Point Fire, 1995
&
Island Fork Fire, 1999
dedication

Point Fire Case Study

• Instructor Guide
• Student Handout

Point Fire Accident Investigation

A. Point Fire Overview

• Overview
• Red Flag Warning
• Rescue Attempts

B. Investigation

• Investigation Process
• Findings
• Causal Factors
• Entrapment Investigation Element Matrix and Entrapment Investigation
• Ten Standard Orders, 18 Situations that Shout "Watch Out"

C. Recommendations

D. Supporting Data

• Sequence of Events
• Organization Charts
• Site Investigation
• Fire Behavior Report
• Property Damage Report
• Witness Statements
• Outline of Kuna Wildland Training Provided by BLM

E. Records and Reports

• Preplanned Dispatch
• BLM Radio Transmission Log
• Ada County Dispatch Log
• Fire Incident Status Summary
• Escaped Fire Situation Analysis
• Wildland Fire Entrapment Report
• Technical Analysis of Personal Protective Equipment
• Vehicle Inspection
• Weather Reports

F. Glossary

      ——————

Island Fork Fire Accident Investigation

• Cover & Dedication
• Executive Summary
• Maps & Introduction
• Sequence of Events
• Findings
• Causal Factors
• Recommendations
• Appendices

  ——————

Island Fork Fire, NIOSH Report

Point Fire — U.S. District Court Civil Case

Ruling on I.C.'s Decisions - Nov. 10, 1998
 • Factual Background
 • Legal Analysis

Ruling on BLM Liability - Feb. 19, 1999
 • Findings of Fact
 • Legal Standards
 • Analysis

Ruling on Public Safety Officer Benefits (PSOB)

      ——————

Surviving Fire Entrapments

      ——————

Colorado Firecamp extends special thanks to Linda Perkins, BLM Idaho State FOIA Coordinator, for her friendly assistance in gathering the Point Fire documents. BLM FOIA Letter

FINDINGS OF FACT AND CONCLUSIONS OF LAW

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF IDAHO

DEANNA C. BUTTRAM, et al,
Plaintiffs,
v.
UNITED STATES OF AMERICA,
Defendant.

Civil Case No. 96-0324-S-BLW
(Consolidated with)
Civil Case No. 96-0452-S-BLW
Civil Case No. 97-0129-S-BLW

Analysis

Definition of BLM's Duty

104. The BLM, through IC Kerby, had a duty to exercise reasonable care to protect Buttram and Oliver from foreseeable hazards incident to fighting the Point Fire.

105. More specifically, the BLM had the following duties:

106. First, the BLM IC had a duty to ensure that Buttram and Oliver were assigned duties commensurate with their ability and with the Kuna RFD’s qualifications. This duty is imposed on the BLM in part due to its own regulation found in § 9215.11E of the BLM Manual on Fire Training and Qualifications. It is also imposed on the basis that the BLM IC had supervisory authority over Buttram and Oliver, and was in the best position to know of the fire's extent and dangers. When the BLM is fighting a fire on BLM property, the BLM IC has access to much more information about the fire than the volunteer firemen supplied by rural fire districts with limited budgets. On the other hand, the BLM IC will typically know little about the qualifications of the volunteers. If the BLM IC assigns tasks to volunteers with no consideration of whether the volunteers' qualifications are sufficient to safely perform the tasks, then the BLM IC has not complied with the general duty to provide for the safety of those volunteers. Thus, the BLM IC must make some determination about the volunteers' qualifications. At the same time, it must be recognized that the BLM IC is forced by the emergency nature of firefighting to make quick decisions. The BLM IC cannot be expected to conduct a sit-down interview with each volunteer, but must be allowed to rely on certain indicators of qualifications. In other words, the BLM IC complies with this duty when he or she makes reasonable assumptions about the qualifications of volunteers based on the appearance and conduct of the volunteers, or other factors that bear on qualifications. However, when the BLM IC makes reasonable assumptions about volunteers' qualifications, rather than depending on actual knowledge, the BLM IC is thereafter operating under a relatively higher duty to provide for the safety of these volunteers. The level of duty varies on a sliding scale depending on the BLM IC's knowledge. The duty is at its highest when the BLM is making reasonable assumptions without any actual knowledge, and lessens as the BLM IC makes appropriate assignments based on actual knowledge of the qualifications. In the present case, the BLM IC's duty to provide for Buttram's and Oliver's safety was at the highest level because the BLM IC was proceeding on reasonable assumptions about their qualifications without having any actual knowledge.see footnote #4

