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SUMMARY - Thirtymile Fire Investigation Report
The Incident
On July, 10, 2001, four Forest Service Firefighters were killed after they became entrapped and their fire shelter deployment site was burned over by the Thirtymile Fire, in the Chewuch River Canyon, about 30 miles north of Winthrop, Washington.
The fire, an escaped picnic cooking fire, was detected on Monday, July 9. Initial suppression activities began that evening. In addition, the Libby South Fire was already burning about 50 miles south of this area, and exceeded 1,000 acres. The Northwest Regulars #6 (NWR #6), a 21-person Type 2 crew from the Okanogan-Wenatchee National Forest, was dispatched to the Thirtymile Fire in the early morning hours of July 10. They arrived about 9 a.m. in relief of the Entiat Hotshots who had been working on the fire overnight.
The area was enduring a lengthy drought and the moisture levels in large fuels were very low. The Energy Release Component, a measure of potential fire intensity, was near historic high levels for this time of year. Temperatures on July 10 reached nearly 100ºF, and the humidity was very low. Although there was no dramatic shift in weather that would have created high winds, such as a dry cold front, up-canyon breezes were present to aggravate burning conditions. Fire conditions were potentially extreme.
By the late afternoon the fire advanced from its perimeter east of the Chewuch River toward the top of the east ridge. At this time, the NWR #6 was suppressing spot fires between the road west of Chewuch River and the river itself. They were attempting to confine the fire east of the road. There were no personnel east of the river at that time since it had been determined that suppression activities there were fruitless. The NWR #6 crew took a break in mid-afternoon to eat, sharpen tools, and rest. About 4 p.m., they responded to a request from an Engine crew for help on a spot fire one-quarter mile north of their position. They sent two squads to assist.
In the moments immediately prior to the entrapment, one of the squads and the crew boss trainee (a total of seven people) were working in association with a fire engine and its three person crew when a spot fire erupted right next to the road. The seven NWR #6 crewmembers and the engine crew immediately got in their vehicles and drove past the fire along the east edge of the road to safety. While driving, they radioed the remaining 14 crewmembers who were working north, further up the river, of their dangerous situation.
The remaining 14 crewmembers (the incident Commander and the two NWR # 6 squads) were actively suppressing spot fires between the river and the road about one-quarter mile north of the first squad when they were informed of the worsening situation that threatened their escape rout. Immediately, 10 of the 14 got in the crew van and began to drive south. The other four preceded the van on foot. The van was driven past these four and approached the fire that was now burning across the road. The Incident Commander (IC) assessed the risk as too great to proceed.
He turned the van around, picked up the four crewmembers, all of the crew gear, and drove north upriver. The IC assessed different areas as potential safety zones or shelter deployment areas.
Approximately one mile north, the IC selected a site characterized by an extensive rock scree field above and west of the road. The Chewuch River and a sand bar were just east of the road. The site also had a relatively sparse vegetation in the surrounding area. The NWR #6 crew unloaded and congregated on and above the road as they watched the fire. The van was turned around and parked on the side of the road next to the river.
Two civilians, a man and woman, arrived in their truck shortly after the crew. In the early afternoon they had driven to a campground near the road terminus about two miles beyond the deployment site. They had noticed the fire suppression work while driving up the road to the trailhead. Later in the afternoon while resting they saw smoke and decided to leave the area. No shelters or information about shelter deployment were made available to them when they encountered the crew.
Although observers had noted the approach of the fire, the crew was not prepared for the suddenness with which it arrived. A rain of burning embers was followed by a rolling, wave of tremendous heat, fire, smoke and wind. Eight of the crew members deployed their shelters on the road. The two civilians took shelter with one of the crewmembers. Once squad boss was high above the road on the rock scree observing the fire. He ran down towards the road, but could not get there before the fire arrived. He turned around and retreated back up the slope. Four crewmembers and another squad boss, who had been sitting on some large boulders above the road observing the approach of the crown fire, also retreated up-slope. These five deployed their shelters in the same vicinity as the squad boss. Four of the six people who deployed shelters in the rock scree field died.
The surviving squad boss and crewmember (who had no gloves) both left their shelters at some point when the fire abated to non-lethal levels. The squad boss fled down the rock scree field to the road and jumped in the river. The other survivor sought shelter from the radiant heat behind a large boulder for a few minutes. He then fled to the safety of the crew van. The crewmembers and the two civilians that had deployed on the road eventually relocated to the river when conditions allowed their safe movement.
