Arizona Forestry Division violated safety standards during Yarnell Hill Fire

Arizona Forestry Division violated safety standards during Yarnell Hill Fire

04 December 2013

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USA — The Arizona Industrial Commission has unanimously approved three major workplace-safety citations against the Arizona Division of Forestry for its handling and oversight of Yarnell Hill Fire that killed 19 hotshots near Prescott last summer.

Late Wednesday afternoon, the commission by a 4-0 vote also approved penalties totaling $559,000 against the agency for the citations, which noted a variety of workplace-safety infractions ranging from inadequate fire-suppression planning to poor communications during the blaze. A fifth member of the commission was not present to vote.

The findings of fault are contained in a lengthy investigative report presented today to the Industrial Commission by the Arizona Division of Occupational Safety and Health. The commission voted to accepted the recommendations on citations and penalties after a 2 ½-hour discussion of the investigative report in a public meeting. Investigators recommended:

–A “willful serious” citation for putting protection of “non-defensible structures and pastureland” in Yarnell ahead of firefighter safety. The citation says the forestry department “knew that suppression of extremely active chaparral fuels was ineffective and that wind would push active fire toward non-defensible structures.”

Because firefighters were not removed from harm’s way promptly and in keeping with established policies, the report concludes, the 19 hotshots perished while Granite Mountain Hotshot lookout Brendan McDonough, 31 other firefighters in the Double A Bar Ranch area, and 30 firefighters elsewhere were exposed to risk of “smoke inhalation, burns and death.”

Investigators recommended the forestry division pay a penalty of $70,000, plus $25,000 per firefighter who died, or a total of $545,000, for this citation. The $25,000 per firefighter would be paid directly to the firefighters’ families or estates.

–Two “serious” citations for the forestry division’s failure to put in place a detailed firefighting plan “during the life-threatening transition between initial attack and extended attack fire operations,” and for allowing “critical incident management personnel” to be absent or late during key moments in the fire.

During the period immediately after the fire grew out of control, command of the blaze was transferred from one team to a larger, more sophisticated team. During that time, the report found, commanders did not conduct a standard complexity analysis, an operational needs assessment, or an Incident Action Plan dictating the new objectives and strategies in fighting the fire.

Investigators said key Safety Officer and Planning Section Chief positions went unfilled, and other important officers arrived late for critical planning activities, increasing the risk to firefighters in the field.

As a result, the report said, maps were not readily available to hotshots and others when they arrived to fight the fire, a safety officer who likely “would have viewed the fire and fire line assignments from a safety viewpoint” was not available that fatal morning, and the team lacked cohesiveness and consistent communications with people on the ground and in the air.

Those shortcomings resulted in proposed penalties totaling $14,000.

The report exonerated the City of Prescott in its handling of the hotshot crew.

The workplace investigation was launched after 19 members of the Prescott-based Granite Mountain Hotshots were overcome by flames and perished in a chaparral canyon about 35 miles south of Prescott.

The fire, pushed by monsoon-storm winds, changed direction and became a fast-moving inferno that trapped the crew.

The Yarnell Hill Fire, which burned from June 28 until July 10 and scorched thousands of acres, destroyed more than 100 structures and forced hundreds of residents to evacuate as flames and embers descended on the community.

State forestry supervised the incident command team and firefighters on the afternoon of June 30, when the hotshots were forced to deploy their aluminum shelters and were overcome by the blaze, which burned hotter than 2,000 degrees.

The death toll was the highest from a U.S. wildfire in at least a half-century. Only one member of the crew, who was serving as a lookout, survived the blaze. He was among those interviewed as part of the ADOSH investigation.

The state forestry division released a statement shortly after the investigative report became public, saying it cooperated with investigators but would not issue a statement on the report’s findings at this time.

“The Arizona State Forestry Division fully cooperated with the Arizona Division of Occupational Safety and Health (ADOSH) throughout their investigation,” the statement read. “However, we have not reviewed the ADOSH Yarnell Hill Report which was just released today, and we cannot provide any statement on the report or the Industrial Commission’s actions. The Forestry Division will have an opportunity to meet with ADOSH representatives to discuss their findings and recommendations after we have reviewed the report.”

Officials with Arizona Gov. Jan Brewer’s office also declined to comment on the investigative report’s findings.

“The Yarnell Hill Fire was a terrible and unprecedented tragic event that took the lives of 19 brave firefighters from the elite Granite Mountain Hotshots,” Brewer spokesman Andrew Wilder said in a written statement to the Republic. “The Governor’s office will study the report released today from the Arizona Division of Occupational Safety and Health. Due to the likelihood of legal action, we will not be providing additional comment.”

The report noted that federal officials denied state investigators access to interview U.S. Forest Service employees who worked on the Yarnell Hill Fire. The Forest Service provided some documents from a federal hotshot crew and air-support crews, but names and “sensitive” information was redacted.

Wildland Fire Associates, a consultant hired to examine firefighting strategies in detail, reached four conclusions regarding the Yarnell Hill Fire in a report prepared for the Arizona Division of Occupational Health and Safety and submitted along with proposed citations to members of the Industrial Commission:

— Extreme fire conditions, fanned by strong winds from a thunderstorm, “continually exceeded the expectations” of fire managers;

— The Arizona State Forestry Division failed to follow its own guidelines for attacking the fire;

— Incident managers in charge of battling the blaze “failed to recognize” that their tactics “could not succeed” with the available resources, and that failure continued as the strategy evolved, and;

— The Forest Division miscalculated the risk of their plan after the early fire jumped fire lines. “The failure of their strategies and tactics … resulted in a life threatening event.”

