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Freeman Reservoir tree felling fatality, 72-hour report & OSHA citation — June, 2009
Andrew Palmer Fatality, Dutch Creek Incident, — June, 2008
Little Grass Valley Tree Felling Accident
Facilitated Learning Analysis
August 17, 2009
US Forest Service, Pacific Southwest Region, Plumas National Forest
Feather River Ranger District
Lessons Learned Analysis
Unlike administrators, policy writers or outside experts, the employees directly involved in
this accident have the most valuable if not the clearest perspective on the real hazards they
were facing, the efficiency and effectiveness of the tools and training they were given and
the pressures they faced to accomplish work safely but efficiently. In his book, Managing
the Unexpected, Karl Weick talks about “Free Lessons”. These are the lessons we can
choose (or not) to learn from close calls or near-misses. This accident wasn’t a “free”
lesson by any means since one of our employees was injured; but considering what could
have been the outcome, it is a comparatively inexpensive lesson. In meetings and
individually, the FLA team asked virtually everyone involved in this accident what they
learned for themselves and what they think the Forest Service organization needs to learn
from this accident.
The following are the Lessons provided by those directly involved in this accident. The FLA
team took those lessons and combined those that were redundant and removed personal
identifiers, etc. Those in quotations are verbatim.
- We need to ensure that people running saws are all certified to do so.
- Our safety briefings should include discussion of who is qualified for each task.
- We need to make sure employees are skilled in the use of the tools they are using -
not just certified.
- The 10 foot spacing requirement between cutters doesn’t work for tree cutting
- It is difficult to train and maintain qualifications of 1039 employees.
- It is important to know the latitude and longitude of your current work location.
- With the amount of driving and long days, the job site is not the only place to be
aware of hazards.
- We need more chainsaw certifiers.
- “Management should know that a 30 foot whip can kill you”.
- We all need to make sure individuals working with chainsaws are adequately
separated from other individuals.
- Crew members really need to be aware of where each other are when felling trees.
- We need to make sure all crew members get the same briefing.
- We should clearly identify the on site supervisor or foreman.
- A foreman should monitor employees to ensure they are skilled on the tools they’re
- We shouldn’t succumb to pressure to work too close together for efficiency.
- It was good that everyone was using their appropriate PPE.
- “We should keep the cutters far apart”.
- “I’ll never be that close to somebody cutting a tree ever again”.
- “My hardhat saved my life”.
- Mobile radios are not always dependable.
- We need to think about contingencies for implementing our Medivac plan.
- “Medivacs take longer than you think.”
Lessons Learned Analysis of the FLA Team
The following is the result of the FLA Team’s analysis of the lessons learned and
shared by those employees directly involved in the accident.
The lessons learned by those involved and shared with the FLA team illuminated several
key points or conditions that set the stage for this accident. Most noticeably, this project
was essentially a thinning operation but for numerous reasons it was planned as if it was to
be a brushing operation. Some of the reasons this made sense at the time are because the
project was to be implemented by the Forest’s Engineering group who were accustomed to
planning road side brushing and clearing operations. This engineering group is very skilled
in safely planning and then managing employees working adjacent to heavy equipment
clearing roads and brushing along the roadsides. Also the sawyers were to be wage-grade
laborers - not forestry technicians. Consequently, the Job Hazard Analysis (JHA) the
managers developed and used for this project was a JHA for a brushing operation; not a JHA
appropriate for a felling operation. For example, the “brushing JHA” referred to making
sure employees stayed at least 10 feet away from a person operating a chainsaw. In
contrast, a falling operation standard requires employees be at least 2 ½ times the height
of the tree being felled from the person operating the saw.
With the perfect clarity of hindsight, those involved in this accident realize requiring only a
10’ clearance between fallers was not only dangerous, but they also now know a 10’
separation was not in accordance with Forest Service policy. This is a great lesson for the
rest of us to ensure when we plan projects, we seek to address the actual risks present and
not just the risks we are accustomed to managing because of past experience.