After the passage of the fire, all but four crewmembers were accounted for. The rescue party arrived approximately 35 minutes after the shelter deployment. One crewmember with severely burned hands was evacuated to a hospital in Seattle while the remaining injured were treated locally and released.
All four deaths were caused by asphyxia due to inhalation of superheated products of combustion.
Significant Casual Factors
A casual factor is any behavior or omission that starts or sustains an accident occurrence. For this investigation, the causal factors have been classified as either significant or influencing. They have been identified from four categories of Factual Report findings (environment, equipment, people and management). The causal factors determined to be significant in the Management Evaluation Report are listed below with identified finding category and incident phase, in relative order.
Inadequate Safety Consideration (Management)
Phases of the Incident: Preparedness, Initial Attack, Transition, Entrapment, & Deployment
The safety considerations were not appropriate to respond to the current, potential, and subsequent fire conditions on this incident. All 10 Standard Fire Orders and 10 of the 18 Watch Out Situations were violated or discarded during the incident.
Lack of Situational Awareness/Inaccurate Assessment (Management)
Phases of the Incident: Preparedness, Initial Attack, Transition, Entrapment, & Deployment
Work/rest cycles for incident and fire program management personnel, both at the forest and district levels were disregarded resulting in mental fatigue. This significantly degraded the vigilance and decision-making ability of those involved.
Command and Control (Management)
Phases of the Incident: Preparedness, Initial Attack, Transition, Entrapment, & Deployment.
Failure to maintain clear command and control resulted in poor risk management and inhibited decisive actions, which contributed to the entrapment and deployment of shelters.
Strategy, Tactics, and Transition (Management)
Phases of the Incident: Initial Attack & Transition
The suppression strategy did not adequately consider objectives, fuels, fire behavior, and fire potential, nor the capability, availability and condition of the suppression resources. This led to the selection of tactics that could not succeed. As the fire complexity changed significantly and initial attack was unsuccessful, there was not a corresponding change in strategy or tactics.
Fire Behavior (Environment)
Phases of the Incident: Preparedness, Entrapment, & Deployment.
A variety of environment factors supported the development of a crown fire, growing from a few acres to several thousand acres on the day of the accident:
- Valley bottom and slope fuels were dense with abundant ladder fuels.
- The moisture content of the fuels was at historically low levels.
- The combination of extremely low relative humidity, high temperature, and atmospheric instability created weather conditions conducive to the rapid movement, growth, and intensity of the fire at the time of entrapment and deployment.
Failure in Road Closure and Area Evacuation (Management)
Phase of the Incident: Initial attack
The entrapment of the two civilians was due to the failure to close the road and to subsequently evacuate the upper valley in a timely fashion.
Management Intervention (People)
Phase of the Incident: Transition
There were missed opportunities for intervention by management personnel on this incident. Leadership's failure to respond to concerns and observations by key individuals exacerbated circumstances that led to the entrapment.
Lack of Escape Routes and Safety Zones (People)
Phase of the Incident: Entrapment
Given the rapidly increasing fire intensity and changing fire situation, adequate consideration was not given to identifying escape routes and safety zones.
Failure to Prepare for Deployment (People)
Phase of the Incident: Deployment
Leadership of the entrapped firefighters failed to utilize available time and resources to coordinate and prepare crewmembers and civilians for shelter deployment.
Deployment Site Selection (Equipment/People)
Phase of the Incident: Deployment
Site selection for the deployment of the shelters above the road contributed to the four fatalities. The rocky nature of the deployment site made it difficult to seal out the superheated air. The large size and the arrangement of the rocks made it difficult to fully deploy the shelters.
Personal Protective Equipment (Equipment/People)
Phase of the incident: Deployment
The improper use of personal protective equipment (PPE) contributed to injuries. Three people occupied one shelter. This exceeded the design capacity (although providing shelter protection for two civilians was appropriate and justified by the emergency). One crewmember and the two civilians did not have gloves: other crewmembers did not wear their gloves. Some of the line gear that was left close to the shelters ignited, and there was burning vegetation close to and under shelters.
Sudden Up Canyon Extreme Fire Behavior (Environment)
Phase of the Incident: Deployment
The dense forest and the strong fire-induced winds on the eastern canyon wall contributed to the intense spotting, causing the fire on the canyon floor to intensify suddenly and surge over the deployment area.
Heat from Fire (Environment)
Phase of the Incident: Deployment
The fatalities were caused by inhalation of superheated air and exposure to high levels of radiant and convective heat. The presence of burnable fuels around and under the chosen deployment sites also contributed to the fatalities and injuries. The higher temperatures of the rock scree slope made conditions worse for deployment than conditions on the road.