107. Second the BLM IC has a duty to fully instruct rural fire district volunteers, before fire suppression efforts begin, about the nature of the fire, fuel conditions, weather information, safety reminders, command structure, and radio use. This information is crucial to provide for the volunteers’ safety, especially when the IC is making assumptions about their qualifications without any actual knowledge. The BLM IC is in the best position to provide such information. In this case, IC Kerby had seen the fire from a helicopter, and could describe the nature and extent of the fire. He had information that the fuel conditions were incendiary. He had the most recent weather information from the National Weather Service that included a fire weather watch. He knew the common safety practices that should be reviewed even by highly trained firefighters. Specifically the existence of a fire weather watch made it imperative to review with the volunteers the significance of a red flag warning, and how the high winds that accompany such heavy weather would intensify the fire and obscure visibility. Briefing about the command structure was important, because the BLM IC knew he was working with volunteers from a rural fire district, and so needed to reduce any chance of confusion as to who was in charge. Finally, he knew the importance of everyone monitoring the same radio channel during a wildland fire where the firefighters are spread out over a large geographic area. IC Kerby had a duty to impart this information to the Kuna RFD firefighters before they started their suppression efforts.

108. Third, the BLM IC had a duty to (1) ensure that all firefighters heard the red flag warning that was issued at 8:22 p.m; (2) ensure that Kuna RFD volunteers understood the significance of that warning, i.e., that the high winds could dangerously intensify the fire and substantially decrease the visibility; and (3) ensure that the RFD volunteers knew that the high winds would be coming immediately and from the south. The Government's own expert, Ronald Johnson, agreed that the BLM IC had a duty to ensure that the firefighters got the red flag warning. The two additional aspects of this duty (items (2) and (3) listed above) arise in this case largely because the BLM IC failed to hold a safety briefing before work began, and had no idea if the Kuna RFD volunteers knew what a red flag warning was.

109. Fourth, the BLM IC had a duty after the red flag warning was issued to take all reasonable steps to ensure that 620 stayed away from the Point Fire's northern perimeter. Because he failed to hold an initial safety briefing, and knew nothing of Buttram's and Oliver's experience, the BLM IC had a special duty to Buttram and Oliver to warn them to stay away from the northern perimeter of the Point Fire because approaching high winds would drive the fire in that direction.

BLM's Breach of Duty

110. BLM did not breach its duty to ensure that Buttram and Oliver were assigned to duties commensurate with their qualifications and the qualifications of the Kuna RFD. IC Kerby requested two brush trucks and a tender from the Kuna RFD. Buttram and Oliver responded to the fire in a brush truck. The brush truck is specifically designed to work the fire line. IC Kerby reasonably assumed that two Kuna volunteers driving a brush truck were qualified by Kuna RFD standards to work the fire line in that brush truck. It was also reasonable for IC Kerby to assume that the Kuna RFD had maintained 620 in a safe condition. However, that was all IC Kerby could reasonably assume without further inquiry. In other words, IC Kerby could not assume from Buttram's and Oliver's appearance in the brush truck that they knew about (1) the Point Fire's nature and extent; (2) the most recent weather report; (3) fuel conditions; (4) safety guidelines; (5) who was in command; (6) what radio channel was being used; (7) that a red flag warning would mean the imminent approach of winds that would increase the intensity of the fire and obscure visibility.

111. The BLM IC breached his duty to hold a briefing on the issues listed in paragraph 107. IC Kerby held no briefing at all before assigning Buttram and Oliver to the fire line. Because IC Kerby was assuming that Buttram and Oliver were qualified without inquiring into their training or asking any questions about their equipment, it was especially important for IC Kerby to review all the issues listed in paragraph 107 before suppression efforts began.

112. The BLM IC breached his duty to (1) ensure that all firefighters heard the red flag warning that was issued at 8:22 p.m; (2) ensure that RFD volunteers understood the significance of that warning, i.e., that the high winds would dangerously intensify the fire and substantially obscure visibility; and (3) ensure that the RFD volunteers knew that the high winds would be coming immediately and from the south. Given the lack of any initial safety briefing, and the BLM IC's ignorance of the Kuna firefighters actual qualifications, it was especially important to ensure not only that the Kuna RFD firefighters heard the red flag warning but that they understood the significance of the warning. The BLM IC failed to comply with this duty.

