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Colorado Firecamp - wildland firefighter training

Apply on-line now for Colorado Firecamp's upcoming S-212 Wildland Fire Chain Saws classes:

  • Oct. 26-29, 2017
  • Nov. 16-19, 2017
  • Apr. 12-15, 2018
  • May 3-6, 2018
  • May 17-20, 2018

Cost: $625 includes tuition, meals & lodging. (Increases to $650 in 2018.)


What to Bring to Class

Job Hazard Analysis (JHA)


MTDC Chain Saw Training

Felling Boss Training


Little Grass Valley Tree Felling Accident FLA — August, 2009

Freeman Reservoir tree felling fatality, 72-hour report & OSHA citation — June, 2009

Storm Mountain Ranch tree felling accident, OSHA citation — May, 2009

Andrew Palmer Fatality, Dutch Creek Incident, — June, 2008

OSHA citations

Volusia County Tree Felling Fatality
Scene Pictures — November, 2007

Big Creek Fire Accident — August, 2006


NWCG Hazard Tree and Tree Felling Task Group — link to hazard tree safety information


USFS Region 2 letter to Sen. Udall, re: S-212 cutting area — June, 2009

CSFS Faller Qualification Guidelines — May, 2006

USFS Region 2 Chainsaw Policy — February, 2005

S-235 Felling Boss Training, Issue Paper #12 — January, 1996


Wildland Fire Chain Saw Glossary — S-212 Pre-course work


 

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.

Planning

  • 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 operations.
  • 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”.

Operations

  • 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 using.
  • 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”.

Contingency Planning

  • 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.

Planning

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.

Operations

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 workers.

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.

Contingency Planning

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.


 


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