Report Details Errors That Led to The Death of A Young National Park Firefighter

Report Details Errors That Led to The Death of A Young National Park Firefighter

4 November 2009

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USA — Fighting forest fires is one of the most dangerous occupations to partake in. And yet, many of those who fight these blazes are energized by the danger they encounter. You might say they get an adrenalin high battling the flames. And some firefighters die, more often than not because they were in the wrong place at the wrong time. That appears to have been the case when a young firefighter from Olympic National Park died on the fire lines in 2008.

Andrew “Andy” Palmer was just 18 when he joined the national park’s firefighting crews in June 2008 just days after graduating from Port Townsend High School on the northern lip of the Washington State peninsula. A husky young man with an engaging smile, Andy and his four-person engine team were dispatched July 22, 2008, to help fight the Eagle Fire that was burning as part of the Iron Complex in northern California’s Shasta-Trinity National Forest.

It was there, on the smoke-obscured slopes of the forest, that Andy bled to death.

A 115-page report released Tuesday paints a picture of an over-anxious crew on an ill-fated assignment, one befallen by mechanical breakdowns, seemingly ignored orders, firefighters ill-equipped to tend to catastrophic injuries, on-the-ground confusion, and smoky skies that delayed a helicopter evacuation of the young man who was on just his second firefighting assignment.

“This was a tragic accident and our hearts go out to the Palmer Family, his friends and his colleagues,” National Park Service Director Jon Jarvis said. “Our intent in releasing this report is for all of us to learn from this incident in order to help prevent recurrences of this type of event in the future. This is how we will honor Andy, by remembering his commitment to self and colleagues. His passing should serve as a constant reminder to honor your fellow employees by watching out for their safety.”

Andy, a 6-foot-5, 240-pounder with a mechanical aptitude, was hired to be a firefighter by the national park four days after he graduated. Twelve days later he had completed his basic training, and on June 29 he was assigned to an engine crew. On July 22, roughly 12 hours after his team was summoned to duty, Andy and the others, anxious to reach a fire line, according to the investigation, were headed south to California. From that point on the assignment seemed overshadowed.

The Eagle Fire was the first out-of-park fire for Andy’s crew. After four hours of driving, the team stopped about 1 a.m. at a motel in Kelso, Washington, to catch some sleep. Six hours later, according to the investigation, the crew was back on the road, but only briefly as the tailpipe of their new truck fell off. After picking up the tailpipe, they reported the problem and continued on south, only to encounter a “check engine” warning light.

While they were able to finally reach the fire’s Incident Command Post near Junction City, California, about 6 p.m. the night of July 23, the crew’s captain spent the next two days trying to get the truck, which was under warranty, fixed. He ended up picking up a loaner truck on the morning of July 25 and began to retrace his route to the fire camp. Andy and the remaining crew members, meanwhile, were sent to a fire line to cut potentially hazardous trees in advance of a fire mop-up crew. Their instructions included a specific direction not to cut trees over 24 inches in thickness at breast height as they weren’t qualified to do so, the report noted.

It was shortly after 1:30 p.m. that day, when the crew captain was stopping for lunch, when a call for help came over the radio dispatch.

“Man Down Man Down. We need help. Medical emergency. Dozer pad. Broken leg. Bleeding. Drop Point 72 and dozer line. Call 911, we need help.”

According to the investigation, “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 (a fire scar) 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 120-foot portion of the sugar pine to break off. As it slammed to the ground another section, approximately 8 feet long, broke off and fell upslope, hitting Andy and causing his injuries, noted the report.

Further radio communications reported that Andy had both a broken leg and fractured shoulder and that he was bleeding badly from his injuries. While a request quickly went out for a helicopter evacuation, one air ambulance said the conditions were too smoky for a rescue.

Complicating the rescue, according to the report, was that the extent of Andy’s injuries were not clearly explained during the calls for help. A team of responding paramedics thought the injury was only a broken leg, and so it carried little more than a “vacuum splint and trauma bag.” It wasn’t until 55 minutes after Andy was injured that the responders visibly saw the profusely bleeding femoral injury.

In the heat of trying to save Andy, decisions over how best to get him to a hospital seemingly led to confusion between the Trinity Sheriff’s Office and a U.S. Forest Service safety officer, as a U.S. Coast Guard helicopter was summoned and then told to “stand down” because a U.S. Forest Service helicopter seemed closer. The need to hoist Andy into a helicopter led to the eventual decision to clear a small landing zone so the USCG helicopter could ferry him to help; the Forest Service whirlybird couldn’t respond quickly enough because it didn’t have hoisting ability, the report noted.

Confusion over how best to get Andy to a hospital was then interrupted by concerns over whether he needed more on-site treatment for his injuries rather than trying to rush him off the mountain. It was during this debate between two paramedics that a decision was made to clear a landing zone — a process that took “about 20 minutes” — where they were so Andy could be hoisted into a helicopter. Two hours and 47 minutes after he was injured, Andy was finally hoisted into a USCG helicopter. Thirty-nine minutes later he was pronounced dead before ever reaching a hospital.

The report identified a series of errors that seemed to cascade and compound matters in leading to Andy’s death:

* Andy’s team “was given a line assignment without adequate supervision for the assigned task,” and, with the captain away trying to get their truck repaired, the second in command “failed to exercise proper supervisory control by allowing” the team to cut down trees above their level of certification.

* “Excessive motivation for (the crew) to obtain a line assignment led to a series of inadequate communications and assumptions which subsequently led to a mismatch between resource request and resource assignment.”

* The Ponderosa pine was “felled by an unqualified sawyer” and “escape routes/safety zones were not effectively utilized by” Andy.

* “There was insufficient pre-planning to integrate incident personnel and resources into the local emergency management system, taking into account local factors, including environmental conditions, to effectively manage a serious injury and the subsequent medical evacuation.”

* “Inadequate leadership, communication, and risk management resulted in a lack of clarity in communicating the severity of the injury, resource availability, and a failure to evaluate the most appropriate method of evacuation relative to risk exposure, resources required, and timeliness.”

* “The National Park Service fleet management procedures for quality control are inadequate to ensure mission ready condition of new wildland fire engines and to appropriately handle maintenance and repair issues.”

Beyond those points, the report pointed to a lack of command at the scene of the accident, a failure to clearly communicate the extent of Andy’s injuries, and a miscalculation in how best to get Andy to a hospital.

While there was a law enforcement investigation of the accident, the assistant U.S. Attorney declined to pursue charges. Other than the captain of Andy’s crew, no other crew members agreed to be interviewed by the interagency Serious Accident Investigation Team, according to the National Park Service.

You can find the full investigative report, and its supporting documentation, atthis site.

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