Blame in Esperanza fire deaths may shift to forest service employees

Blame inEsperanza fire deaths may shift to forest service employees

11 November 2006

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USA — Even though a jailed arson suspect ischarged with murdering five firefighters in the Esperanza Fire, some ForestService employees fear they too could be targeted for blame in the deaths.

At least four separate investigations are under way to explain exactly whathappened Oct. 26 on Gorgonio View Road, where the crew of Engine 57 perished ina burn-over while trying to protect a home.

Some Forest Service employees are particularly wary of an investigation bythe U.S. Department of Agriculture’s Office of the Inspector General.

Veteran firefighters and advocate groups worry the IG will assign blame inthe Esperanza Fire deaths rather than identify lessons that can improvefirefighter safety in future blazes.

“I am concerned there is a need to introduce the human perspective intofirefighting investigations, to ensure we learn as much as we can from thesetragedies,” said Richard J. Manga, Montana-based president of the nonprofitInternational Association of Wildland Fire. Mangan helped investigate the 1994Storm King deaths of 14 smokejumpers and firefighters in Colorado. “Toooften we look at weather, fuels and fire behavior, but we don’t look at humanfactors.

“With Engine 57, these guys lived nearby and they were

protectingtheir own community,” Mangan said. “I’d let a house burn down in someinstances. But put me in my own community, and that might change things. That’sa human factor to be considered.”

The Federal Wildland Fire Service Association, a lobbying and advocacy group,has started a legal defense fund for anyone who was in a decision-makingposition at the scene of the burn-over on Gorgonio View, from engine operatorson up.

“We were asked by some of our folks on the forest, San Bernardino, tolook into availability of legal counsel,” said Casey Judd, FWFSA businessmanager, who is based in Idaho.

“Some have already secured the help of a legal defense team who workedon the Cramer Fire,” Judd said Monday, referring to the July 2003 fire inthe Salmon-Challis National Forest in central Idaho. Two firefighters whorappelled from a helicopter to clear brush on a steep slope died when they wereoverrun by flames.

In the wake of investigations that followed, six Forest Service managers weredisciplined, including an incident commander who left his job and served 18months on federal probation.

The criminal prosecution stemmed in part from a U.S. Department ofAgriculture Inspector General’s investigation mandated by a 2002 law, Judd said.

“The Forest Service is the only federal land management agencyinvestigating accidents and fatalities so aggressively, specifically toburnovers and entrapments,” Judd said.


Mike Dietrich, fire chief for the San Bernardino National Forest, said hetells all his management employees to protect themselves with insurance.

“Because of this new law, every Forest Service employee who’s in amanagement position should have professional liability insurance,” Dietrichsaid. “This is a case of arson where federal employees have died, and Idon’t know what the outcome will be as far as the IG’s investigation.”

The 2002 Hastings Cantwell Act calls for an independent investigation of any ForestService firefighter death caused by wildfire entrapment or burnover. Lawmakerscited four firefighter deaths in the 2001 Thirtymile Fire in Washington state,and the 1994 Storm King tragedy.

Paul Feeney, deputy counsel for the Department of Agriculture’s inspectorgeneral in Washington, D.C., said Tuesday his office has dispatchedinvestigators to the site of the fatalities in the Esperanza Fire. He said hecould not discuss details of the inspector general’s investigation.

“We’re not trying to be coy or secretive,” Feeney said in a phoneinterview. “We’re just trying to do our work.”

Mangan raised several concerns about the inspector general’s anticipatedapproach.

“When we’re on the fire line, we have a decision-making space of seconds,”Mangan said. “But the U.S. Attorney can take two and a half years to revieweverything I did in my whole career and my training.”

Before the Cramer Fire disciplinary and criminal actions, firefighters whowitnessed or took part in fatal incidents were more open and forthcoming aboutdiscussing details that could improve firefighter safety, Mangan said.

“On the Thirtymile Fire, people were honest – Hey, I screwed up,”‘Mangan said. “It was about lessons learned, not slamming your ass andputting you in jail.”

Since the Esperanza Fire is only the second time the USDA inspector generalhas been assigned to a burnover or entrapment situation with Forest Servicefirefighter fatalities, many people are worried, Mangan said.

Fear of discipline and-or prosecution may discourage people from sharinginformation that could enhance firefighter safety, Mangan said.

“Everybody is looking very, very carefully at what comes out ofEsperanza,” Mangan said. “Could they say if these guys didn’t followtheir training, that they screwed up, that it was not the arsonist’s fault theydied? It’s raising these kind of first-time questions.”

Mangan and others who have worked on previous firefighter fatalityinvestigations have been critical of the process.


Ted Putnam, an 11-year smokejumper, fire behavior specialist and psychologistbased in Montana, studied the fatal fires at Storm King in 1994 and otherfirefighter fatalities before he retired in 1998.

Last year, Putnam received an IAWF Wildland Fire Safety Award and the PaulGleason Lead by Example Award at a 10-year reunion conference addressing humanfactors in wildland firefighting.

Putnam is an outspoken critic of fire agency fatality investigations.

“Stress, fear and panic predictably lead to the collapse of clearthinking and organizational structure,” Putnam said in a 1995 paper for theForest Service on decision-making breakdowns that preceded the Storm KingMountain fatalities in Colorado in 1994.

“While these psychological and social processes have been well studiedin the military and the aircraft industry, the wildland fire community has notsupported similar research for the fireline,” Putnam said.

“The fatal wildland fire entrapments of recent memory have a tragiccommon denominator: human error. The lesson is clear: studying the human side offatal wildland fire accidents is overdue.”

The void has yet to be filled, Putnam said in phone interviews.

“The one thing we never did, we have no training system on how toimprove decision-making,” Putnam said.

Mangan said Putnam worked for him during those investigations and that he andPutnam both refused to sign the initial report.

Mangan said he joined Putnam in not signing off on the initial report aboutStorm King fatalities because he felt there was “too much emphasis onmistakes made by individual firefighters, and not enough examination ofmanagerial factors.”

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