Yarnell Hill Fire: Findings may prevent future firefighter deaths, experts say

Yarnell Hill Fire: Findings may prevent future firefighter deaths, experts say

11 August 2013

published by www.azcentral.com

USA — Weeks after a backcountry blaze killed 19 Arizona firefighters, the discomfiting question lingers like acrid smoke: What went wrong?

How did the Granite Mountain Hotshots, a professional crew schooled in the safety-first mentality, become trapped and engulfed in flames?

In a wildfire world where mistakes can mean deaths, experts say the questions demand answers.

Investigators so far have issued only a terse 72-hour report that addressed dynamics rather than causality: As a thunderstorm moved in, fire reversed direction and exploded into a hellish inferno. That is the modus operandi of most killer fires. The Yarnell Hill blaze was unique in the number of victims.

The review process is sobering and meticulous: Team members must interview witnesses and study dispatch logs, aerial photographs, weather reports, fuels, topography, training, leadership, autopsies and every imaginable factor in the June 30 deaths.

Detailed findings are expected in mid-September, but prospects of blame already have churned controversy.

In fact, wildfire-fatality reviews nearly always identify mistakes and safety violations by the victims, compounding the pain.

Dick Mangan, a retired U.S. Forest Service investigator from Montana who has participated in about two dozen accident inquiries across the nation, said investigators owe it to the hotshots to determine why they died.

“The biggest obligation to the dead is to tell the truth,” Mangan said. “It steps on people’s toes sometimes, it offends some people’s sensitivity sometimes, it changes the image that they have of the firefighters.”

Hotshot tutorials are unequivocal: Lives should not be lost. That is the mantra of national academies and safe-ty agencies. It is the No. 1 priority.

Protocols are devised to prevent fatalities even when blazes defy expectations. Over and over, firefighters are admonished to avoid risks and complacency. Time and again, they are shown videos explaining how others got killed — scenarios chillingly similar to what transpired June 30 in the chaparral country near Yarnell.

The U.S. Bureau of Land Management has a 93-page rulebook for post-disaster inquiries that focuses heavily on human error, listing scores of possibilities. It stresses that an inquiry is mandatory — not to affix blame, but so future firefighters won’t die.

Yet they do, again and again. During the past half-century, more than 900 firefighters in the U.S. have died battling wildfires. The Yarnell Hill Fire was the deadliest.

And, now, investigators delegated by the Arizona Division of Forestry are grappling with the question again: What went wrong?

Can the tragedy be blamed on a freaky firestorm, an unavoidable act of God?

Are the nation’s wildfire safety standards inadequate?

Or were there miscalculations, missed safety protocols, communications breakdowns?

Late last month, Deputy Forester Jerry Payne incurred the wrath of those close to the victims when he was quoted by an independent journalist as saying hotshot boss Eric Marsh made a fatal mistake leading his crew into a chaparral-filled canyon without a lookout. Payne was quoted as saying Marsh broke basic fire-safety rules and “put those people at risk,” adding, “It was a serious miscalculation.”

Forestry Division officials denounced Payne’s “unauthorized opinion.” Prescott Fire Chief Dan Fraijo characterized the comments as disgusting, insensitive, unethical and insulting to Marsh’s family.

Sharon Knutson-Felix executive director of the 100 Club of Arizona, a charity assisting families of the Granite Mountain Hotshots, said speculations about fault were “unconscionable … just devastating for the families.”

If the investigative team discovers mistakes by those who died, she said, the information should be shared only with families and other firefighters, not the public.

“We know they still died as heroes fighting fires,” Knutson-Felix said. “Nobody did this on purpose.”

Mangan said it is difficult for investigators to balance the protection of a firefighter’s memory with a need to learn the truth. “One of the hardest things I’ve done numerous times is to sit down with parents and spouses of firefighters who died and talk about the findings,” said Mangan, now a consultant and expert witness. “You sometimes have to tell people your son, daughter or spouse made a mistake. But the obligation we have is to be as totally honest as we can.”

Subtle distinction

Experts strike a subtle distinction between identifying causes and laying blame.

If mistakes occurred, it does not mean those responsible were malicious, or even negligent. It is not an indictment of character.

In the heat of battle, good-faith miscalculations occur, especially among firefighters driven by adrenaline and determination to defeat the fire.

“This subtle cultural pressure to stay till the last minute is, in fact, extremely dangerous,” said Jim Furnish, a retired U.S. Forest Service deputy chief.

Some of those who faced the Yarnell Hill Fire flatly reject the notion that its victims erred. Instead, they refer to Mother Nature, bad luck or the Almighty.

“This was the most extreme fire behavior I’d ever witnessed,” said Darrell Willis, wildland division chief for Prescott Fire Department and Marsh’s close friend. “You can call it an accident. I just think God had a different plan for those men.”