Immediately after the accident many people felt that the accident was ‘caused’ because
the employee that cut down the tree upon another employee was not certified to run a
chainsaw. This feeling is counterfactual and distracting to identifying and addressing the
conditions present at the time, that set up the accident. The fact is that whether or not the
employee was certified s/he would have not have been operating any differently. S/he
would have been using the 10’ standard set for this project just like everyone else; just like
the project was planned and implemented.
This is not to say that proper certification and the skill verification that goes with that
certification isn’t extremely important. Training, skill verification and certification are
pillars’ of risk management and must be continuously emphasized and enforced. Those
involved in this accident have learned this lesson the hard way.
With respect to certification, the Plumas, like many other forests, rely entirely upon their
fire program to manage their chainsaw certification process for the entire forest. While
this practice may seem logical since the fire program is already training and certifying so
many firefighters, this practice creates significant problems for other disciplines that are
not flexible to meet fire’s time schedule. Many employees expressed frustration with the
inability to obtain training and certification to the FLA team and these concerns appear in
the lessons learned above. In one sense this practice has created unintentional and
maybe unnecessary risks in that we are asking employees to use chainsaws, but we make
it very challenging, if not difficult, for them to obtain the training and certification necessary
to do so.
With shrinking organizations and continuing high work demands, Forests are finding
creative ways to blend staffing to get important work done on the ground. This type of work
would have been done in the past with organized crews such as TSI or marking crews.
Those crews, like today’s fire crews, had organizational structure with crew leaders and
The thinning project in the Little Grass Valley Recreation Area was a project implemented
with an assembled crew from a couple of departments. It was made up of highly talented
folks with a mix of skills yet the lessons learned shared with the FLA team brought up that
workers were concerned that they needed to have someone designated as the on-site crew
leader with oversight responsibility. The people involved in this accident recognized they
needed a person with sufficient training and experience to assess the safety of the
operation and the authority to take corrective action.
As the Lessons Learned above indicate, there were employees noticing hazards and
barriers to safe performance; such as, long drives to and from the work site, uncertified
sawyers, and not enough chainsaw certifiers, not enough direct supervision and sawyers
working too closely together. As with any operation of this size and complexity there
inevitably would have been close calls, near-misses and risks discovered on site that were
not considered when the JHA was constructed or when safety was briefed everyMonday
morning. Risk is a by-product of work especially on a project this complex with so many
moving parts. The FLA team believes employees would have spoken up had there been a
feedback mechanism (such as daily After Action Reviews) for the workers to regularly
report or talk with their supervisors about these emerging risks particularly human errors
and mistakes. These lessons show the importance of encouraging workers at the tip of the
spear (those workers on the front line who have the best knowledge of the real world risks)
to regularly share with management their, near-misses, mistakes, close calls and errors.
The Forest and District did a remarkable and outstanding job of preparing for an emergency
event and they implemented the plan very well. It may have seemed to those involved like
it took an inordinate amount of time to get emergency personnel on site and to complete
the evacuation, but in reviewing the record, the truth is that it would have been difficult to
have conducted this rescue operation any faster. One of the Lessons Learned quotes is
simple but important: “Medivacs take longer than you think”. This is an especially valuable
lessons learned to share and we should all plan accordingly.
The District has done an exceptional job in preparing for medical emergencies. Having lists
of locations around the Forest with latitude and longitude data is a great help in guiding
medical personnel to accident sites.
During the FLA process, several employees complained that the radio system was partially
at fault for the seemingly long rescue. The FLA team did not agree. While the 10 minutes
or so it took to contact the dispatch office was very stressful it was probably not the radio
system that caused the delay. The FLA team believes the delay was more likely due to
employees unfamiliar with how to navigate between tones and towers, move around dead
spots, use relays and other processes used by employees that regularly use the radio in
their daily work.
Fire and law enforcement employees for example regularly check-in with dispatch and
confirm that they have communications where ever they are. By and large, they are fluent
in negotiating frequencies, towers and tones and if they are outside of a coverage area they
have rehearsed how to mitigate the situation using relays.