113. The BLM IC breached his duty to warn Buttram and Oliver after the red flag warning to stay away from the fire's northern perimeter because high winds would drive the fire in that direction. Instead of so warning 620, the BLM IC instructed them to refill. He knew that to refill, 620 would most likely drive toward the fence break at the northeast corner of the fire. In other words, the BLM IC directed 620 toward the northern perimeter of the fire at a time when high winds were forecast to drive the fire in that very direction. As the Court discussed previously in paragraph 65, the black's function as a safety zone is partly dependent on whether the firefighters are moving through the black towards the unburned fuels that are in the path of oncoming winds. The BLM contends that IC Kerby gave 620 "the safe assignment of going to the road and staying there. " See BLM's Post-Trial Brief at 11. The BLM asserts that "it does not make sense that [Buttram] would drive wildly around if he could not see at all." Id. From this, the BLM concludes there is no proof that the "BLM proximately caused Buttram to drive out of the safe zone and into harm's way." Id. The Court disagrees. At the time IC Kerby gave his refill order, it was foreseeable that the high winds could kick up the dust and ash in the black and completely obscure Buttram's and Oliver's visibility. It was also foreseeable that Buttram and Oliver would be very near the fire's northern perimeter -- and moving toward that perimeter--at the time the high winds were due to come through the area. Finally, it was foreseeable that the lack of visibility could cause panic and disorientation that would expose the firefighters to great risk because of their close proximity to the dangerous northern perimeter of the fire. By instructing 620 to refill, the BLM IC placed Buttram and Oliver in a foreseeably dangerous position, and thereby breached his duty to provide for their safety.

Definition of Kuna RFD's Duty

114. The Kuna RFD had a duty to exercise reasonable care to protect Buttram and Oliver from foreseeable hazards incident to fighting the Point Fire. This duty continued even after IC Kerby assigned duties to Buttram and Oliver and the two volunteers began working the fire line. While IC Kerby was the leader with primary responsibility, the Kuna RFD had a continuing responsibility to monitor its firefighters, warn them of dangers, and make recommendations to IC Kerby based on Kuna RFD's superior knowledge of Buttram's and Oliver's lack of experience. This duty arises because Captain McPherson sent 620, manned by two men experiencing their first fire season, to the BLM for duty assignment (1) without notifying the BLM IC that 620 was operated by rookies, (2) knowing that the BLM IC would have no time himself to inquire into Buttram's and Oliver's experience and training, and (2) knowing virtually nothing about the extent of the fire and the weather forecast. Under these circumstances, it was especially important that Chief Cromwell and Captain McPherson monitor the suppression efforts and the weather, so that they could suggest courses of action to IC Kerby that would ensure the safety of Buttram and Oliver.

115. More specifically, the Kuna RFD had the following duties:

116. First, the Kuna RFD had a duty to provide within reasonable limits the equipment necessary to ensure the firefighters' safety. Specifically, the Kuna RFD had a duty to provide adequate radios to its firefighters. Chief Cromwell knew that the Point Fire was a grass/wildland fire, and that suppression efforts could spread his firefighters out to the point where they would be out-of-sight of leadership. Adequate radios were the only way that Chief Cromwell and Captain McPherson could comply with their duty to monitor their firefighters during the suppression efforts, as discussed above.

117. Second, the Kuna RFD had a duty to make personnel assignments that were designed to ensure the firefighters' safety. Specifically, the Kuna RFD had a duty to (1) send only qualified volunteer firefighters to fight any fire, and (2) to pair firefighters in two-person trucks in a manner that reasonably provided for the firefighters' safety.

118. Third, the Kuna RFD had a duty to obtain a weather report from the National Weather Service before proceeding to fight the Point Fire. Kuna RFD Assistant Chief Darwin Taylor testified that he believed that the National Weather Service Reports were only available to federal agencies, but he was mistaken--the unrebutted testimony of Richard Ochoa, a staff meteorologist for the National Weather Service, established that the National Weather Service reports would have been easily and immediately available to the Kuna RFD on July 28, 1995. These reports contained the most detailed weather information, and the testimony at trial established that such information is absolutely crucial to the safety of firefighters during wildland fires.

