The Thirtymile Fire Fatality Incident.

On July 10, 2001, four Forest Service fire suppression personnel 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 area was enduring a lengthy drought and the moisture levels in large fuels were very low. Ladder fuels were abundant at the point of origin, on the east slope of canyon, and throughout the canyon floor. The day of the event, temperatures reached 94° F and relative humidity reached a low of 8% on the Chewuch River canyon floor. Slopes were steep (with slopes 70% to 100%) on both sides of the canyon. Fire conditions were potentially extreme.

Investigation Findings

The Investigation Team identified a large number of findings based on their review of the events that led to the Thirtymile Fire fatality incident, the findings have been organized into four subject categories:

1. Environment of the location of the incident
2. Equipment involved in, or contributing to, the incident
3. People involved in, or contributing to, the incident
4. Management issues or principles associated with the incident

Summary of Significant Findings

Although there were many findings identified for each of the four subject categories, the investigation team identified a smaller set of findings that were considered to be of significant importance to understanding the underlying causal factors that are associated with this incident.

Significant Environment Findings

• The combination of weather (at or near historic extremes for temperature and relative humidity, and the extended drought in the region) and fuel conditions (complex fuels on the canyon floor, extremely low moisture content of both the live and dead fuels) created extraordinary circumstances for fire growth on July 10th .
• Potential fire behavior was consistently underestimated throughout the incident.

Significant Equipment Findings

In spite of the ready availability of water, relatively little water was applied to the fire during the initial attack phase. This was largely due to operational problems with pumps and hoses, as well as delays in availability of a Type III helicopter.

Significant People Findings

• The fatalities and injuries all occurred during fire shelter deployment. Failure to adequately anticipate the severity and timing of the burnover, and failure to utilize the best location and proper deployment techniques contributed to the fatalities and injuries.
• Leadership, management, and command and control were all ineffective due to a variety of factors, such as the lack of communication and miscommunication, fatigue, lack of situational awareness, indecisiveness, and confusion about who was in control.
• Two civilians were involved in the entrapment due to a failure to properly close a potentially hazardous area.

Significant Management Findings

• All 10 Standard Fire Orders were violated or disregarded at some time during the course of the incident.
• Ten of the eighteen Watch Out Situations were present or disregarded at some time during the course of the incident.
• Records indicated that personnel on the Thirtymile Fire had very little sleep prior to their assignments, and mental fatigue affected vigilance and decision- making.
• District fire management personnel did not assume incident command when the size and complexity of the fire exceeded the capacity of the NWR #6 crew.
• Command roles on the Thirtymile Fire were unclear and confusing to those in command of the incident, to the rest of the crew, and to others associated with the fire.

Additional findings noted below illustrate the fundamental finding that incident management was confusing and unclear.

• The elements of fire complexity dictated a transition from initial to extended attack. The IC did not revise the strategy and tactics to address these changed circumstances.
• Between 3:24 and 3:27p.m Engines #701 and #704 arrived on the fire scene and did not check in with the Incident Controller or obtain a tactical briefing.
• Although adequate time to prepare for shelter deployment was available, leadership did not prepare the crew for a possible burnover or initiate actions to control the situation.
• The Thirtymile Fire was considered 'basically a mop-up show.

10 Standard Fire Orders

All 10 Standard Fire Orders were violated or disregarded at one time or another during the course of the incident. The following are some examples of these situations.

2. Initiate all actions based on current and expected fire behavior.

• Aggressive attack with over-extended resources continued in spite of onsite indicators of an increased rate of spread, multiple spots, and crown fire.

4. Ensure that instructions are given and understood.

• Instructions were coming from multiple sources adding to the confusion.

6. Remain in communication with your crew members, supervisors and adjoining forces.

• Although the communication equipment was adequate, the lines of communications on the incident were poor due to lack of a plan and poorly established command structure.

9. Retain control at all times.

• Leadership was fragmented and ineffective at all levels during the afternoon of July 10th.
• Resources were being ordered and directions given by others than the Incident Controller.

10. Stay alert, keep calm, think clearly, act decisively.

• Supervisors, managers, and firefighters failed to stay alert and recognize changing conditions.
• Fatigue and collateral duties impeded the abilities of key leadership to think clearly and to act decisively to use available time on the shelter deployment site to prepare for the burnover.

Watch Out Situations

Ten Watch Out Situations were present or disregarded at one time or another during the course of the incident. The following are some examples of these situations.

5. Uninformed about strategy tactics and hazards

• Chosen strategy and tactics were not achievable or viable due to fuel and environmental conditions.
• Hazards were never properly recognized, evaluated, and addressed.

6. Instructions and assignments not clear!

• The Incident Commander did not make sure that all instructions were complied with.
• Many people throughout the incident gave instructions.

8. Constructing fire line without a safe anchor point

• When action was taken on the spot fires at the head of the main fire there was no secure anchor point.

11. Unburned fuel between you and the fire

• When engaged in suppression actions on the spots there was a large amount of unburned fuel between the main fire and the spots about 150 to 300 yards away.

12. Cannot see main fire, not in contact with anyone who can.

• Air attack could not see the entire fire; no one could see the part of the fire that presented the greatest hazard.
• Terrain smoke and vegetation blocked firefighters view of the main fire.
• A look out who could continually view the main fire was not posted.

Safety is an uncompromising master. Most people compromise safety routinely in their daily activities, usually with no consequences. But neglect of safety eventually leads to 'near misses', and 'near misses' lead to accidents, some with tragic consequences. Fire suppression can be a dangerous business, and it has a history of tragic deaths. Safety and fire suppression need not be mutually exclusive, and safety must come first.

All organizations involved in wildland fire suppression, and especially each individual, need to rededicate themselves to the fundamental principle that a choice for safety is the right choice -- every time.

The above 'extract' reprinted here courtesy of the USFS