“There were no mistakes,” agreed Jake Moder, a captain with the Peeples Valley Fire Department who was battling the blaze less than a mile away when Granite Mountain Hotshots were overcome. “Everybody’s trained in what they do. But nobody can control the weather.”

Gary White, a retired Bureau of Land Management criminal investigator from Bend, Ore., stressed the inherent perils of the job.

“There are a lot more objective dangers in wildland firefighting than working in an office,” said White, who served on a hotshot crew. “You’re never going to get rid of those. The only way you can make that completely change is not respond.”

Andrea Thode, associate professor in fire ecology at Northern Arizona University’s School of Forestry, said speculation about causality only harms the families of the fallen.

“The reality of it is, we have no clue at this point what happened and no one should be laying blame on anyone — especially when you lost an entire crew and you have no one left from that crew that knows what happened,” she said.

Sensitive investigations

Determining causality in a fatal accident is sensitive not just because it threatens the reputations of those who died, but also the careers of colleagues who suffer survivor’s guilt and may share responsibility.

Investigators uncovered a tragedy of errors after the Thirtymile Fire killed four U.S. Forest Service employees in 2001 near Winthrop, Wash.

All 10 of the industry’s “Standard Fire Orders” were violated, and many of the “18 Watch Out Situations” were disregarded.

According to the inquiry, burn conditions were misjudged. Communications broke down. Lookouts were not posted. Fatigued hotshots made countless mistakes.

On most fatal fires, experts uncover myriad contributing factors. But they may also identify a primary cause, and assign blame.

Furnish, the retired Forest Service deputy chief who led the Thirtymile investigation, said his team wrestled with questions of accountability after finding that firefighters bore some responsibility for their fate.

He stressed that those who died got into trouble initially because of poor decisions by fire commanders. Still, the victims might have survived — as many others did — if they had responded differently.

“It’s sad, but I just think they made a choice to be where they were, and it cost them their lives,” Furnish said, discussing the Washington state blaze. “I think it’s regrettable but true that they bore some of the responsibility.”

For the sake of other wildland firefighters, Furnish said, the Yarnell Hill Fire investigators should not allow emotions to dissuade them from identifying any mistakes that may have been made.

In the Thirtymile investigation, he added, “We made a very conscious effort not to allow that to influence our undertaking. That’s a real dangerous road to go down — down that path lies dodging the truth.”

After the Thirtymile Fire, investigative findings were used to obtain a grand-jury indictment against Incident Commander Ellreese Daniels for negligent homicide and other crimes.

Daniels eventually pleaded guilty to false statements, a misdemeanor, and was sentenced to probation.

Payne and other wildfire veterans said the prosecution of Daniels had a chilling impact on subsequent investigations because firefighters, already in mourning, fear results of accident investigations may be used against them.

Emotional backdrop

Members of the Serious Accident Investigation Team led by Florida State Forester Jim Karels are conducting the Yarnell fact-finding mission with those emotion-charged elements as a backdrop.

When the inquiry is completed, Payne said, lessons learned likely will become part of the national wildfire-safety guidelines.

“An incident of this magnitude gets everyone in the wildland firefighting community’s attention,” he noted.

The Dude Fire of 1990, near Payson, is a case study that led to major fire-safety reforms.

A training video of the event on YouTube conveys the horror, as well as the mistakes.

“Black heat. Blaze of death,” recalled a hotshot who survived. “One way out. Can’t quit. Life or death. Don’t stop running. If you stop, you’re dead.”

Conditions defied expectations. Commanders were confused. Crews miscalculated the fire’s speed, direction and fury.

Turn the calendar forward to 2013 and the Yarnell Hill Fire appears to present a deja vu scenario.

The Idaho-based National Wildfire Coordinating Group warns of thunderstorm “downbursts that can cause extreme fire behavior” and “a sudden reversal in wind direction.”

Instructions on “Entrapment Avoidance” caution against entering canyons that may become fire chimneys and advise crew members to establish a fallback clearing with little or no fuel, its radius four times the height of the tallest flames.

Some say the tragedy on Yarnell Hill is no reflection on safety protocols. The fire’s behavior could not have been anticipated.

But the explanation may include myriad factors.

Peter Morrison, executive director of the Pacific Biodiversity Institute, which already has published a report on the fire, said conditions screamed danger.

“The behavior of that fire was very predictable,” he added. “You can call it an act of God, but it was a predictable act of God.”

Morrison and others said incident commanders, analysts and hotshots are supposed to recognize the potential for a firestorm and prepare for the worst.

Still, he eschewed the notion of laying blame because responsibility for 19 deaths runs much deeper than what transpired during a horrifying few minutes, or even a few days.

He said Americans build homes in the outback, fail to clear surrounding brush, then insist that firefighters risk their lives to save them.

“I think it’s really important not to blame incident commanders in this situation because they are under tremendous societal and political pressure to do something,” Morrison said.

“There’s this attitude that we can stop nature dead in its tracks, but we can’t. These are immense, nasty fires. … We need to learn to stand down.”

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