and the Red flag Cuoco of NWS had issued.

Lots of ass-covering afterwards. where Agencies worked to cover theri Legal LIABILITY instead of self examination. So yes, i can see that investigation and blaming the dead CAN be counter productive.


BACK TO THIS THREAD
having said all that, I still see major character flaws in the the little triggermen who laweryered up and would not tell what really happened.

One thing for sure, the REMF who has never done a job is slowly taking over American Management!!

[char]

A.) A Law Enforcement investigation was initiated immediately after the accident. The individuals involved got lawyers, took the 5th and chose to say nothing about the incident. Once the criminal investigation was concluded without any charges, the fact finding investigation quoted in this thread was resumed. The individuals obviously decided not to make any comments about the incident due to their previous interactions with Law Enforcement.

B.) I look at the falling diagrams and the pictures from the technical assessment and come to the conclusion that they may have been attempting to "drive" the tree that was burned out and leaning that killed Palmer. In other words, they may have intentionally struck the 2nd tree with the 1st tree and terribly miscalculated the results. It is very difficult to tell.

C.) Worst stump I have ever seen. They were obviously out of their league.

D.) If you are going to go after the 19-22 year olds for getting in over their heads and violating procedures, you should go after the guy who canceled the Coast Guard ship as well. And the direct line supervisor (task force leader) for failing to provide/require adequate oversight (single resource qualified supervision). And then, why not the IC for running a shody operation? See where this goes? Pretty soon you have an organization that is so paralyzed by risk that NOTHING happens to stop fires. On the other hand, there need to be consequences...

E.) Calling in contract fallers on campaign fires is a great idea. They have the experience and knowledge for the most part to operate safely if they have a Felling Boss with them to run the fire side of things. You should know that agency "C Fallers" are certified by an outside individual from the timber community. One such individual in Oregon and Washington is Douglas Dent.
Can we compare an agency faller and a private timber faller? Probably not. But I'd wager that the agency C Fallers are more risk averse. I know I am. One key factor in being certified "C" is the ability to judge ones own skills and be comfortable turning down a tree even with peer pressure or mission pressure on your back.

[newsawtooth]

Techdave, you have addressed the complexity of the situation that is not present in most smaller scale operations. There was more at work in the accident than just one mistake. I can appreciate your contention that refusing to cooperate with investigators amounts to shirking responsibility.

char, good post. I wondered if they were using the Ponderosa as a driver tree as well. Your assertion that C cutters are trained to refuse unsafe assignments is compelling as well. I have heard this from friends that are C certifiers, who are for the most part relatively risk averse people.

superfire, you have illustrated the swiss cheese model of accident progression. Often, accidents cannot be pinned on a single event, or one hole. But a series of events or holes that contribute to a failure.

[superfire]

I see this as how the basic incident management can be FUBARed. Most tree falling accident can be put into three categories :

A :
Sawyer has limited time running saw or is running two big of power saw for their physical ability.

B :

Sawyer is doing work that is beyond the technical knowledge they need to do the job

C:

Sawyer rushes the job because of time pressure to get the the job completed


These are what I have seen as a Pro Hand Faller and have been on several fires. This just seems to be happening to the wild land fire system more often. The IC system is standardized for the whole country . The one thing I said about the need for pro fallers is the person running the saw needs more education and a lot more to become a higher level
of Sawyer to handle the removal of KILLER TREES.