119. Fourth, the Kuna RFD had a duty to ensure that its firefighters received a briefing either by Kuna RFD personnel or BLM personnel--before suppression efforts began--about the nature of the fire, fuel conditions, weather information, safety reminders, command structure, and radio use. This duty arises in part because Chief Cromwell and Captain McPherson knew that (1) the Point Fire was a wildland fire, (2) the Kuna RFD firefighters had received very little formal training on wildland fires, and (3) 620 was manned by two firefighters experiencing their first fire season.

120. Fifth, the Kuna RFD had a duty to train its volunteer firefighters to fight wildland fires in a safe and effective manner. This duty arises because the main type of fire fought by the Kuna RFD in the time period of the Point Fire was the grassland/wildland type fire. This duty becomes particularly significant when the Kuna RFD elects to assign their volunteer firefighters to work with other agencies who will have no knowledge of the training that such firefighters possess.

Breach of Kuna RFD's Duty

121. The Kuna RFD breached its continuing duty to ensure the safety of Buttram and Oliver during their suppression efforts. Chief Cromwell and Captain McPherson should have known that IC Kerby was unaware that Buttram and Oliver were rookies. Yet Chief Cromwell and Captain McPherson took no steps to inform IC Kerby of this fact. That failure would not necessarily have been negligent if Chief Cromwell and Captain McPherson had taken extra care to monitor Buttram and Oliver, and monitor any dangerous fire or weather conditions. Both Chief Cromwell and Captain McPherson recognized the importance of this monitoring when they testified that if they had known that high winds were approaching, they would have pulled 620 off the fire line. Yet despite recognizing the importance of monitoring, neither man monitored the BLM channel for warnings about dangerous conditions. Thus, when the high wind warning was given over the BLM channel, neither Chief Cromwell nor Captain McPherson heard the warning. Captain McPherson had no capability to tune into the BLM channel; Chief Cromwell had the capability but failed to do so. The end result was that both men missed a crucial warning, and lost the opportunity to (1) recommend to IC Kerby that he put 620 in a safe zone, and (2) talk to Buttram and Oliver about the significance of the warning. These circumstances constitute a breach of Kuna RFD's continuing duty to ensure the safety of Buttram and Oliver during their fire suppression efforts.

122. The Kuna RFD breached its duty to pair firefighters in two-person trucks in a manner that reasonably provided for the firefighters safety. Allowing two rookies to pair up is not necessarily a negligent decision if, for example, the rookies were operating a water tender far from the fire line. But here the rookies were operating a brush truck that was designed to work directly on the fire line. Captain McPherson had an opportunity at the initial staging site to switch Oliver and Black. That would have put a seasoned firefighter with a rookie in each truck. In addition, Assistant Chief Darwin Taylor, an experienced firefighter, was available to ride in 620, but was not used in that capacity. Thus, the Kuna RFD was not faced with a lack of resources that often, and understandably, plague small fire protection units. The Kuna RFD already had the resources--that is, experienced firefighters--but negligently failed to deploy them in a way that would ensure the safety of Buttram and Oliver. This was also not a situation where it was reasonable to assume that two rookies could work together because the fire presented little danger. In fact, Chief Cromwell knew almost nothing about the extent of the fire or the weather. He also knew or should have known that Captain McPherson would be unable to monitor the BLM channel .see footnote #5 Under these circumstances, it was unreasonable for the Kuna RFD to allow two rookies to operate 620. Thus, the Kuna RFD breached its duty to pair firefighters in two-person trucks in a manner that reasonably provided for the firefighters' safety.

123. The Kuna RFD breached its duty to obtain a weather report from the National Weather Service before proceeding to fight the Point Fire. The National Weather Service report was available but was not obtained by anyone from Kuna RFD.

124. The Kuna RFD breached its duty to train its volunteer firefighters to fight wildland fires in a safe and effective manner. Despite the fact that the main type of fire fought by the Kuna RFD was the grass/wildland fire, the Kuna RFD had only two training sessions in fighting these types of fires.

Definition of Buttram's and Oliver's Duty

125. Buttram and Oliver had a duty to exercise reasonable care to provide their own safety while fighting the Point Fire.

Buttram's and Oliver's Compliance With Their Duty

126. At the time the Point Fire Blew up at about 8:46 p.m., Buttram and Oliver were following directions. They were returning to Swan Falls Road to refill as directed by IC Kerby. Their conduct after the high winds started was a product of disorientation and panic caused by the obscured visibility and fast-moving fire. At no time did Buttram and Oliver negligently fail to exercise reasonable care to provide for their own safety.

