Helitack Crew 404 Burnover
Glen Allen Fire
Download 60-page Glen
Allen report, 4.6 mb pdf
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Contributing Factors :
Fire Behavior; Human Factors
Human Factors :
Decision Making; Leadership; Risk Assessment; Situational Awareness
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|Describe in detail what happened including the concern or potential issue, the environment (weather, terrain, fire behavior, etc), and the resulting safety/health issue.|
September 12, 2004; Tuolumne Fire, Stanislaus National Forest. The death of CDF Firefighter Eva Schicke was the direct result of the following factors:
1) The CDF Fire Captain on the ground with the Helitack crew that included Miss Schicke was not qualified for the position. His background was in rural structure fire and medical aide operations (as a fire dept. medic) and his experience in wildland fire was minimal.
2) His inability to: evaluate fire behavior potential; identify appropriate escape routes and safety zone/s; initiate mitigating actions; and determine appropriate safe tactics; resulted in a downhill line-dig operation with no mitigation of applicable "18 Situations..." and/or "Downhill Line Construction Checklist" elements.
2) ATGS and Helitack officers in the air disregarded/denied the IC's request for bucket work at the heel of the fire for the purpose of creating an anchor point in support of the Helitack crew, choosing instead to waste unsupported drops along the middle of the south flank 1000's of feet above the heel, without benefit of an anchor point.
The result of the Captain's inexperience and poor decision making, and the lack of support by the crew's own helicopter was three fold: the crew commenced a downhill line-dig without any support, instead of initiating their attack from the easily accessible bottom of the slope; the Captain aboard the helicopter failed to provide an anchor point, suggestions as to tactics and safety, or otherwise support the crew on the ground; neither the identified "safety zone" nor the "escape route" required to get there met the respective definitions as found in any number of agency training materials. In fact both were completely inadequate.
As a result, FF Schicke was killed when an easily anticipated change in wind and fire behavior caught the Helitack crew on the ground by surprise.
SUGGESTED CORRECTIVE ACTION
|Reporting Individual : Please list anything that, if changed, would prevent this safety issue in the future.|
1) CDF currently has no standards or prerequisites by which Helitack Captains are selected. CDF must develop and implement a system by which candidates for Helitack Captain can be evaluated for appropriate fire line experience and knowledge of basic fire behavior and control tactics, at a minimum.
2) CDF Helicopters must be first and foremost dedicated to the support of their crews on the ground. Unsupported drops with no clear purpose must be avoided.
3) All concerned apparently need to be reminded of the most basic of all wildland fire fighting tactical considerations: anchor point, anchor point, anchor point!!!
4) The USFS must post the documents associated with their investigation of the incident on the USFS Fire Safety page along side the reports from the Cramer and Thirty Mile fires.
5) CDF must release/post their investigation reports and distribute to the field.
6) The CDF Helitack Captain on the ground must be held accountable for his actions.
7) The ATGS and Helitack Captain (on board the Helicopter) must receive remedial training.
|Please document how you tried to resolve the problem and list anything that, if changed, would prevent this safety issue in the future.|
I have no authority to change the process by which CDF chooses their Helitack Captains. By virtue of my rank I have no authority over the ATGS program or the means to influence the decision making of Helitack Captains in the air. All I can do is continue to train my firefighters and encourage them to take responsibility for their own safety by evaluating situations and assignments for themselves and not let inexperienced rookies lead them to disaster.
SUPPLEMENTAL CORRECTIVE ACTION