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South Canyon Fire - Executive Summary
http://www.nifc.gov/scanyon/execsumm.html
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The Incident On July 2, 1994, during a year of drought and at a time of low humidity and record high temperatures, lightning ignited a fire 7 miles west of Glenwood Springs, Colorado. The fire was reported to the Bureau of Land Management on July 3 as being in South Canyon, but later reports placed it near the base of Storm King Mountain. The fire began on a ridge, which was paralleled by two canyons or deep drainages, called in this report the east and west drainages. In its early stages the fire burned in the pinyon-juniper fuel type and was thought to have little potential for spread. Dry lightning storms had started 40 new fires in BLM’s Grand Junction District in the 2 days before the South Canyon fire started, requiring the District to set priorities for initial attack. Highest priority was given to fires threatening life, residences, structures, utilities, and to fires with the greatest potential for spread. All initial attack firefighting resources on the Grand Junction District were committed to the highest priority fires. In response to a request from the Grand Junction District, the Garfield County Sheriff’s Office and White River National Forest monitored the South Canyon Fire. Over the next 2 days the South Canyon Fire increased in size, the public expressed more concern about it, and some initial attack resources were assigned. On the afternoon of July 4 the district sent two engines. Arriving at 6:30 p.m. at the base of the ridge near Interstate 70, the crew sized up the fire but decided to wait until morning to hike to the fire and begin firefighting efforts. The next morning, a seven person BLM/Forest Service crew hiked 2 ½ hours to the fire, cleared a helicopter landing area (Helispot 1) and started building a fireline on its southwest side. During the day an air tanker dropped retardant on the fire. In the evening the crew left the fire to repair their chainsaws. Shortly thereafter, eight smokejumpers parachuted to the fire and received instructions from the Incident Commander to continue constructing the fireline. The fire had crossed the original fireline, so they began a second fireline from Helispot 1 downhill on the east side of the ridge. After midnight they abandoned this work due to the darkness and the hazards of rolling rocks On the morning of July 6 the BLM/Forest Service crew returned to the fire and worked with the smokejumpers to clear a second helicopter landing area (Helispot 2). Later that morning eight more smokejumpers parachuted to the fire and were assigned to build the fireline on the west flank. Later, ten Prineville Interagency Hotshot Crew members arrived, and nine joined the smokejumpers in line construction. Upon arrival, the remaining members of the hotshot crew were sent to help reinforce the fireline on the ridgetop. At 3:20 p.m. a dry cold front moved
into the fire area. As winds and fire activity increased, the fire made
several rapid runs with 100-flame lengths within the existing burn. At
4:00 p.m. the fire crossed the bottom of the west drainage and spread up
the drainage on the west side. It soon spotted back across the drainage
to the east side beneath the firefighters and moved onto steep slopes
and into dense, highly flammable Gambel oak. Within seconds a wall of
flame raced up the hill toward the firefighters on the west flank
fireline. Failing to outrun the flames, 12 firefighters perished. Two
helitack crew members on top of the ridge also died when they tried to
outrun the fire to the northwest. The remaining 35 firefighters survived
by escaping out the east drainage or seeking a safety area and deploying
their fire shelters. The Investigation Within 3 hours of the blowup, an interagency team was forming to investigate the entrapment on the South Canyon fire. The team first met on the evening of July 7. Team members were given their assignments, and the team presented a charter to the Chief of the USDA Forest Service and the Director of the Bureau of Land Management. Les Rosenkrance, BLM’s Arizona State Director, was designated team leader. In the next few days the team
investigated the fire and fatality sites and began a series of 70
interviews with witnesses. In addition, the team met once or twice a day
to discuss progress, clarify assignments, plan their report, and review
their findings. On July 22, with the interviews and much of the
investigation report completed, the team adjourned. The following week
some team members met in Phoenix, Arizona to complete work on the
incident overview. On August 9-11, the team reconvened to review a draft
of the completed report in preparation for its publication. Causal Factors The Investigation Team determined that the direct causes of the entrapment in the South Canyon fire are as follows. Fire Behavior
Weather
Topography
Predicted Behavior
Observed Behavior
Incident Management
Safety Briefing and Major Concerns
Involved Personnel Profile
Equipment
The following factors contributed to the entrapment on the South Canyon fire. Incident Management and Control Mechanisms
Support Structure
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South Canyon Fire Investigation