Causation

127. The BLM's negligence was a proximate cause of the deaths of Buttram and Oliver.

128. The Kuna RFD's negligence was a proximate cause of the deaths of Buttram and Oliver.

129. The negligence of the BLM and the Kuna RFD caused Buttram and Oliver to be near the northern perimeter of the fire at the time of the fire's blow-up. The fact that Buttram and Oliver were in this location at the time of the high winds was a substantial factor in their deaths.

130. The BLM's failure to hold an initial safety briefing, failure to explain the significance of the red flag warning, failure to warn 620 to stay away from the northern perimeter in combination with its refill instruction that directed 620 toward the fire's northern perimeter, were substantial factors in Buttram and Oliver being exposed to an unreasonable risk of danger that led to their deaths.

131. The Kuna RFD's failure to (1) ensure safety of Buttram and Oliver, (2) provide adequate equipment, (3) make safe personnel assignments, (4) obtain a weather report, (5) properly train Buttram and Oliver in wildland fire suppression safety, and (6) advise the BLM IC of Buttram and Oliver's limited training and experience, were substantial factors in Buttram and Oliver being exposed to an unreasonable risk of danger that led to their deaths.

Comparative Responsibility

132. The BLM and the Kuna PFD were both responsible for the deaths. Each had knowledge the other lacked.

133. The BLM knew a great deal about the fire but nothing about the experience and knowledge of Buttram and Oliver.

134. The Kuna RFD knew a great deal about Buttram and Oliver but nothing about the fire.

135. If either had shared its knowledge, this tragedy could have been avoided.

136. Ultimately, the Kuna RFD was in the best position to use its knowledge to ensure the safety of Buttram and Oliver. The Kuna RFD's failure to do so was therefore the greatest contributing factor to the deaths.

137. The Kuna RFD's decision to allow two rookies to operate a brush truck was the key threshold decision that set in motion the chain of events that would end in tragedy. By presenting the rookies to the BLM in a brush truck, the Kuna RFD was essentially vouching for their qualifications to work directly on the fireline--that is, after all, the purpose of the brush truck. Thereafter, knowing that the rookies would be in harm's way, the Kuna RFD never informed the BLM of their rookie status, or took the special care necessary to monitor their firefighting and the fire's condition. Of course, the BLM was also negligent because it had a special duty to monitor as well because it knew it had little knowledge of the Kuna RFD's qualifications, and no actual knowledge of the training, qualifications, and experience of the Kuna RFD firefighters assigned to the Point fire. The percentages of responsibility might be allocated equally if the failure to monitor was the only negligence. But the Kuna RFD's pairing decision and its failure to advise the BLM IC of Buttram and Oliver's lack of training and experience, places more of the responsibility on the Kuna RFD.

138. The Kuna RFD is therefore allocated 65% of the responsibility of the deaths and the BLM is allocated 35%.

Damages see footnote #6

139. Plaintiffs Deanna Buttram and Jeremiah Buttram have sustained economic damages in the amount of $961,092. They have sustained damages for out-of-pocket funeral expenses in the amount of $6,074.85. Jeremiah Buttram has sustained damages for loss of society and companionship in the amount of $900,000 that must be reduced to the statutory cap of $590,291.26. Deanna Buttram has sustained damages for loss of consortium, society and companionship in the amount of $900,000 that must be reduced to the statutory cap of $590,291.26. The total damages sustained by Deanna Buttram and Jeremiah Buttram are $2,147,749.37.

140. Plaintiff Darla Reber has sustained damages for loss of the society and companionship of her son in the amount of $300,000.

141. Plaintiff Michael Oliver has sustained damages for loss of the society and companionship of his son in the amount of $50,000. see footnote #7

142. With regard to plaintiffs Deanna Buttram and Jeremiah Buttram, the BLM is liable in damages for 35 % of their total damages of $2,147,749.37, or $751,712.28.

143. With regard to plaintiff Darla Reber, the BLM is liable in damages for 35% of her total damages of $300,000, or $105,000.

144. With regard to plaintiff Michael Oliver, the BLM is liable in damages for 35% of his total damages of $50,000, or $17,500.

145. The Court will issue a separate Judgement in accord with Federal Rule of Civil Procedure 58.

Dated this 19th day of February, 1999

______________________
B. LYNN WINMILL
UNITED STATES DISTRICT COURT