New Report Blames State Forest Service Mistakes for Yarnell Firefighter Deaths
New Report Blames State Forest Service Mistakes for Yarnell Firefighter Deaths
06 December 2013
published by www.popularmechanics.com
USA — A new report on the Yarnell Hill fire that killed 19 “hotshot” firefighters this summer places blame for the tragedy with the Arizona State Forestry Division. The study, commissioned by the Arizona Department of Occupational Safety and Health (ADOSH), concludes that the Forestry Division mismanaged the fire from its early hours, neglected to follow its own rules for managing a complex incident, and ultimately failed to prioritize firefighter safety over the protection of non-defensible structures and property.
The findings come with a $559,000 fine for the Forestry Division and may fuel lawsuits against the state agency. The investigation, which was conducted by a five-person board of independent wildfire experts, is distinct from an earlier study commissioned by the State Forester himself. That first study, completed in September, largely avoided placing blame. The ADOSH report is less timid.
“There are lessons that can be learned from this horrible tragedy and we owe it to the firefighters who died, and to those that risked their lives fighting the Yarnell Hill Fire, to do so,” ADOSH Director Bill Warren said in a prepared statement.
The report paints a distressing picture of an understaffed and unfocused leadership team whose strategy in attacking the firewhich was sparked by a June 28 lightning strike in the dry, desert mountains northwest of Phoenixwas not appropriate to the conditions. “Yarnell, Arizona, is a classic example of the wildland urban interface (WUI) situation,” the report reads, meaning it’s a region where homes are built into fire-prone wilderness. “The structures within town are located in chaparral scrubland that had not burned in at least 40 years.” The climate and fuel conditions on June 30 were such that commonly used firefighter references would have predicted “an elevated potential for large, rapidly growing, and difficult to manage fires,” according to the report. Early in the day on June 30, staff on scene determined that most homes in Yarnell were indefensible with available resources.
Nevertheless, as hotshot crews arrived they were sent out on the fire, seemingly with little in the way of a coordinated strategy for suppressing the growing blaze. Many key personnelincluding the leader of the Granite Mountain Hotshotsmissed the morning briefing where strategy and safety standards should have been better established. The ADOSH report repeatedly notes that aviation and ground resources were not following the same tactical plan. At one point, the Granite Mountain Hotshots were attempting to burn out firelineintentionally setting a small fire to create a barrier to block flameswhen aircraft assigned to the fire dropped retardant on their burnout. Once their fire was extinguished, the hotshots moved on to cutting line by hand, an approach that also proved ineffective.
By mid-afternoon, there had been accounts of flames 40 feet high, moving at 16 miles per hour. “Yet no one seemed to recognize these signs as trigger points that should have led to a change in tactics and relocation of [the Granite Mountain Hotshots].” The ADOSH investigation found no evidence that supervisors conducted a risk assessment for the strategies and tactics crews were using in the field. “We also could not find evidence that the probability of success for the chosen strategy and tactics was examined,” they write. Soon after 4 p.m., the Granite Mountain Hotshots decided on their own to move to a new location, a ranch that had been identified as a good safety zone early that morning. They died before they got there, overcome by steamrolling flames that likely reached 2000 degrees Fahrenheit.
As the report points out, the hotshots final actions violated several of the 10 Standard Firefighting Orders, a set of rules developed in response to other mass wildfire casualties. The hotshots did not request a lookout when moving to the safe zone, even though there was an aircraft nearby that could have done the job. They did not let supervisors know that they planned to move to an alternative location, a mistake that prevented the possibility of aircraft reaching them when it became clear they were in trouble. And, in the end, they did not choose the safest route to the ranch, perhaps in part because they did not have a detailed map or aerial photo of the area, something that, according to the ADOSH findings, should have been provided at that morning briefing.
Fatigue may have contributed to the poor decision-making, according to the report, which states that mistakes were not intentional, “but a function of an overwhelming and understaffed situation.” The Granite Mountain Hotshots had worked 28 of 30 days during the month of June. The incident commander had worked the last 28 days straight.