Citation worksheets prepared for commissioners state that the Granite Mountain Hotshots should have been ordered out of the area earlier in the afternoon of June 30 before they died.

“By 1530 (3:30 p.m.) the weather conditions had dramatically changed, and the employer chose to evacuate the incident command post but allowed the Granite Mountain IHC to work downwind of a rapidly progressing wind driven fire past 1530. Granite Mountain IHC should have been evacuated on or about 1530,” the report said.

Investigators also noted, “McDonough (the team’s lookout) should have been evacuated on or about 3:30 p.m. What should have been a planned retreat ended up being an emergency escape resulting in a fortuitous drive-by.”

Had Brian Frisby, superintendent of the Blue Ridge Hotshots, not driven up and seen McDonough as he redeployed his own team, McDonough would have faced a burnover of his own. Both men would have faced a decision to deploy emergency shelters if there had been a problem with their escape Jeep, investigators wrote.

Concluded the report: “Fire management’s failure to reevaluate firefighter safety based on continuously observed extreme fire behavior and expected and observed thunderstorm activity resulted in a complete failure to protect employees working downwind of the fire from exposure to smoke, burns and death.”

The report cited examples of what investigators concluded was lax safety planning. In one, 31 firefighters at Double A Bar Ranch were assigned a tennis court as their safety zone, the designated place to go if flames became threatening. The report said it was “known to be too small for the approaching 40 foot flames.”

The report also found that commanders miscalculated “trigger points” that were to be used to establish when and where to take action.

In Yarnell and Glen Ilah, 30 firefighters from Structure Protection Group 1 were endangered, the report said, because the “previously established trigger points did not provide adequate time to avoid exposure to smoke and fire.”

Penalties levied against the forestry division included $25,000 per firefighter killed, with that money intended to go directly to the firefighters’ survivors or estates. In order for those payments to be made, Industrial Commission Chairman David Parker announced a formal finding during Wednesday’s meeting that none of the Granite Mountain team members disobeyed any specific safety instructions.

The report noted that the hotshots “successfully followed most of the ten Standard Firefighting Orders” and other rules. However, some errors were made.

For example, there is no evidence the hotshots “scouted and timed alternative escape routes or checked the escape route they used for loose soils, rocks or excessive vegetation.”

A second error made by the team was not having a lookout when they descended into the box canyon: “Based upon interviews and incident documents, we could find no evidence that they requested that they requested a lookout as they traveled towards Boulder Spring Ranch.”

Finally, the report said, the hotshots were obligated to notify their supervisor where they were moving to and what route they would travel.

“The confusion that surrounded the search for the crew after the entrapment and burn over illustrates the importance of notifying the supervisor,” according to the report.

The report found that the chaotic transition between fire-management teams left the hotshots and others unprepared for what they faced. For example, the report noted, maps were not handed out to crews before they hit the fire line.

“A map would have helped the crew estimate how far the Boulder Springs ranch site was away from the lunch spot and evaluate alternative escape routes including the two-track road to Boulder Springs Ranch,” states the report. The ranch appears close from the top of the ridge where the hotshots began their descent into the canyon where they died, the report says.

However, heavy brush and rocky area made travel difficult and slow.

“They may have underestimated the speed with which the fire was moving,” the report says.

A separate inquiry by a Serious Accident Investigation Team found in a report released in September there was “no indication of negligence, reckless actions or violations of policy or protocol” on the part of any of those who oversaw or fought the fire. That team concluded that the fire that overtook the men was not survivable.

That team’s official incident report noted a communications breakdown during a critical juncture in the fire fight as flames reversed direction and accelerated towards the hotshots. The report described how other officials involved in the fire were uncertain about the crew’s location after they left a safe area that had already been burned over. The report also noted problems with radios, which the crew worked around, as well as a misjudgment of weather changes.

The Serious Accident Investigation Team did not analyze whether fundamental wildfire safety rules were violated, and did not establish a cause or lay blame for the deaths.

ADOSH launched its investigation into the deaths of 19 members of the Granite Mountain Hotshots in early July, joining an interagency investigative team to review circumstances surrounding the tragedy. A short time later, ADOSH broke off from the Serious Accident Investigation Team and continued its investigation separately.

The Serious Accident Investigation Team recommended that state forestry, among other things, review communications systems and better track weather, hotshot crews and aircraft. The team also suggested the state could update its approach to mitigating wildfire threat to life and property.

An inspection narrative illustrates the scope of the state investigation. Investigators interviewed personnel with various incident management teams, structure-protection group supervisors, state Department of Corrections hand crews, Prescott fire officials, officials with the federal Bureau of Land Management, as well as the Arizona Department of Public Safety. Investigators also reviewed safety and health records and hotshot crew handbooks.

Forestry officials this week declined to speak to The Republic about what efforts have been made to implement those recommendations.

The fatalities almost immediately triggered a public debate over the state’s fire suppression and safety procedures on the Yarnell Hill Fire.

They also triggered a $36 million notice of claim by the mother of Grant McKee, a 21-year-old hotshot who perished. She asserts officials were negligent and failed to oversee, communicate with and track her son, who was preparing to marry. Marcia McKee’s claim seeks $12 million each from the state, Prescott and Yavapai County.

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